Multimodal physiotherapy treatment based on a biobehavioral approach for patients with chronic cervico-craniofacial pain: a prospective case series.

The purpose of this prospective case series was to observe and describe changes in patients with chronic cervico-craniofacial pain of muscular origin treated with multimodal physiotherapy based on a biobehavioral approach. Nine patients diagnosed with chronic myofascial temporomandibular disorder and neck pain were treated with 6 sessions over the course of 2 weeks including: (1) orthopedic manual physiotherapy (joint mobilizations, neurodynamic mobilization, and dynamic soft tissue mobilizations); (2) therapeutic exercises (motor control and muscular endurance exercises); and (3) patient education. The outcome measures of craniofacial (CF-PDI) and neck disability (NDI), kinesiophobia (TSK-11) and catastrophizing (PCS), and range of cervical and mandibular motion (ROM) and posture were collected at baseline, and at 2 and 14 weeks post-baseline. Compared to baseline, statistically significant (p < 0.01) and clinically meaningful improvements that surpassed the minimal detectable change were observed at 14 weeks in CF-PDI (mean change, 8.11 points; 95% confidence interval (CI): 2.55 to 13.69; d = 1.38), in NDI (mean change, 5 cm; 95% CI: 1.74-8.25; d = 0.98), and in the TSK-11 (mean change, 6.55 cm; 95% CI: 2.79-10.32; d = 1.44). Clinically meaningful improvements in self-reported disability, psychological factors, ROM, and craniocervical posture were observed following a multimodal physiotherapy treatment based on a biobehavioral approach.

Disfunciones temporomandibulares y su relación con trastornos de ansiedad en niños: un caso clínico / Temporomandibular joint dysfunctions and their relationship with anxiety disorders in children: report of a clinical case

La presencia de desórdenes temporomandibulares (TTM) en el niño es un tema controversial. Algunos autores sostienen su ausencia en la población infantil; sin embargo, otros han observado signos y síntomas de TTM en poblaciones pediátricas. Nosotros creemos que tales desórdenes pasan inadvertidos con frecuencia por la falta de un examen clínico completo y minucioso que incluya el estudio de la ATM como parte del sistema estomatognático y como revisión rutinaria en la clínica odontopediátrica. Ante las reiteradas consultas que recibimos en la asignatura Odontología Niños de la FOLP, surgió la inquietud de profundizar en el tema y decidimos realizar un trabajo de investigación denominado : "Disfunciones temporomandibulares y su relación con trastornos de ansiedad en una población infantil". El objetivo general de este trabajo fue determinar los signos y síntomas de los TTM y su relación con los distintos niveles de trastornos emocionales en una población infantil, con el propósito de brindar información a odontólogos y odontopediatras acerca de la importancia de realizar un correcto examen clínico de la ATM que nos alerte sobre la posibilidad de aparición de TTM en niños, sin dejar de estar atentos a los miedos o los diferentes grados de ansiedad que los niños pueden desarrollar y que contribuyen en buen grado a agravar o desencadenar el cuadro.

Propriedades clinimétricas da variável eletromiográfica duty factor para desordem temporomandibular / Clinimetric properties of duty factor for temporomandibular disorder

Objetivo Avaliar a confiabilidade e responsividade do duty factor à dor provinda da desordem temporomandibular Métodos Participaram 20 voluntárias, com média de idade de 29 anos e 6 meses (±9,2), portadoras de desordem temporomandibular miogênica, segundo o critério diagnóstico para pesquisa em Desordem Temporomandibular (RDC/TMD). Foram coletados sinais eletromiográficos nas condições de repouso dos músculos mastigatórios, na presença de dor moderada a severa e na diminuição ou eliminação desta dor após aplicação de Estimulação Elétrica Nervosa Transcutânea durante 45 minutos. Os sinais eletromiográficos de repouso foram processados para obtenção dos valores do tempo de ativação muscular acima de 10% do valor da máxima força de apertamento dentário. A confiabilidade foi testada pelo coeficiente de correlação intraclasse em dados repetidos antes da analgesia. Também foi calculado o erro padrão de medida e mínima mudança detectável. A responsividade da variável foi analisada entre as coletas eletromiográficas realizadas antes e após a analgesia pelo tamanho de efeito e média de resposta padronizada. Resultados Duty factor apresentou valores de coeficiente de correlação intraclasse acima de 0,75 para todos os músculos. O erro padrão foi entre 4% e 8% e a mínima mudança detectável entre 5% e 12%. Na responsividade da variável para a dor, o tamanho de efeito obteve valores entre 0,2 e 0,5 e a média da resposta padronizada, valores acima de 0,8. Conclusão O duty factor apresentou confiabilidade excelente e responsividade à dor da desordem temporomandibular baixa para tamanho de efeito e excelente para média da resposta padronizada. .

