A efetividade de dois tratamentos para disfunção temporomandibular muscular: estudo piloto / The effectiveness of two treatments for muscle temporomandibular dysfunction: pilot study

Objetivo: comparar a eficácia de dois protocolos de tratamento para disfunção temporomandibular (DTM) de origem muscular. Sujeitos e método: Estudantes da Faculdade Especializada na Área de Saúde do Rio Grande do Sul foram selecionados por meio de questionário, para avaliar a presença de sinais e sintomas de DTM e diagnóstico de DTM muscular pelos Critérios de Diagnóstico para Transtornos da Pesquisa Temporomandibular. Dez estudantes compuseram a amostra, divididos em dois grupos, de acordo com o protocolo de tratamento: G1 ­ hipertermia induzida, exercícios mandibulares e massagem; e G2 ­ agulhamento seco, hipertermia induzida, exercícios mandibulares e massagem. Os alunos foram instruídos a realizar o protocolo do tratamento G1 todos os dias em casa e na instituição de ensino por três sessões, que ocorreram a cada cinquenta dias. O agulhamento seco foi realizado no G2 apenas nas segunda e terceira sessões de tratamento. Para avaliar a efetividade dos dois tratamentos antes e após cada sessão, avaliaram-se: abertura bucal (AB), por meio de régua milimetrada; dor, pela escala visual analógica; força de mordida (FM), usando um medidor de força digital; e qualidade de vida, avaliada imediatamente antes do início do tratamento e depois do término do tratamento. Resultados: a dor mostrou diferença estatística significativa no G2 após a segunda sessão (p=0,020) e a terceira sessão (p=0,047). Os demais resultados mostram que não houve diferença estatisticamente significativa entre os grupos (p>0,05). Conclusão: considera-se que neste estudo piloto ambos os tratamentos foram eficazes para DTM muscular, uma vez que todos os pacientes apresentaram melhora dos sintomas. Não houve diferença estatisticamente significativa entre os tratamentos, exceto a dor pós-procedimento, causada pela técnica do agulhamento seco. (AU)

Objective: the present study aims to compare the efficacy of two treatment protocols for temporomandibular dysfunction (TMD) of muscular origin. Subjects and method: students of the Faculdade Especializada na área de Saúde do Rio Grande do Sul, that were selected through the questionnaire to evaluate the presence of TMD signs and symptoms and diagnosis of muscular TMD from the Diagnostic Criteria for Temporomandibular Research Disorders. Ten students composed the sample, divided into two groups according to the treatment protocol: hyperthermia induced by G1, mandibular exercises and massage; G2 ‒ dry needling, induced hyperthermia, mandibular and massage exercises. Students were instructed to complete the G1 treatment protocol every day at home and at the educational institution for three sessions that occurred every fifty days. Dry needling was performed in G2 only in the second and third treatment sessions. To evaluate the effectiveness of the two treatments before and after each session, we evaluated: mouth opening (AB), through a millimeter ruler; visual analogue scale; bite force (FM) using a digital force gauge and quality of life was assessed immediately prior to initiation of treatment and after termination of treatment. Results: pain obtained a statistically significant difference in G2 after the second session (p=0.020) and the third session (p=0.047). The other results show that there was no statistically significant difference between the groups (p>0.05). Conclusion: it is considered that in this pilot study both treatments were effective for muscular TMD, since all the patients presented improvement of the symptoms. There was no statistically significant difference between treatments, except for post- -procedure pain, caused by the dry needling technique. (AU)

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.

Clinical and electromyographic follow-up of myofascial pain patients treated with two types of oral splint: a randomized controlled pilot study.

