Evaluation of the efficacy of different treatment modalities for painful temporomandibular disorders

doi:10.1016/j.ijom.2019.08.010

International Journal of Oral and Maxillofacial Surgery

Volume 49, Issue 5, May 2020, Pages 628-635

https://doi.org/10.1016/j.ijom.2019.08.010 Get rights and content

Abstract

The purpose of this study was to clinically evaluate the efficacies of three treatment methods and to compare their outcomes in patients with painful disc displacement. The study group comprised 45 patients with unilateral temporomandibular disorders who fell into Axis I group II (with limited mouth opening) of the Research Diagnostic Criteria for Temporomandibular Disorders. Magnetic resonance imaging was used for definitive diagnosis. The patients were divided randomly into three groups according to the treatment method: splint therapy, splint therapy with ultrasound-guided arthrocentesis, and splint therapy with low-level laser therapy. Patients were followed up after treatment for 6 months. The groups were compared in terms of pain and functional jaw movements (unassisted mouth opening without pain, maximum unassisted mouth opening, and contralateral movements). At the end of treatment, functional jaw movements were significantly increased while pain values were significantly decreased in all groups (P < 0.05). Group 2 had a quicker improvement in terms of mouth opening scores at the end of the first month, and unassisted mouth opening without pain was found to be more than 35 millimetres in all groups at the end of 6 months. All treatment modalities showed effective results on pain and functional jaw movements in the treatment of temporomandibular disorders.

Section snippets

Materials and methods

This prospective clinical study was conducted with the approval of the local ethics committee (Marmara University Faculty of Dentistry, Department of Clinical Research Ethics Committee) and the Turkish Medicine and Medical Devices Agency. Written consent was obtained from the patients.

Based on data from a previous study¹⁸, a sample size of 45 subjects was calculated using G*Power version 3.1.9.2 (Heinrich-Heine-Universität Dusseldorf, Germany; power 0.95, a = 0.05, b = 0.05). A flow chart of

Results

The 45 patients included in this study ranged in age from 18 to 53 years (mean ± standard deviation, 29.9 ± 9.20 years). Of these 45 patients, 84.4% were female (n = 38) and 15.6% were male (n = 7). None of the participants dropped out of the study.

The average baseline values were comparable and there were no significant differences between the groups: UMO (P = 0.434), MMO (P = 0.367), CLM (P = 0.056), and pain VAS (P = 0.807) (Table 1, Table 2) (Figs ).

MMO and CLM increased while VAS scores decreased at all

Discussion

The diagnosis of TMD may occasionally be challenging because of potential pathologies that may occur in the neighbouring tissues or complicated anatomical structures of the joint. As a consequence, imaging of the hard and soft tissues, as well as a proper clinical examination, is clearly important.

MRI has a superior high resolution on soft tissue compared to other methods and is used as a gold standard imaging method in the diagnosis of disc displacement7, 8, 9. Pupo et al.²⁰ have reported that

Funding

This research was supported by the Marmara University Scientific Research Project Coordination Unit (SAG-C-DRP-091116-0490).

Competing interests

Nothing to declare.

Ethical approval

Marmara University Faculty of Dentistry, Department of Clinical Research Ethics Committee (2017-129); Turkish Medicine and Medical Devices Agency (10643207-511.06-E.227770).

Patient consent

Not required.

Acknowledgements

We thank Prof. Dr Filiz Mediha Pekiner for performing the ultrasound imaging and Prof. Dr Yasar Ozkan for performing the arthrocentesis in the group 2 patients.