Purpose To assess the reliability and responsiveness of the duty factor variable for assessing pain originating from temporomandibular disorders. Methods The sample comprised 20 female volunteers, mean age 29 years 6 months (± 9.2), with a diagnosis of myogenic temporomandibular dysfunction according to the Research Diagnostic Criteria for Temporomandibular Disorders. Electromyographic (EMG) signals were collected at three times: during mandibular rest; in the presence of moderate to severe pain; and when pain was reduced to mild or absent after 45 minutes of transcutaneous electrical nerve stimulation (TENS). Electromyographic signals during mandibular rest were processed to obtain values for muscle activation time greater than 10% of maximum bite force. Reliability was tested with intraclass correlation for repeated data before analgesia. Standard error of measurement (SEM) and minimum detectable change (MDC) were also computed to determine reliability. Responsiveness of duty factor was analyzed between EMG recordings, before and after analgesia, by calculating effect size (ES) and standardized response mean (SRM). Results Duty factor presented intraclass correlation coefficient above 0.75 for all muscles. Standard error of measurement ranged from 4% to 8% and minimum detectable change from 5% to 12%. Regarding the responsiveness of duty factor to pain, effect size values fell between 0.2 and 0.5 and SRM values were greater than 0.8. Conclusion Duty factor showed excellent reliability. However, responsiveness to TMD-related pain was low as expressed by effect size and excellent as expressed by standardized response mean. .

Estudo do efeito analgésico da acupuntura na resposta dolorosa de pacientes portadores de Disfunção Temporomandibular / Study on the analgesic effect of acupuncture on the pain response in patients with temporomandibular disorders

O presente estudo foi clínico duplo-cego randomizado, placebo controlado. Avaliou o efeito analgésico do acuponto Estômago 7 (E7) em pacientes portadores de Disfunção Temporomandibular. A possível analgesia foi estudada bilateralmente nos músculos masséter e temporal anterior. A proposição se estendeu a fim de elucidar se existem diferenças nos resultados quando se utiliza um ponto em um lado da face, se o resultado repercute do outro lado da face e se a acupuntura atua no limiar de dor do indivíduo. O estudo foi aprovado pelo Comitê de Ética em Pesquisa. A amostra constou de 56 pacientes. Todos os pacientes receberam a acupuntura real e acupuntura placebo, em sessão única. O acuponto E7 foi puncionado sempre do lado direito da face dos indivíduos. Os parâmetros utilizados para a avaliação foram a Escala Visual Analógica (EVA) e o Limiar de dor à Pressão (LDP). Avaliados antes e após o tratamento. A diminuição média do parâmetro EVA do lado direito foi de 39,73. Para o lado esquerdo, a diminuição média foi de 41,81. O parâmetro LDP aumentou imediatamente. O ponto isolado de acupuntura E7 promoveu a diminuição da dor do músculo masséter dos indivíduos. Foi possível agulhar um lado do paciente e atuar no lado oposto. O limiar de dor a pressão (LDP) medida no músculo-temporal anterior foi aumentado bilateralmente.

