Farmacopuntura en pacientes con disfunción dolorosa de la articulación temporomandibular / Pharmacopuncture in patients with temporomandibular joint painful dysfunction

Introducción: El síndrome de disfunción temporomandibular constituye un problema de salud importante, que afecta a más de 50 % de la población mundial. Objetivo: Describir la evolución terapéutica de pacientes con afecciones temporomandibulares tratados con farmacopuntura. Métodos: Se realizó un estudio descriptivo de 60 pacientes con síndrome de disfunción temporomandibular en fase aguda, atendidos en el Hospital Clinicoquirúrgico Faustino Pérez de Matanzas, desde enero hasta diciembre de 2018. Se administró una solución compuesta por lidocaína, vitamina B12 y betametasona en puntos acupunturales determinados. Además, se utilizó la escala verbal del dolor. Resultados: Se encontró que el grupo etario de 60 años y más, así como el sexo femenino fueron los más afectados. De los factores asociados a este síndrome predominó el estrés en 100 % de los pacientes; 63,3 % presentaron dolor moderado y 53,3 % se aliviaron totalmente. Conclusiones: La farmacopuntura alivió el dolor asociado al síndrome de disfunción temporomandibular en la mayoría de los afectados, entre las 3 primeras sesiones de tratamiento.

Introduction: The temporomandibular dysfunction syndrome constitutes an important health problem that affects more than 50 % of the world population. Objective: To describe the therapeutic clinical course of patients with temporomandibular affections treated with pharmacopuncture. Methods: A descriptive study of 60 patients with temporomandibular dysfunction syndrome in acute phase was carried out, they were assisted in the Faustino Pérez Clinical Surgical Hospital from Matanzas, from January to December, 2018. A solution composed by lidocaine, B12 vitamin and betamethasone was administered in certain acupunctural points. Also, the pain verbal scale was used. Results: It was found that the 60 years and over age group, as well as the female sex were those most affected. Of the factors associated to this syndrome stress prevailed in 100 % of patients; 63.3 % presented moderate pain and 53.3 % were totally relieved. Conclusions: Pharmacopuncture relieved the pain associated with the temporomandibular dysfunction syndrome in most of those affected, in the first 3 treatment sessions.

Treatment of Temporomandibular Dysfunction With Hypertonic Dextrose Injection (Prolotherapy): A Randomized Controlled Trial With Long-term Partial Crossover.

OBJECTIVE: To assess the efficacy and longer-term effectiveness of dextrose prolotherapy injections in participants with temporomandibular dysfunction. PATIENTS AND METHODS: A randomized controlled trial with masked allocation was conducted from January 14, 2013, through December 19, 2015. Forty-two participants (with 54 joints) meeting temporomandibular dysfunction criteria were randomized (1:1) to 3 monthly intra-articular injections (20% dextrose/0.2% lidocaine or 0.2% lidocaine) followed by as-needed dextrose/0.2% lidocaine injections through 1 year. Primary and secondary outcome measures included a 0 to 10 Numerical Rating Scale score for facial pain and jaw dysfunction; maximal interincisal opening (MIO) measured in millimeters, percentage of joints with 50% or more change (improvement) in pain and function, and satisfaction. RESULTS: Randomization produced a control group with more female participants (P=.03), longer pain duration (P=.01), and less MIO (P=.01). Upon 3-month analysis, including pertinent covariates, dextrose group participants reported decreased jaw pain (4.3±2.9 points vs 1.8±2.7 points; P=.02), jaw dysfunction (3.5±2.8 points vs 1.0±2.1 points; P=.008), and improved MIO (1.5±4.1 mm vs -1.8±5.1 mm; P=.006). Control group participants received dextrose injections beginning at 3 months. No between-group differences were noted at 12 months; pooled data suggested that jaw pain, jaw function, and MIO improved by 5.2±2.7 points (68%), 4.1±2.8 points (64%), and 2.1±5.5 mm, respectively. Pain and dysfunction improved by at least 50% in 38 of 54 (70%) and 39 of 54 (72%) jaws, respectively. CONCLUSION: Intra-articular dextrose injection (prolotherapy) resulted in substantial improvement in jaw pain, function, and MIO compared with masked control injection at 3 months; clinical improvements endured to 12 months. Satisfaction was high. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01706172.

Evaluation of the Efficacy of Different Concentrations of Dextrose Prolotherapy in Temporomandibular Joint Hypermobility Treatment.

