Lecture 11. TMD Management PDF

Temporomandibular Joint Disorders: Management Occlusion 22-26/12/2024 First Semester 2024 Dr Ibrahim Khatib DDS MClinDent MPros Outline Quick revision Non surgical management Self Management Physical therapy...

Temporomandibular Joint Disorders: Management Occlusion 22-26/12/2024 First Semester 2024 Dr Ibrahim Khatib DDS MClinDent MPros Outline Quick revision Non surgical management Self Management Physical therapy Pharmacological therapy Occlusal appliances According to the Glossary of Prosthodontic Terms, temporomandibular disorders (TMD) are defined as conditions producing abnormal, incomplete, or impaired function of the temporomandibular joints. We always start with conservative non surgical management before progressing to more invasive treatment modalities Treatment should be tailored to individual patients and should take into consideration the history of the presenting complaint Non surgical management  Self management There is now consensus in the literature that the initial management strategy for patients with TMD should involve reversible self-management protocols. Patient education Awareness of parafunctional behavior Thermal therapy Massage Relaxation techniques  Self management Patient education: It is important to explain to patients that despite self- management strategies, some symptoms may persist, such as clicking. Dental practitioners should be able to provide reassurance, a clear explanation of the diagnosis, tailored advice to raise awareness of parafunctional activity and sensitively identify any potential psychological factors.  Self management Patient education should be delivered using simple and understandable language and should include the following: the nature of the condition predisposing, precipitating and prolonging factors anatomy of the TMJ management strategies and goals of therapy. There is good evidence that educating patients about their condition can in itself be effective in reducing pain. Those patients with temporomandibular hypermobility (subluxation) should be advised to avoid ‘end of range’ mouth opening positions, for example during yawning. Placing the tongue on the palate during yawning will limit movement during this action.  Self management Awareness of parafunctional behavior: Patients should be informed of any potential parafunctional behaviors, and recommended to monitor and avoid any behaviors that exacerbate their symptoms. Avoiding habits, such as unilateral chewing (where possible), chewing pens, nails and gum, can minimize stresses on the masticatory system. It is important that patients learn to keep their masticatory muscles relaxed by keeping their teeth apart, rather than in occlusion.  Self management Thermal therapy: Localized thermal therapy can be effective in relieving pain and relaxing muscles in myalgia patients, by encouraging vasodilation, which increases blood flow to the area. When symptomatic, the application of hot compresses to the painful muscle for at least 5 minutes, three times a day is useful (low evidence).  Self management Massage: Self-massage, in the form of kneading, friction and stretching should be limited to the area of discomfort or the tense masticatory muscle. Self-massage can improve blood circulation and reduce tension in the masticatory muscles. Relaxation techniques: Positive emotional states, self confidence, relaxation and beliefs that pain is manageable, may improve a patient’s pain experience.  Physiotherapy Physiotherapy helps to restore movement and function when someone is affected by injury, illness or disability. It focuses on exercises, stretches, and treatments like massage or heat therapy to heal injuries, manage conditions, or recover after surgeries. Physiotherapy is provided by specially trained and regulated practitioners called physiotherapists. Reversible and relatively low cost. Education and advice movement, tailored exercise and physical activity advice – exercises may be recommended to improve general health and mobility, and to strengthen specific parts of the body manual therapy – physiotherapist use their hands to help relieve pain and stiffness, and to encourage better movement of the body Physiotherapy Therapeutic goals: decrease pain aid muscle relaxation reduce muscular hyperactivity improve function improve quality of life Techniques used in physiotherapy Manual therapy Jaw exercises Stretching Postural training  Psychological Intervention If a patient discloses any underlying or associated mental health problems, it is important to ensure that they are already receiving appropriate support or that a referral to their general medical practitioner is made. Cognitive behavioral therapy: Cognitive Behavioral Therapy (CBT) is a structured, evidence-based form of psychotherapy that helps individuals identify and modify negative patterns of thinking and behavior. Cognitive behavioral therapy (CBT) aims