This was a clinical, double blind, randomized, placebo controlled study. It had the purpose of assessing the analgesic effect of acupoint Stomach 7 (S7) in patients with Temporomandibular Disorders. The possible analgesia was studied bilaterally on the masseter and anterior temporalis muscles. The proposal intended to find if there are differences in the results when a point on one side of the face is used and whether there is a repercussion on the other side of the face. Moreover, if acupuncture acts on the pain threshold of individuals. The study was approved by the Ethics Committee of Researches of the School of Dentistry of the University of São Paulo under number 544519. Fifty-six patients took part in the study. All the patients received real acupuncture and placebo acupuncture in a single appointment. Acupoint St7 was stimulated always on the right side of the patients faces. The parameters used for the assessment were the Visual Analog Scale (VAS) and the Pressure Pain Threshold (PPT), assessed before and after treatment. The mean decrease of VAS parameter on the right side was 39.73; and on the left side, the mean decrease was 41.81. The parameter PPT increased immediately. The isolated point of acupuncture St7 organized decrease of pain in the masseter muscle of patients. It was possible to puncture one side of the patient and act on the opposite side. The Pressure Pain Threshold (PPT) measured on the anterior temporalis muscle increased bilaterally.

[Pharmacological therapy of temporomandibular joint pain]. / Medikamentöse Therapie bei Kiefergelenkschmerzen.

Pharmacological interventions in temporomandibular joint (TMJ) pain differ from corresponding therapeutic interventions of jaw muscle (myofascial) pain. An actual systematic literature search lists and evaluates available articles on randomised controlled trials for treatment of arthralgia of the TMJ. On the basis of the few available trial reports, non-steroidal anti-inflammatory drugs (NSAIDs) seem to be effective, but side effects and drug interactions need to be considered. In relation to other therapeutic modalities, the rapidity of the onset of action of NSAIDs seems to be different, and the extension of side effects can be varied or reduced by changing the application route (oral versus topical). Palmitoylethanolamide (PEA) as dietary supplement for special medical purposes can apparently evoke positive therapeutic effects in TMJ arthralgia which need to be analysed in further studies.

Myofascial trigger point pain.

Myofascial trigger point pain is an extremely prevalent cause of persistent pain disorders in all parts of the body, not just the head, neck, and face. Features include deep aching pain in any structure, referred from focally tender points in taut bands of skeletal muscle (the trigger points). Diagnosis depends on accurate palpation with 2-4 kg/cm2 of pressure for 10 to 20 seconds over the suspected trigger point to allow the referred pain pattern to develop. In the head and neck region, cervical muscle trigger points (key trigger points) often incite and perpetuate trigger points (satellite trigger points) and referred pain from masticatory muscles. Management requires identification and control of as many perpetuating factors as possible (posture, body mechanics, psychological stress or depression, poor sleep or nutrition). Trigger point therapies such as spray and stretch or trigger point injections are best used as adjunctive therapy.

Validity of the 'protocol of oro-facial myofunctional evaluation with scores' for young and adult subjects.

UNLABELLED: The aims of this study were to analyse the validity, sensitivity and specificity of the protocol of oro-facial myofunctional evaluation with scores (OMES) for oro-facial myofunctional disorder (OMD) diagnosis in young and adult subjects. Eighty subjects were examined. The OMES was validated against the Nordic orofacial test-screening (NOT-S) protocol (criterion validity) (Spearman correlation test). The construct validity was tested by analysis of the ability of the OMES (i) to differentiate healthy subjects (n = 22) from temporomandibular disorder (TMD) patients (n = 22), which frequently have OMD (Mann-Whitney test) and (ii) to measure the changes that occurred in a subgroup with TMD between the period before and after oro-facial myofunctional therapy (T group, n = 15) (Wilcoxon test). Two speech therapists trained with the OMES participated as examiners (E). There was a statistically significant correlation between the OMES and NOT-S protocols, which was negative because the two scales are inverse (r = -0·86, P < 0·01). There was a significant difference between the healthy and TMD subjects regarding the oro-facial myofunctional status (OMES total score, P = 0·003). After therapy, the T group showed improvement in the oro-facial myofunctional status (OMES total score, P = 0·001). Inter- and intra-examiner agreement was moderate, and the reliability coefficients ranged from good to excellent. The OMES protocol presented mean sensitivity and specificity = 0·80, positive predictive value = 0·76 and negative predictive value = 0·84. CONCLUSION: The OMES protocol is valid and reliable for clinical evaluation of young and adult subjects, among them patients with TMD.