Increased resting electromyographic activity (EMG), reduced EMG during maximum voluntary clenching, and a shift to lower frequencies of the mean/median power frequency (MPF) of the EMG power spectrum have been reported for patients with temporomandibular disorder pain. It is unclear, however, whether these electrophysiological phenomena can be correlated with symptom improvement during the follow-up of myofascial pain patients in treatment. The objective of this study was to monitor the therapeutic effects of two different splint concepts (standard method and a complex splint procedure assisted by transcutaneous electrical nerve stimulation, TENS) for a period of 12 weeks, by use of clinical outcome criteria and EMG recordings. We tested the hypotheses that both measures evaluated will change in parallel during treatment and that the different splint concepts will result in no outcome differences between the variables studied. For two randomly selected groups, each containing 20 non-chronic myofascial pain patients, the clinical course after splint insertion was documented over a period of 12 weeks on the basis of pain and pain on palpation ratings, in parallel with EMG recording. Baseline values were monitored for matched healthy subjects. Although there was no correlation between the course of symptom improvement and significant changes in EMG data, MPF differed significantly (p < 0.05) between healthy subjects and patients. The therapeutic effects of splints of different clinical complexity differed significantly (p < 0.05) between the patient groups, in favor of the complex oral appliances, and substantial (p < 0.001) but temporary pain relief was achieved by additional TENS. For non-chronic myofascial TMD pain patients treated with splints, the course of symptom improvement is not paralleled by significant changes in EMG data. MPF can, however, be used to distinguish between healthy subjects and patients. Splints of different clinical complexity differ in their therapeutic effects in non-chronic myofascial TMD patients, and substantial temporarily limited pain relief can be achieved by additional muscle stimulation by TENS.

Efficacy of massage treatment technique in masseter muscle hardness: robotic experimental approach.

The study aimed to clarify the masseter muscle hardness in patients with myofascial pain, to examine their changes after massage, and to analyze whether the hardness can be an index for massage treatment. Sixteen patients with myofascial pain (12 with unilateral and 4 with bilateral masseter muscle pain) and 24 healthy volunteers were enrolled in this study. The masseter hardness between patients and the healthy volunteers was compared. The changes in the hardness in patients after massage were examined. The relation of the hardness with massage regimens and efficacies was analyzed. There was a significant right-and-left difference of the hardness in patients, although there was no difference in the healthy volunteers. The hardness decreased after massage. The pretreatment asymmetry index of the hardness showed a significant correlation with the massage pressure. It was concluded that there was a significant difference between the right and left masseter hardness in patients with myofascial pain. After massage treatment, the masseter hardness and right-and-left difference decreased. The hardness may be an index for determining the massage pressure.

Temporomandibular joint pain: a critical role for Trpv4 in the trigeminal ganglion.

Temporomandibular joint disorder (TMJD) is known for its mastication-associated pain. TMJD is medically relevant because of its prevalence, severity, chronicity, the therapy-refractoriness of its pain, and its largely elusive pathogenesis. Against this background, we sought to investigate the pathogenetic contributions of the calcium-permeable TRPV4 ion channel, robustly expressed in the trigeminal ganglion sensory neurons, to TMJ inflammation and pain behavior. We demonstrate here that TRPV4 is critical for TMJ-inflammation-evoked pain behavior in mice and that trigeminal ganglion pronociceptive changes are TRPV4-dependent. As a quantitative metric, bite force was recorded as evidence of masticatory sensitization, in keeping with human translational studies. In Trpv4(-/-) mice with TMJ inflammation, attenuation of bite force was significantly less than in wildtype (WT) mice. Similar effects were seen with systemic application of a specific TRPV4 inhibitor. TMJ inflammation and mandibular bony changes were apparent after injections of complete Freund adjuvant but were remarkably independent of the Trpv4 genotype. It was intriguing that, as a result of TMJ inflammation, WT mice exhibited significant upregulation of TRPV4 and phosphorylated extracellular-signal-regulated kinase (ERK) in TMJ-innervating trigeminal sensory neurons, which were absent in Trpv4(-/-) mice. Mice with genetically-impaired MEK/ERK phosphorylation in neurons showed resistance to reduction of bite force similar to that of Trpv4(-/-) mice. Thus, TRPV4 is necessary for masticatory sensitization in TMJ inflammation and probably functions upstream of MEK/ERK phosphorylation in trigeminal ganglion sensory neurons in vivo. TRPV4 therefore represents a novel pronociceptive target in TMJ inflammation and should be considered a target of interest in human TMJD.

Laser acupuncture in patients with temporomandibular dysfunction: a randomized controlled trial.