PURPOSE: The aim of this study was to compare and evaluate the efficacy of different concentrations of dextrose prolotherapy for the treatment of temporomandibular joint (TMJ) hypermobility. PATIENTS AND METHODS: A prospective, randomized clinical trial including patients with subluxation or dislocation was performed. The study comprised 40 patients. Patients were randomly divided into 4 groups: control group, 10% dextrose, 20% dextrose, and 30% dextrose group. Patients in all groups received injections into 4 different areas of each TMJ in 4 sessions at monthly intervals. Visual analog scale of TMJ pain intensity, maximum mouth opening (MMO), joint sounds, and frequency of luxations were recorded preoperatively and postoperatively after 1 month of last injection. The collected data were then statistically analyzed. RESULTS: Each group showed postoperatively significant improvement in TMJ pain, significant decrease in both MMO and joint sound. Besides that, TMJ locking was not observed in any patient during the follow-up period. There were no statistically significant differences throughout the study intervals between the groups. CONCLUSION: It was concluded that there was no significant difference between control group and dextrose groups and there is no superiority of any concentration of dextrose over the others in TMJ prolotherapy, and all treatment procedures were efficient in improvement of clinical symptoms related to TMJ hypermobility. If dextrose is used as a proliferant, it can be said that 10% dextrose can be sufficient in TMJ hypermobility treatment.

Effect of combination of trigger point injection and stellate ganglion block on non-odontogenic mandibular molar pain referred from masseter muscle: a case report.

We report a case of myofascial pain syndrome (MPS), manifested as nonodontogenic mandibular molar pain referred from the masseter muscle, relieved by a combination of trigger point injection (TPI) and stellate ganglion block (SGB). The patient was a 32-year-old woman who had experienced cold hypersensitivity in the right third mandibular molar 2 months prior to visiting our department. Subsequently, she had visited a family dentist and undergone pulpectomy under local anesthesia. She eventually visited our clinic because there was no marked change in her symptoms. On the first visit, no tooth abnormality was found and the patient was neither anxious nor depressive. Tender points were found in the right masseter and temporal muscles during muscle palpation. Referred pain radiating to the right mandibular molars was observed when pressure was applied to the central portion of the right masseter muscle. As a result, we diagnosed MPS based on evidence of nonodontogenic tooth pain caused by referred pain from the masseter muscle. We performed TPI with 2% lidocaine hydrochloride to the tender point in the masseter muscle. Although the visual analog scale (VAS) pain score dropped from 97 to 36, complete pain relief was not achieved. The TPI was effective for approximately 7 hrs, after which severe throbbing pain returned. The sustained nature of the tooth pain suggested that it was sympathetic nerve-dependent. Subsequently, we performed SGB, resulting in a reduction in the VAS pain score from 90 to 32. Therefore, we performed another TPI and the VAS pain score dropped to 0. We continued SGB and TPI for the next 3 days and the symptoms disappeared. Thus, a combination of TPI and SGB controlled MPS manifested as masseter muscle-mediated nonodontogenic tooth pain.

[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.

Laser therapy and needling in myofascial trigger point deactivation.

The aim of this study was to evaluate different approaches to deactivating myofascial trigger points (MTPs). Twenty-one women with bilateral MTPs in the masseter muscle were randomly divided into three groups: laser therapy, needle treatment and control. Treatment effectiveness was evaluated after four sessions with intervals ranging between 48 and 72 h. Quantitative and qualitative methods were used to measure pain perception/sensation. The Wilcoxon test based on results expressed on a visual analog scale (VAS) demonstrated a significant (P < 0.05) decrease in pain only in the laser and needle treatments groups, although a significant increase in the pressure pain threshold was evident only for needling with anesthetic injection (P = 0.0469), and laser therapy at a dose of 4 J/cm² (P = 0.0156). Based on these results, it was concluded that four sessions of needling with 2% lidocaine injection with intervals between 48 and 72 h without a vasoconstrictor, or laser therapy at a dose of 4 J/cm², are effective for deactivation of MTPs.

Botulinum injection for the management of myofascial pain in the masticatory muscles. A prospective outcome study.