Dental occlusion, body posture and temporomandibular disorders: where we are now and where we are heading for.

The aim of this investigation was to perform a review of the literature dealing with the issue of relationships between dental occlusion, body posture and temporomandibular disorders (TMD). A search of the available literature was performed to determine what the current evidence is regarding: (i) The physiology of the dental occlusion-body posture relationship, (ii) The relationship of these two topics with TMD and (iii) The validity of the available clinical and instrumental devices (surface electromyography, kinesiography and postural platforms) to measure the dental occlusion-body posture-TMD relationship. The available posturographic techniques and devices have not consistently found any association between body posture and dental occlusion. This outcome is most likely due to the many compensation mechanisms occurring within the neuromuscular system regulating body balance. Furthermore, the literature shows that TMD are not often related to specific occlusal conditions, and they also do not have any detectable relationships with head and body posture. The use of clinical and instrumental approaches for assessing body posture is not supported by the wide majority of the literature, mainly because of wide variations in the measurable variables of posture. In conclusion, there is no evidence for the existence of a predictable relationship between occlusal and postural features, and it is clear that the presence of TMD pain is not related with the existence of measurable occluso-postural abnormalities. Therefore, the use instruments and techniques aiming to measure purported occlusal, electromyographic, kinesiographic or posturographic abnormalities cannot be justified in the evidence-based TMD practice.

Massage therapy in myofascial TMD pain management.

Myofascial pain located in the area of the head is a very common disease of the stomatognathic system. The fact that the mechanism of its development is very complex may cause a variety of problems in diagnosis and therapy. Patients diagnosed with this type of affliction usually need a variety of different therapies. Massage therapy can be a significant method of treatment of myofascial pain. That kind of therapy is clinically useful as it improves the subjective and objective health status of the patient and is easy to follow. The aim of this paper is to show the physiological effect and different massage techniques applied in myofascial pain treatment. The authors would also like to present the protocol for dealing with patients who demand that kind of therapy for masseter and temporal muscles.

Study on the effectiveness of the kinetic method in patients with rheumatic diseases and temporomandibular joint dysfunction.

UNLABELLED: Selecting the appropriate treatment decision is essential for achieving optimal results in the management of algo-dysfunctional syndrome of the temporo-mandibular joint (TMJD). The study aims to decide on the most effective (symptomatic control, preserved motility) kinetic program in patients with TMJ involvement. MATERIAL AND METHODS: prospective observational study on 83 consecutive patients with rheumatic diseases and TMJ dysfunction. Clinical assessment (pain, noises, muscle spasm, range of motion, ROM) was performed at baseline and after 3 months of specific kinetic rehabilitation program. Change in clinical parameters and TM3 index was reported, p<0.05. RESULTS: over 45% TMJ involvement at baseline as defined by TMJ index (mean value of 13.56) and only 36.66% at 3 months (p<0.05). Significant improvement in pain (presence, severity) was demonstrated at 3 moths (p<0.05): 18.05% spontaneous pain, 75.9% provoked pain, with 12.11% respectively 2.41% decreased in nocturnal respectively diurnal pain. Significant decrease (p<0.05) in joint noises at movements: 27.71% when opening and 12.04% when closing the mouth, 8.43 at protrusion and 3.61% at retraction, while 18% at the side movements. CONCLUSIONS: Complex accurate kinetic reeducation is mandatory for achieving correct posture (head, neck and trunk), normal mastication, swallowing and respiration, as well as correction of neuromuscular imbalances in patients with TMJD secondary to rheumatic disorders.

Intraoral myofascial therapy for chronic myogenous temporomandibular disorder: a randomized controlled trial.