A prospective, double-blind, randomized, and placebo-controlled trial was conducted in patients with chronic temporomandibular disorder (TMD) to check the analgesic efficacy of infrared low-power GaAlAs diode laser applied to acupuncture points. Forty female subjects, ranging in age from 20 to 40 years, with diagnoses of chronic myofascial pain and arthralgia were randomly allocated to two groups: an experimental group (EG) who received the laser acupuncture as adjunct to reversible occlusal splint therapy and a control group (CG) who received a placebo laser associated with occlusal splint therapy. Both approaches were applied once a week for 3 months. Laser acupuncture was defined by the following parameters: 50-mW continuous radiation for 90 s to acupoints ST6, SI19, GB20, GB43, LI4, LR3, NT3, and EX-HN3; defining 4.5-J energy; 1250-W/cm(2) density point; and 112.5-J/cm(2) total density. The outcome measurements included a symptom evolution assessment carried out by checking spontaneous and palpation pain intensity, which was indicated on a visual analog scale (VAS). All evaluations were made by an assessor who was blind to the treatment. The symptom reduction was significant in both groups (EG: VAS = 0, n = 20; CG: VAS between 2 and 4, n = 18). The measurements showed significantly faster and lower pain intensity values in the EG (p ≤ 0.002), where there was a higher proportion of patients with remission of symptoms related to the action of laser acupuncture. For patients in whom conservative treatment was adopted, the laser acupuncture is a secure, noninvasive, and effective treatment modality because it improves the chronic pain associated with TMD and has no side effects.

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.

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.

Emg analysis after laser acupuncture in patients with temporomandibular dysfunction (TMD). Implications for practice.

The aim of this study was to analyze the effect of low level laser applied to acupuncture points of patients diagnosed with temporomandibular dysfunction (TMD). Ten patients aged between 20 and 50 years were clinically examined with regard to pain and dysfunction of the masticatory system. They received laser applications (GaAlAs diode laser, 780 nm wavelength; 70 mW power output, 35 j/cm(2)) in acupuncture specific points (Ig4, C3, E6, E7) once a week, for ten sessions. The range of jaw movement was registered after each session and visual analogue scale (VAS) was applied. Results were analyzed (SPSS-15.0-Chicago) during the comparison, before and after treatment. Statistical tests showed significant improvements (p < 0.01) in painful symptoms and electromyographic activities of masseter muscles in maximal habitual occlusion after laser applications but no significant improvements (p = 0.05) in measurements of mandibular movements. The laser therapy in specific acupuncture points promoted improvement of symptoms and it may be used as complementary therapy for TMD.

[Massage of the lateral pterygoid muscle in acute TMJ dysfunction syndrome]. / Massage du muscle ptérygoïdien latéral dans le SADAM aigu.

INTRODUCTION: Massage of the lateral pterygoid muscle according to Cyriax's principles is an unrecognized procedure. This procedure was tried on patients presenting with temporomandibular joint dysfunction syndrome. MATERIAL AND METHODS: Fifteen patients were treated. Pain, joint clicking, measurement of mouth opening, lateral excursion and propulsion were recorded. Assessment was made before and after the massage in the same consultation. RESULTS: Joint clicking was solved in 80% and pain in 50% of the cases. Mouth opening increased by 12.8%, propulsion by 11.6% and lateral excursion by 41.3%. DISCUSSION: Massage of the lateral pterygoid muscle according to Cyriax's principles is a simple and efficient method that can be recommended for patients presenting with temporomandibular joint dysfunction syndrome. We performed a brief anatomical and radiological MRI study supporting the feasibility of lateral pterygoid muscle palpation.

Low-level laser therapy and myofacial pain dysfunction syndrome: a randomized controlled clinical trial.