We prospectively analysed the outcome after botulinum injection in patients who did not recover after conservative measures to manage masticatory myofascial pain, and who were not willing to take low dose tricyclic antidepressants as a muscle relaxant. We prospectively 62 patients were assessed with visual analogue scores (VAS) for pain on the affected side before, and 6 weeks after botulinum injection(s) (50 units Dysport in up to 3 sites), and measured mouth opening in mm. Of those treated 49 (79%) showed at least some improvement (pain reduced by more than 25%). Patients reported more than a 90% reduction in the VAS for 25 (30%) of the 84 sides of the face treated. Only 22 of the 62 patients had more than one course of treatment to the same side. Interincisal distance improved by a mean/median of 0.9 mm (p<0.03) after treatment. Side effects included 3 cases of temporary weakness of a facial muscle. Ranking the VAS pain scores using the Wilcoxon test before and after injection showed a significant reduction in pain (median change -29.5, interquartile range -53 to -16, p<0.0001). The treatment significantly improved patients' pain scores and the overall mean/median reduction in pain was 57%. Botulinum injection does not guarantee complete resolution of myofascial pain, but it usually has some beneficial effect in improving the symptoms, and should be considered as an alternate treatment for masticatory myofascial pain if conservative methods have failed.

Enhancing the efficacy of treatment for temporomandibular patients with muscular diagnosis through cognitive-behavioral intervention, including hypnosis: a randomized study.

OBJECTIVE: This study evaluated the efficacy of a cognitive-behavioral therapy (CBT), including hypnosis, in patients with temporomandibular disorders (TMDs) with muscular diagnosis. STUDY DESIGN: Seventy-two patients (65 women and 7 men with an average age of 39 years) were selected according to the Research Diagnostic Criteria for TMD, and assigned to the experimental group (n = 41), receiving the 6-session CBT program, and the control group (n = 31). All patients received conservative standard treatment for TMD. The assessment included pain variables and psychologic distress. RESULTS: There were significant differences between the groups, the experimental group showing a higher improvement in the variables evaluated. Specifically, 90% of the patients under CBT reported a significant reduction in frequency of pain and 70% in emotional distress. The improvement was stable over time, with no significant differences between posttreatment and 9-month follow-up. CONCLUSIONS: CBT, including hypnosis, significantly improved conservative standard treatment outcome in TMD patients.

Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique.

A randomized controlled trial was performed to compare the short-term effectiveness of botulinum toxin injections and physiatric treatment provided by means of Fascial Manipulation techniques in the management of myofascial pain of jaw muscles. Thirty patients with a Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) diagnosis of myofascial pain were randomized to receive either single-session botulinum toxin injections (Group A) or multiple-session Fascial Manipulation (Group B). Maximum pain levels (VAS ratings) and jaw range of motion in millimeters (maximum mouth opening, protrusion, right and left laterotrusion) were assessed at baseline, at the end of treatment, and at a three-month follow-up. Both treatment protocols provided significant improvement over time for pain symptoms. The two treatments seem to be almost equally effective, Fascial Manipulation being slightly superior to reduce subjective pain perception, and botulinum toxin injections being slightly superior to increase jaw range of motion. Differences between the two treatment protocols as to changes in the outcome parameters at the three-months follow-up were not relevant clinically. Findings from the present investigation are in line with literature data supporting the effectiveness of a wide spectrum of conservative treatment approaches to myofascial pain of the jaw muscles. Future studies on larger samples over a longer follow-up span are needed on the way to identify tailored treatment strategies.

Trigger point injection therapy in the management of myofascial temporomandibular pain.

OBJECTIVES: Myofascial pain is the most common temporomandibular disorder. The objective of this study was to compare the effectiveness of combined treatment modalities in the management of myofascial temporomandibular pain. METHODS: Fifty patients (44 female, 6 male) clinically and radiologically diagnosed with myofascial temporomandibular disorder (TMD) were selected for the study and randomly assigned to two groups of 25 patients. Group 1 patients were treated with stabilization splint (SS) and Group 2 patients were treated with trigger point injection combined with SS therapy. RESULTS: Positive improvement in overall signs and symptoms with statistically significant differences was observed in both groups. Group 2 showed significant reduction in visual analogue scale (VAS) scores, and statistical analysis revealed a significant difference between the VAS scores of Group 1 and Group 2 at the 4th and 12th weeks of treatment follow-up (p<0.001). CONCLUSION: Our results indicate that trigger point injection therapy combined with splint therapy is effective in the management of myofascial TMD pain. Further research, especially randomized controlled trials, should be carried out to ascertain its effectiveness over other treatment modalities.