OBJECTIVE: Studies investigating the efficacy of intraoral myofascial therapies (IMTs) for chronic temporomandibular disorder (TMD) are rare. The present study was an expansion of a previously published pilot study that investigated whether chiropractic IMT and the addition of education and self-care were superior to no-treatment or IMT alone for 5 outcome measures-interincisal opening range, jaw pain at rest, jaw pain upon opening, jaw pain upon clenching, and global reporting of change-over the course of 1 year. METHODS: Ninety-three participants with myogenous TMD between the ages of 18 and 50 years experiencing chronic jaw pain of longer than 3 months in duration were recruited for the study. Successful applicants were randomized into 1 of 3 groups: (1) IMT consisting of 2 treatment interventions per week for 5 weeks, (2) IMT plus education and "self-care" exercises (IMTESC), and (3) wait-list control. The main outcome measures were used. Range of motion findings were measured by vernier callipers in millimeters, and pain scores were quantified using an 11-point self-reported graded chronic pain scale. Global reporting of change was a 7-point self-reported scale, balanced positively and negatively around a zero midpoint. RESULTS: There were statistically significant differences in resting, opening and clenching pain, opening scores, and global reporting of change (P < .05) in both treatment groups compared with the controls at 6 months and 1 year. There were also significant differences between the 2 treatment groups at 1 year. CONCLUSIONS: The study suggests that both chiropractic IMT and IMTESC were superior to no-treatment of chronic myogenous TMD over the course of 1 year, with IMTESC also being superior to IMT at 1 year.

Uso da acupuntura no manejo da dor em pacientes com alterações na articulação temporomandibular (ATM) / Use of acupuncture in the management of the pain in patients with changes in temporomandibular joint

A acupuntura, técnica bastante difundida devido às suas propriedades antiinflamatórias, ansiolíticas, miorelaxantes e ativadoras da função imunológica no organismo humano, tem sido muito utilizada como terapia coadjuvante em diversas especialidades odontológicas. O objetivo deste trabalho é apresentar o caso clínico de uma paciente com Disfunção Temporomandibular (DTM), tratada com acupuntura, e os resultados obtidos por essa técnica terapêutica no serviço odontológico da Faculdade de Odontologia de Piracicaba (FOP-UNICAMP). A paciente VASN, 34 anos, com queixa de dor na ATM, mais intensa no lado direito, com diagnóstico clínico de DTM e bruxismo, foi submetida ao tratamento por acupuntura. De acordo com a MTC (Medicina Tradicional Chinesa), foi encontrado o padrão de desequilíbrio energético da mesma e foi estabelecido um protocolo de tratamento que se demonstrou efetivo para redução dos sintomas.

Acupuncture has increasingly been used as a complementary therapy in tooh treatment for its widely acknowledged properties: antiflamatory, ansiolitic, miorelaxing and as a stimulator of the human immunity system. The aim of this paper is to report a study case with the results of a temporomandibular joint (TMD) disorder treated with acupuncture in the Dental Service Department at the Dental School of Piracicaba (FOP- UNICAMP). The 34-years-old female patient was diagnosed with TMD, more intense on the right side of her face, and bruxism. The patient was taken to acupuncture treatment, according to the Traditional Chinese Medicine, and it was found a pattern of energetic imbalance. The protocol of treatment in this therapy was effective to reduce symptoms.

Síndrome odonto-otológico o síndrome de costen / Odonto-otológico Syndrome or syndrome costs

Es frecuente que en la consulta cotidiana del servicio de otorrinolaringología atendamos a pacientes que acuden porun “dolor” de mediana a gran intensidad localizado en un oído o en ambos, y además refieran que ese dolor continuoo intermitente, pero repetitivo, data de mucho tiempo, ya sea de meses o incluso de años. Al proceder a la exploración del oído, en el cual refieren la otalgia u otodinia, es característico no encontrar patología, ni del conducto auditivo externo ni del tímpano;asimismo, no presentan hipoacusia, al menos en el interrogatorio mencionan audición normal.