to challenge and break down negative thoughts, and provide management strategies to improve state of mind. CBT can help patients reduce stress and anxiety, which are common triggers for TMD symptoms CBT alone is not better than other non-surgical interventions; however, it can complement management of TMD. Physical Therapy Includes: Therapeutic exercises Manual therapy Electrotherapy Transcutaneous electrical nerve stimulation (TENS) Low level laser therapy Acupuncture Physical Therapy Provides short term relief of symptoms. Therapeutic exercises: Aim to restore function by reducing inflammation, pain and muscular activity, and promoting repair and regeneration. There appears to be a distinct lack of consensus on the optimal exercise prescription, in particular the recommended frequencies, durations and intensities. TENS: Analgesic and muscle relaxing Safe and non invasive Small electrical pulses are delivered to the painful areas through electrodes Blocks transmission of pain signal Stimulates production of endorphins LLLT: Localized analgesic and anti-inflammatory effects through direct light irradiation without causing a thermal response Improves local blood circulation Acupuncture: Although limited, there is evidence to support that acupuncture provides a short-term analgesic effect in those with myofascial pain without restricted mouth opening  Pharmacological Therapy Taking a thorough medical history will help prevent drug interactions and adverse reactions, particularly in those with complex medical backgrounds. A broad range of medications has been suggested to help manage both acute and chronic TMD. Broadly speaking these can be categorized as: Analgesics Anti-inflammatories Muscle relaxants and anxiolytics Neuromodulatory agents Miscellaneous agents  Analgesics Opioid or non-opioid Paracetamol The most common non-opioid analgesic Paracetamol is a weak inhibitor of the cyclooxygenase (COX) enzymes 1 and 2. Reduces prostaglandin production resulting in its weak anti-inflammatory properties Reviews looking at its efficacy in chronic pain have questioned its benefit, showing that in isolation, paracetamol tends to provide inadequate analgesia. Opioids: Activate descending anti-nociceptive pathways to moderate pain signals codeine, tramadol, morphine, oxycodone and fentanyl. Long term use of opioids is controversial Significant side effects include respiratory depression, constipation, urinary retention, sedation and dependency Oxycodone has been suggested as the preferred choice for TMD because it is easier to titrate than morphine and has fewer side effects but it is highly addictive Anti-inflammatory NSAIDs: Commonly used for pain relief and control of inflammation Inhibit COX enzyme more potently than paracetamol Can be selective (celecoxib) or non selective for COX 2 Prolonged use can lead to significant side effects, such as peptic ulceration and acute kidney injury Ibuprofen is considered effective in the management of mild–moderate osteoarthritis; however, there is only limited evidence relating to degenerative TMJ disease or myofascial pain Time is required for these medications to achieve their full potential (3 weeks in one study) NSAIDs interactions Decrease lithium clearance --> Lithium toxicity Displace methotrexate from binding proteins, significant in cancer patients With ACE inhibitors, may cause acute kidney injury When given for long periods, may attenuate effect of antihypertensive drugs May cause severe bleeding in patients on blood thinners Corticosteroids Decrease production of PG and leukotrienes by blocking phospholipase A2. Can be injected into TMJ, taken orally, or applied topically. May be beneficial in pain reduction but are usually NOT recommended for TMDs due to their side effects. Side effects: Acute adrenal crisis Hypertension Electrolyte anomalies Muscle Relaxants The few controlled clinical trials generally show a limited benefit of these medications compared to no treatment controls, although a recent network meta-analysis did report a potential benefit from cyclobenzaprine. Result in drowsiness. Many systemic muscle relaxants carry significant side effects (e.g. dry mouth, sedation, depression, constipation, etc) Anxiolytics Benzodiazepines - reduce the excitability of neurons within the central nervous system by enhancing the activity of GABA. Results are conflicting, with both positive and negative outcomes, making it difficult to demonstrate a strong benefit. Can cause significant sedation and potential dependency. Only short-term prescriptions in acute presentations of myofascial pain are advocated. Botulinum Toxin A Bot-A is a potent inhibitor of presynaptic acetylcholine release, thus preventing muscle contractions. The effects of the toxin are temporary with maximal onset occurring around 1 month and synaptic inhibition overcome around 3 months. Offers only limited benefit, if any, over placebo alone. Being