Neuro-reflexotherapy for the management of myofascial temporomandibular joint pain: a double-blind, placebo-controlled, randomized clinical trial.

PURPOSE: To assess the efficacy of neuro-reflexotherapy intervention (NRT) for treating temporomandibular joint dysfunction attributed to myofascial pain. Neuro-reflexotherapy intervention consists of the temporary implantation of epidermal devices in trigger points in the back and ear. It has shown efficacy, effectiveness, and cost-effectiveness in treating subacute and chronic common back pain. No study, however, has explored its efficacy in treating myofascial temporomandibular joint pain (MF/TMJP). PATIENTS AND METHODS: This was a randomized, double-blind, placebo-controlled trial. Patients with MF/TMJP for more than 3 months in spite of conservative treatment, and with no evidence of major structural damage in the joint, were recruited at the Maxillofacial Department of the Hospital Clínico Universitario, a teaching hospital in Madrid, Spain. Patients were randomly assigned to an intervention group and to a control group. Patients in the treated group underwent 2 NRTs, immediately after baseline assessment and 45 days later. Sham interventions in the control group consisted of placement of the same number of epidermal devices within a 5-cm radius of the target zones. In both groups, conservative treatment during follow-up was allowed and recorded. Patients underwent clinical evaluations on 4 occasions: 5 minutes before intervention, 5 minutes after intervention, and 45 and 90 days later. The preintervention assessment was performed by the physician at the hospital service who included the patient in the study. The 3 follow-up assessments were performed independently by 1 of 2 physicians who had no connection with the research team, and who were blinded to patients' assignments. The primary outcome variable was level of pain severity during jaw movements at the last assessment (90 days), and the key comparison of interest was change in pain over time (pain levels at baseline and at 90 days). Level of pain was measured using a visual analog scale (VAS). RESULTS: Fifty-one patients with MF/TMJP were recruited into the study. Random assignment allocated 27 patients to the intervention group, and 24 to the control group. Differences in pain severity in favor of the intervention group appeared immediately after the intervention, persisted for 45 days, and increased after the second intervention. Differences at last follow-up were highly clinically and statistically significant (4 to 5 points on the VAS, P = .000), allowing for patients in the intervention group to cease drug treatment (P = .005). There were no differences in the evolution of crepitus or clicking in the joint. There were no clinically relevant side effects associated with the intervention. CONCLUSIONS: For patients in whom conservative treatment has failed, NRT improves the chronic pain associated with MF/TMJP syndrome.

Meal pattern changes associated with temporomandibular joint inflammation/pain in rats; analgesic effects.

Establishing a valid animal model to study temporomandibular joint (TMJ) pain has proven extremely difficult. Using complete Freund's adjuvant (CFA) to induce TMJ inflammation, we recently showed that meal pattern analysis could be used as a noninvasive biological marker to study TMJ pain in an animal model. The purpose of this study was to further validate our animal model by determining whether aspects of CFA-induced TMJ inflammation/pain are reversed with ibuprofen (IBU) treatment. In the first trial, 48 male rats were used and in the second trial, 32 female ovariectomized rats, given 17beta-estradiol replacement, were used. The rats were assigned to one of four groups: control (CON-CON); control+IBU (CON+IBU); CFA-CON; and CFA+IBU. In the male trial, CFA injection (P<.01) caused TMJ swelling and chromodacryorrhea (CFA-CON); IBU eliminated these changes in the CFA+IBU group. Meal pattern analysis showed the pertinent CFA-induced change and the IBU effect was that meal duration was increased in the CFA-CON group (P<.01), but normal in the CFA+IBU-treated group on the first, but not second, day postinjection. In the female trial, CFA increased TMJ swelling, but did not cause significant chromodacryorrhea (CFA-CON); IBU eliminated swelling in the CFA+IBU group. Meal duration was increased (P<.01) in the CFA-CON group, but was normal in the CFA+IBU-treated group on both the first and second days postinjection. In both trials, interleukin-1beta (IL-1beta) levels were increased similarly in CFA-CON and CFA+IBU groups (P<.01). This study shows that CFA-induced TMJ inflammation/pain can cause changes in meal patterns (i.e., meal duration), which may be used as a behavioral marker for TMJ inflammation/pain.

The effects of collagen hydrolysat on symptoms of chronic fibromyalgia and temporomandibular joint pain.