Myofacial pain dysfunction syndrome (MPDS) is the most common reason for pain and limited function of the masticatory system. The effects of low-level lasers (LLLs) for controlling the discomfort of patients are investigated frequently. However, the aim of this study was to evaluate the efficacy of a particular source producing 660 nm and 890 nm wavelengths that was recommended to reduce of the pain in the masticatory muscles. This was a double-blind and placebo-controlled trial. Sixteen MPDS patients were randomly divided into two groups. For the laser group, two diode laser probes (660 nm (nanometers), 6.2 J/cm(2), 6 min, continuous wave, and 890 nm, 1 J/cm(2) (joules per square centimetre), 10 min, 1,500 Hz (Hertz)) were used on the painful muscles. For the control group, the treatment was similar, but the patients were not irradiated. Treatment was given twice a week for 3 weeks. The amount of patient pain was recorded at four time periods (before and immediately after treatment, 1 week after, and on the day of complete pain relief). A visual analog scale (VAS) was selected as the method of pain measurement. Repeated-measures analysis of variance (ANOVA), the t-test and the paired t-test were used to analyze the data. In each group the reduction of pain before and after the treatment was meaningful, but, between the two groups, low-level laser therapy (LLLT) was more effective (P = 0.031) According to this study, this type of LLLT was the effective treatment for pain reduction in MPDS patients.

Temporomandibular disorders and facial pain: a psychophysiological perspective.

This article presents a psychophysiological perspective on temporomandibular muscle and joint disorders (TMJD) and facial pain. After a brief introduction to TMJD, the article presents data, largely derived from work carried out in my laboratory, that address four questions: (1) What are the consequences of parafunctional activities? (2) Do TMJD patients engage in parafunctional activities? (3) Why are TMJD patients unaware of these activities? and (4) What are the implications of these findings for treatment? The findings suggest that low-level parafunctions increase pain in otherwise pain-free individuals and can produce symptoms sufficiently severe to meet the diagnostic criteria for TMJD diagnoses of myofascial pain and/or arthralgia. Patients with certain forms of TMJD report very high levels of parafunctional tooth contact. Their lack of awareness of these behaviors may arise from uncertain definitions of the term "clenching", from proprioceptive deficits, or from the presence of adjunctive behaviors. Preliminary work shows that reduction in tooth contact via habit reversal techniques may be a promising mechanism for reducing pain in these patients.

The short-term effects of acupuncture on myofascial pain patients after clenching.

AIM: Short-term pain reduction from acupuncture in chronic myofascial pain subjects was evaluated using an 11-point (0 to 10) numeric rating scale, visual analog scale (VAS), and pain rating of mechanical pressure on the masseter muscle. METHODS: A single-blind, randomized, controlled, clinical trial with an independent observer was performed. Fifteen chronic myofascial pain subjects over the age of 18 were randomly assigned into groups: nine subjects received real acupuncture; six subjects received sham acupuncture. Each subject clenched his/her teeth for 2 minutes. Acupuncture or sham acupuncture was administered at the Hegu Large Intestine 4 acupoint. Sham acupuncture was conducted by lightly pricking the skin with a shortened, blunted acupuncture needle through a foam pad, without penetrating the skin. The foam pad visually conceals the needle's point of the entry, so that the subject cannot discern which technique is being used. The subjects rated their general pain on a numeric rating scale. A mechanical pain stimulus was applied with an algometer and the subject rated his/her pain on a VAS. Statistical analysis was performed using the repeated measures anova, paired t-tests, and Fisher's exact test as appropriate. RESULTS: There was a statistically significant difference in pain tolerance with acupuncture (P = 0.027). There was statistically significant reduction in face pain (P = 0.003), neck pain (P = 0.011), and headache (P = 0.015) with perception of real acupuncture. CONCLUSION: Pain tolerance in the masticatory muscles increased significantly more with acupuncture than sham acupuncture.

The efficacy of acupuncture in the treatment of temporomandibular joint myofascial pain: a randomised controlled trial.

OBJECTIVES: To compare the effect of real acupuncture and sham acupuncture in the treatment of temporomandibulat joint myofascial pain, in order to establish the true efficacy of acupuncture. METHODS: A double blind randomised controlled trial conducted in the TMD Clinic, at the School of Dentistry, The University of Manchester. Twenty-seven patients were assigned to one of two treatment groups. Group 1 received real acupuncture treatment whilst Group 2 received a sham acupuncture intervention. Both the assessor and the patient were blinded regarding the group allocation. Baseline assessment of the outcome variables was made prior to the first treatment session, and was repeated following the last treatment. RESULTS: The results demonstrated that real acupuncture had a greater influence on clinical outcome measure of TMJ MP than those of sham acupuncture, and the majority of these reached a level of statistical significance. CONCLUSION: Acupuncture had a positive influence on the signs and symptoms of TMJ MP. In addition, this study provides evidence that the Park Sham Device was a credible acupuncture control method for trials involving facial acupoints.