most accessible, the Temporalis and Masseter muscles are the most frequent targets. Neuromodulatory agents Good choice for patients that are refractory to splint therapy. More evidence exists for older therapeutics such as tricyclic antidepressants. They have the additional beneficial effects on orofacial pain, comorbid depression, and sleep disturbances. Selective serotonin reuptake inhibitors (SSRIs) have also been examined for their pain- relieving effects. Their benefits include a lower side-effect profile, but efficacy appears to be inferior and, paradoxically, they can induce bruxism. SSRI are also used with idiopathic facial pain. Some positive outcomes are reported for amitriptyline and gabapentin (anticonvulsant). It can be concluded that neuromodulators are best suited to situations resistant to conservative management. Occlusal Appliances Occlusal splints, also known as bite splints or night guards, are removable dental appliances typically made of acrylic or thermoplastic material. They are used to manage a variety of dental and musculoskeletal conditions by modifying the occlusal (biting) surfaces and altering the position of the mandible (lower jaw). May reduce TMD by separating the teeth, reducing joint loading, or restoring the vertical dimension of occlusion Can be fabricated from a soft or hard material Soft splints are usually referred to as ‘night guards’ Hard splints are usually referred to as ‘stabilization splints’ Appliances are used alongside other conservative measures such as self-management, physical therapies and pharmacological treatments. OSS: Maxillary - Michigan splint Mandibular - Tanner splint Splints can be soft or hard, full coverage or partial coverage, maxillary or mandibular, fabricated in MIP or CR Soft splints constructed out of thermoplastic polyvinyl and are more comfortable for the patient but may increase muscular activity therefore worsening TMD symptoms Hard splints are made from heat cured acrylic, are rigid, and durable but more difficult to adapt to Patients prefer maxillary splints over mandibular Soft/Resilient Splints Made from soft materials, these splints are often more comfortable but less durable than hard splints. Only an impression is needed, does not take the bite into account May encourage grinding or cause occlusal changes Indications: Often used as diagnostic splint or as a protective appliance in sports. Examples: Custom-made soft night guards. Stabilization Splints Full coverage splints fabricated from hard acrylic resin. Require maxillary/mandibular impressions, bite recorded in CR and a facebow transfer. These splints provide a flat surface that allows the teeth to contact evenly and disclude posterior teeth on lateral movements. The primary aim is to eliminate occlusal interferences and distribute occlusal forces evenly. Frequently provided to patients to protect teeth and restorations from fracture in bruxists Indications: Used to manage bruxism and TMDs Examples: Michigan splint, Tanner appliance. While the evidence is inconclusive, splints likely reduce pain and improve function A Cochrane review of 12 randomized controlled trials (RCTs) showed no significant advantage of an SS over any other active treatment (acupuncture, bite plates, biofeedback/stress management, visual feedback, relaxation, jaw exercises and placebo appliance) and only weak evidence for their effectiveness versus no treatment. (Al-Ani 2004) Splints protect the teeth from wear/fracture but DO NOT eliminate bruxism Occlusal Stabilisation Splints Key design features Constructed on the arch with the least amount of teeth to allow maximum number of occlusal contacts Provides full occlusal coverage with contact on every tooth simultaneously in centric relation Provides posterior disclusion on protrusive/lateral excursions Provides canine guidance on lateral excursions if possible, or group function on first premolar Provides shared incisal guidance in anterior excursions Anterior repositioning splints Designed to recapture anteriorly displaced disk in patient that are diagnosed with ‘disk displacement with reduction’. Not indicated in patient where the disk does not reduce! Evidence to support its use is limited and the appliance may cause remodeling of the condyle and a posterior open bite Bite is recorded at the position where the disk is recaptured by the condyle Anterior bite splint Partial coverage splint Discludes posterior teeth Long term use results in occlusal discrepancies due to over eruption of uncovered teeth Health hazard Indicated in acute TMD with limited mouth opening  References Pharmacotherapy in Temporomandibular Disorders: A Review (2017) Temporomandibular Disorders. Part 1: Anatomy, Aetiology, Diagnosis and Classification, Pete Clarke Temporomandibular Disorders. Part 2: Non-surgical Management, Martin James Temporomandibular Disorders. Part 3: Pain and Pharmacological Therapy, Funmi Oluwajana,