Twenty (20) people who had medically diagnosed fibromyalgia for two to 15+ years participated in and completed a 90-day evaluation to determine effects of collagen hydrolysat on symptoms of chronic fibromyalgia, with twelve reporting temporomandibular joint pain. Collagen hydrolysat is a food supplement that is available without prescription, with no known side effects. Participants were evaluated initially and then at 30-, 60-, and 90-day periods. Final results were obtained and comparisons made. The average pain complaint levels decreased significantly in an overall group average, and dramatically with some individuals. It was concluded that patients with fibromyalgia and concurrent temporomandibular joint problems may gain symptomatic improvement in their chronic symptoms by taking collagen hydrolysat.

Pain-pressure threshold in painful jaw muscles following trigger point injection.

Pain and tenderness at trigger points and referral sites may be modified in subjects with myofascial pain in the head and neck region by injecting local anesthetic into active trigger points, but the effect of injection on jaw muscle pain-pressure thresholds has not been measured. The mechanism by which trigger-point injection affects muscle tenderness is also unclear and may be related to the "hyper-stimulation analgesia" induced by stimulation of an acupuncture point. A pressure algometer was used before and after an active trigger point injection in the masseter to measure the pain-pressure threshold in the masseter and temporal muscles of 10 subjects with jaw muscle pain of myogenous origin. The pain-pressure threshold in the masseter and temporal muscles was also measured in a matched control group before and after an acupuncture-point injection in the masseter. The pain-pressure threshold was significantly lower in myofascial pain subjects than in control subjects at all recording sites. Pain-pressure thresholds increased minimally in the masseter after trigger-point injection, whereas the temporal region was relatively unaffected. In the control group, the pain-pressure threshold increased significantly at all recording sites in the masseter after acupuncture-point injection. Although local anesthetic injection acts peripherally at the painful site and centrally where pain is sustained, pain-pressure thresholds were not dramatically increased in myofascial pain subjects, in contrast to controls. This suggests that in subjects with myofascial pain, there was continued excitability in peripheral tissues and/or central neural areas which may have contributed to the persistence of jaw muscle tenderness.

Laser helio neon en el tratamiento del dolor articular temporomandibular / Heliu laser in the treatment of temporomandibular joint pain

Se presenta un estudio en 30 pacientes con diagnóstico de síndrome dolor disfunción temporomandibular de causa articular que fueron organizados en 3 grupos, según el tratamiento recibido. Grupo A: tratamiento con medicamentos ; grupo B :tratamiento con radiación láser helioneón: Grupo C: tratamiento combinado de medicamentos y radiación láser helioneón. Se comparan los resultados obtenidos en cada grupo de estudio; se observa mayor efectividad y permanencia del efecto analgésico logrado con la radiación láser helioneón y la combinación de fármacos con helioneón

Laser helio neon en el tratamiento del dolor articular temporomandibular / Helium laser in the treatment of temporomandibular joint pain

Se presenta un estudio en 30 pacientes con diagnóstico de síndrome dolor disfunción temporomandibular de causa articular que fueron organizados en 3 grupos, según el tratamiento recibido. Grupo A: tratamiento con medicamentos ; grupo B :tratamiento con radiación láser helioneón: Grupo C: tratamiento combinado de medicamentos y radiación láser helioneón. Se comparan los resultados obtenidos en cada grupo de estudio; se observa mayor efectividad y permanencia del efecto analgésico logrado con la radiación láser helioneón y la combinación de fármacos con helioneón

Diagnosis and treatment of myofacial pain-dysfunction (MPD) syndrome.

The successful management of patients with MPD syndrome is dependent on establishing an accurate diagnosis and using proper therapy based on an understanding of the etiology of the disorder. Establishing an accurate diagnosis is accomplished by taking a careful history, doing a thorough examination, and having a knowledge of the various other conditions that can produce signs and symptoms similar to those of MPD syndrome. Using proper therapy is related to recognition that MPD syndrome is a stress-induced psychophysiologic disease originating in the muscles of mastication and not an organic disease arising in the temporomandibular joint. Thus, therapy should be directed at reducing stress, relaxing tense jaw muscles, and creating an awareness by the patient of the causes of the problem, rather than at analyzing occlusion, measuring joint spaces, and producing irreversible structural changes in the dentition and the articulation. Because good results can be achieved with these uncomplicated, reversible forms of therapy, it is important that the clinician does not succumb to an unproven fad or use of an irreversible procedure that will not achieve better results.