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A systematic review and meta-analysis of randomized controlled trials comparing arthrocentesis with conservative management for painful temporomandibular joint disorder
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The aim of this study was to determine whether arthrocentesis is superior to conservative treatment in the management of painful temporomandibular joint disorders with restricted opening. A systematic review was undertaken of prospective randomized controlled trials (RCT) comparing arthrocentesis to conservative management, identified in the MEDLINE and PubMed databases. Inclusion criteria included a 6-month follow-up, with clinical assessment of the patients and painful restricted mouth opening. Data extracted included pain measured on a visual analogue scale and maximum mouth opening measured in millimetres. Risk of bias was assessed using the Cochrane Risk of Bias Tool 2 for RCTs, and a meta-analysis with the random-effects model was undertaken. Of 879 records retrieved, seven met the inclusion criteria; these RCTs reported the results at 6 months for 448 patients. One study had a low risk of bias, four studies had an uncertain risk, and two had a high risk of bias. In the meta-analysis, arthrocentesis was statistically superior to conservative management at 6 months for an increase in maximum mouth opening (1.12 mm, 95% confidence interval 0.45–1.78 mm; P = 0.001; I² = 87%) and borderline superior for pain reduction (−1.09 cm, 95% confidence interval −2.19 to 0.01 cm; P = 0.05; I² = 100%). However, these differences are unlikely to be clinically relevant.
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Subsequent to the initial screening, a total of 2449 relevant publications were identified. Twenty-six studies,3–28 published from January 2001 to June 2021, appeared to meet the inclusion criteria and were subjected to further examination. The flow chart of study selection is shown in Fig. 1.
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A prospective clinical cohort study was conducted among patients presenting to outpatient department of Oral and Maxillofacial Surgery at Maulana Azad Institute of Dental Sciences. The study sample was alternatively allocated into 2 treatment groups; Group I: modified condylotomy (MC) and Group II: high-condylar shave with eminectomy (HCSE). The primary outcome variables included pain on function, tenderness on palpation, and maximum mouth opening. The secondary outcome variables included joint sounds, jaw deviation on opening, maximum protrusive jaw movement, maximum ipsilateral jaw movement, and maximum contralateral jaw movement. The covariates were age, sex of the patient, duration of illness, the diagnosis based on Wilkes's staging, and the laterality (whether unilateral or bilateral). Descriptive, comparative, and regression analyses were conducted.
Twenty-one patients with Wilkes Stage II, III, and IV were included in the study (MC: 10 patients and HCSE: 11 patients). The mean age of the study sample was 32.67 (±11.66) years. Among 21 patients recruited in our study, 18 were females. It was observed that after 1-year follow-up, patients in Group I had significantly lower pain on function (0.30 ± 0.48) compared with Group II (3.00 ± 1.18). (P < .001). Similarly, tenderness on palpation was significantly decreased in Group I (0.80 ± 0.48) compared with Group II (2.45 ± 0.93; P < .001). Joint sounds were significantly lower in Group I (1.20 ± 0.63) compared with Group II (2.27 ± 0.90) after 1 year (P < .001). Maximum protrusive jaw movement and maximum ipsilateral jaw movement were significantly higher in Group I compared with Group II after 1 year.
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reported that there was a significant reduction in pain in the laser group compared to the placebo group in TMD patients, and there was no significant difference in chewing function between the two groups. Cetiner et al. [19]. found a statistically significant improvement in maximum mouth opening and pain in the laser therapy group compared to the placebo group in patients with myogenic TMD.
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Clinical PaperTMJ DisordersEvaluation of the efficacy of different treatment modalities for painful temporomandibular disorders

Abstract

Section snippets

Materials and methods

Results

Discussion

Funding

Competing interests

Ethical approval

Patient consent

Acknowledgements

Dent Clin North Am

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

Br J Oral Maxillofac Surg

Int J Oral Maxillofac Surg

Dent Clin North Am

Oral Surg Oral Med Oral Pathol Oral Radiol

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

Br J Oral Maxillofac Surg

Int J Oral Maxillofac Surg

J Oral Maxillofac Surg

Management of temporomandibular disorders and occlusion

Temporomandibular disorders diagnosis and treatment

Age-related differences in temporomandibular disorder diagnoses

Cranio

Prevalence of temporomandibular disorders discovered incidentally during routine dental examination using the Research Diagnostic Criteria for Temporomandibular Disorders

Oral Surg Oral Med Oral Pathol Oral Radiol

A study to determine the prevalence of temporomandibular disorders in a young adult population and its association with psychological and functional occlusal parameters

J Prosthodont

Clinical Paper
TMJ Disorders
Evaluation of the efficacy of different treatment modalities for painful temporomandibular disorders