Síndrome odonto-otológico o síndrome de costen / Odonto-otológico Syndrome or syndrome costs

Es frecuente que en la consulta cotidiana del servicio de otorrinolaringología atendamos a pacientes que acuden porun “dolor” de mediana a gran intensidad localizado en un oído o en ambos, y además refieran que ese dolor continuoo intermitente, pero repetitivo, data de mucho tiempo, ya sea de meses o incluso de años. Al proceder a la exploración del oído, en el cual refieren la otalgia u otodinia, es característico no encontrar patología, ni del conducto auditivo externo ni del tímpano;asimismo, no presentan hipoacusia, al menos en el interrogatorio mencionan audición normal.

Diagnosis and management of non-dental orofacial pain.

UNLABELLED: Careful history-taking improves diagnosis of non-dental orofacial pain, a not uncommon group of conditions. Accurate diagnosis of conditions such as chronic idiopathic facial pain, temporomandibular disorders, burning mouth syndrome and trigeminal neuralgia is essential if inappropriate dental treatment is to be avoided. There are few investigations to help in the diagnostic process and many of these patients have other forms of chronic pain. All the conditions are best treated using a holistic approach. Drugs, such as tricyclic antidepressants and anticonvulsants, are often effective and surgery can be highly successfully in trigeminal neuralgia. Patient education is paramount. CLINICAL RELEVANCE: Although the majority of pain seen in general dental practice is dental in origin, chronic non-dental orofacial pain must be recognized as its management is entirely different.

Oral acupuncture in the therapy of craniomandibular dysfunction syndrome -- a randomized controlled trial.

CONTEXT: Patients with disorders of the stomatognathic system describe pain and clicking phenomena as primary symptoms. Rapid improvement of the pain is required to ensure and maintain adequate patient compliance. OBJECTIVE: The study was intended to assess the effects of acupuncture in patients with temporomandibular disorders as compared to placebo therapy (sham laser); the primary target parameter was the subjective pain sensation. DESIGN: Randomized, placebo-controlled trial. PATIENTS AND METHODS: 23 patients were enrolled and randomly assigned to one of the two groups. One group received acupuncture treatment according to the very-point technique, the other group received sham laser treatment. The following observer-blinded findings were evaluated before and after treatment: subjective pain, mouth opening, and muscular tenderness and pain on pressure. In addition, mandibular joint movement pathways were recorded using electronic axiography. OUTCOMES: Improvements in pain scores (scale, 0-100) in the acupuncture group (19.1 +/- 11.9) were significant (p = 0.03) versus those in the placebo group (6.2 +/- 14.8). Mouth opening showed an insignificant trend towards improvement (p > 0.1) in the acupuncture (5.0 +/- 6.2 mm) versus the placebo group (1.0 +/- 4.7 mm), differences in tenderness and pain on pressure in neck and masticatory muscles were significant (p < 0,05) for most of the muscles having shown pretreatment tenderness or pain. The axiographic tracings were assessed for quality, symmetry and curve characteristics. Recordings of the opening and closing movement in the acupuncture group showed an increased frequency of improvements of curve characteristics as compared to the placebo group. The acupuncture group also showed an increased frequency of improvement in protrusion and retrusion movements, though no statistical significance could be obtained. CONCLUSION: On the basis of the results of the present study, acupuncture may be recommended as acute treatment of craniomandibular disorders, but studies with larger numbers of patients as well as about long-term treatment outcomes should be conducted.

O uso do laser de baixa potência no tratamento das disfunções temporomandibulares: uma revisão / The use of low lewel laser therapy (LLLT) in the treatment of temporomandibular disorders (TMD): a review

A DTM caracteriza-se principalmente pela dor na região da ATM e nos músculos da mastigação. Atualmente, a etiologia multifatorial das DTMs denota um tratamento sintomático como a primeira abordagem dos pacientes. Os efeitos terapêuticos da LBP têm sido a principal justificativa para o seu emprego como um meio físico no tratamento das DTMs. Apesar das poucas evidências científicas da bioestimulação e da carência de protocolos de aplicação do LBP para DTMs específicas, a revisão da literatura demonstra resultados que estimulam a continuidade de pesquisas com o LBP, como um instrumento para analgesia e melhora na biomecânica mandibular dos pacientes com DTM