The effect of disclusion time reduction on maximal clench muscle activity levels.

Simultaneous recording of excursive function and muscle activity on 62 MPDS patients demonstrated that reducing prolonged disclusion time (1.4 seconds per excursion) to short disclusion time (0.41 seconds per excursion) created a therapeutic effect such that within one month's time following treatment, there was an observed increase in the maximal clenching capacity of the masseter and temporalis muscles. This clinical treatment effect appears to be the result of decreased ischemia in these same muscles resultant from minimizing the time posterior teeth compress their periodontal ligament mechanoreceptors as these teeth are engaged and disengaged during excursive function.

Enfermedad de Jacob asociada con el síndrome de disfunción de la articulación temporomandibular: Presentación de un caso / Jacob’s disease associated with temporomandibular joint dysfunction: A case report

La enfermedad de Jacob se describe como una entidad infrecuente en la cual se establece una formación articular sinovial entre una apófisis coronoide mandibular elongada y el hueso malar homolateral. El Síndrome de disfunción de la articulación temporomandibular(ATM) ha sido postulado como posible factor etiológico del alargamiento este proceso coronoideo. Presentamos el caso de una mujer de 23 años con un desplazamiento discal de ATM de larga evolución y limitación de la apertura oral, que desarrolló una asimetría malar progresiva. La paciente fue sometida a tratamiento quirúrgico mediante una coronoidectomía intraoral y una artroscopia de la ATM homolateral en el mismo acto operatorio. El diagnóstico histológico de la apófisis coronoide examinada fue de exóstosis óseo-cartilaginosa con presencia de fibrocartílago articular en dicha formación. A pesar de la baja prevalencia de esta patología, debe ser considerada como un posible diagnóstico en aquellos pacientes con limitación progresiva de la apertura oral de larga evolución, si bien en ocasiones puede acompañarse de una disfunción articular crónica concomitante como posible causa de la misma

Jacob´s disease is regarded a rare condition in which a joint formation is established between an enlarged mandibular coronoid process and the inner aspect of the zygomatic body. Chronic temporomandibular joint (TMJ) disk displacement has been proposed as etiological factor of coronoid process enlargement. We present a 23-year-old woman with long-standing TMJ dysfunction and restricted interincisal opening, who developed a progressive zygomatic assymetry. The patient underwent treatment by intraoral coronoidectomy and homolateral TMJ arthroscopy in the same surgery. The histopathological diagnosis of the coronoid sample was cartilage-capped exostoses with presence of articular fibrous cartilage. Although the low prevalenceof this entity, it should be considered as a possible diagnosis inpatients with progressive limitation of mouth opening, althougha TMJ syndrome may be present as a cause of this entity

Luxación anterior del disco articular reductible. Tratamiento por medio de la posición neurofisiológica inicial. Parte I: introducción / Reductable anterior articular disk luxation. Treatment by means of the initial neurophysiological position. Part I: introduction

Las patologías de la articulación temporomandibular (PAT) han traído muchos desacuerdos y confusiones en el momento de planear el diagnóstico, pronóstico y plan de tratamiento. El fin de este trabajo es describir una filosofía para el estudio y tratamiento de las PAT, por medio de la posición neurofisiológica inicial (AU)

Luxación anterior del disco articular reductible. Tratamiento por medio de la posición neurofisiológica inicial. Parte I: introducción / Reductable anterior articular disk luxation. Treatment by means of the initial neurophysiological position. Part I: introduction

Las patologías de la articulación temporomandibular (PAT) han traído muchos desacuerdos y confusiones en el momento de planear el diagnóstico, pronóstico y plan de tratamiento. El fin de este trabajo es describir una filosofía para el estudio y tratamiento de las PAT, por medio de la posición neurofisiológica inicial