Medical Care
Most temporomandibular disorders (TMDs) are self-limiting and do not get worse. Simple treatment, involving self-care practices, rehabilitation aimed at eliminating muscle spasms, and restoring correct coordination, is all that is required. Nonsteroidal anti-inflammatory analgesics (NSAIDs) should be used on a short-term, regular basis and not on an as needed basis. [14]
On the other hand, treatment of chronic TMD can be difficult and the condition is best managed by a team approach; the team consists of a primary care physician, a dentist, a physiotherapist, a psychologist, a pharmacologist, and in small number of cases, a surgeon. The different modalities include patient education and self-care practices, medication, physical therapy, splints, psychological counseling, relaxation techniques, biofeedback, hypnotherapy, acupuncture, and arthrocentesis.
Medications
Commonly used medications include NSAIDs, muscle relaxants, and tricyclic antidepressants. More recently, injections of botulinum toxin [15, 16] have been used, in some cases as an adjunct to arthrocentesis (see Arthrocentesis).
Ibuprofen and naproxen are commonly used NSAIDs. They work best when given on a regular basis for a period of 2-4 weeks with a gradual taper rather than a prn basis. Narcotics are reserved for patients with severe acute pain and should be used sparingly.
The commonly used muscle relaxants are diazepam, methocarbamol, and cyclobenzaprine. The lowest effective dose should be used initially. Adverse effects include sedation, depression and addiction.
Tricyclic antidepressants, in low doses, have been used effectively for a long time in chronic painful conditions. They act by inhibiting pain transmission and also may reduce nighttime bruxism. Amitriptyline and nortriptyline, in small doses, are the most common tricyclic antidepressants used for chronic painful conditions.
Botulinum toxin is used both as a single treatment [17] and in conjunction with arthrocentesis [18] (see Arthrocentesis). No controlled studies exist of the use of this medication in TMD. As noted in the article by Schwartz and Freund, care must be taken to isolate the muscle properly and inject appropriate doses. The authors know of no large-scale double-blind controlled trials on this subject, but some open-label studies have looked promising. A promising controlled study on facial pain associated with masticatory hyperactivity did show a significant benefit to botulinum toxin. [19] However, the patients were not diagnosed with TMD and it is not possible to tell which patients fulfilled diagnostic criteria for TMD.
Occlusal splints
These are known as nightguards, bruxism appliances, or orthotics. Various kinds of splints are available and can be classified into 2 groups—anterior repositioning splints and autorepositional splints. Physiologic basis of the pain relief provided by splints is not well understood. Factors such as alteration of occlusal relationships, redistribution of occlusal forces of bite, and alteration of structural relationship and forces in the temporomandibular joint (TMJ) seem to play some role.
Autorepositional splints, also known as muscle splints, are used most frequently. Some sort of pain relief is seen in as many as 70–90% of patients using splints. In acute cases the splint may be worn 24 hours a day for several months and as the condition permits, worn at night only.
Hyaluronic acid injections
There have been some recent musings in the literature about the effectiveness of this treatment for TMD. A meta-analysis was published that drew inconclusive results regarding the effectiveness of this treatment, citing that it seemed to be comparable to treatment with occlusal splints. This study did comment on the fact that there was a response compared to placebo, but more data needs to be accumulated and examined prior to drawing any conclusions concerning the effectiveness of hyaluronic acid injections for the treatment of TMD. [20] Another recent study examined the effectiveness of hyaluronic acid injections in various forms of osteoarthritis and they too came to the conclusion that its effectiveness is questionable and is not superior to intra-articular injections of corticosteroids. [21]
Surgical Care
The treatment of chronic TMD is difficult and it may appropriate during the course of the disease to discuss surgical treatment options.
Arthrocentesis
A 22-gauge needle is inserted gently in the superior joint space and a small amount of saline is injected to distend the joint space, after which the fluid is withdrawn and evaluated. The joint then is redistended and a second needle is placed in the same joint space to lavage the joint; steroids and/or local anesthetics can be injected into the joint space at the conclusion of the procedure.
Simple washing of the upper compartment of TMJ using arthrocentesis has been very effective in patients with a history of condylomeniscal incoordination; results have been comparable to those of arthroscopic surgery.
The benefit of this treatment brings into question the significance of disk position in the etiology of TMD.
Arthroscopic surgery
Indications include internal derangements, adhesions, fibrosis, and degenerative joint diseases.
It appears to be as efficient as open surgical procedure and has the added benefits of fewer severe complications and less surgical morbidity. [22] One retrospective short-term study found it to be safe, minimally invasive, and an effective treatment method, with 80% of patients reporting reduced pain and increased range of motion; in acute TMJ lock, however, arthroscopy and arthroscopic lysis and lavage of the upper compartment of TMJ produce comparable success rates.
In one study, only 10.3% of 301 patients who underwent arthroscopic lysis and lavage had complications. More than 80% of complications were otological in nature; neurological complications were seen in 5 cases—of which 3 were fifth cranial nerve injury and 2 were seventh cranial nerve injury.
Open surgery
Hemijoint replacement has been performed with good result in those patients with advanced osteoarthritis of the TMJ.
Total alloplastic replacement (arthroplasty) has been shown to provide a safe and effective treatment for reankylosis of the TMJ. [23]
Open surgery was the main surgical option in the 1970s and 1980s, and the most common procedure was disk repositioning and plication. In cases of severe disk damage, procedures such as disk repair and removal were done using artificial or autogenous material.
Myrhaug technique: Described in 1951, this procedure, by resecting the temporal condyle, creates a permanent and reducible chronic dislocation of the joint. One study found 70% good or excellent results in 60 patients. The main indications include (1) TMD not responding to all other treatments and (2) chronic subdislocations of one or both TMJ.
Consultations
See the list below:
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Physical therapy: Apart from patient education and pain control, the main goal of physical therapy is to stabilize the joint and restore its mobility, strength, endurance, and function. Common modalities used to accomplish these goals are the following:
Relaxation training using electromyographic (EMG) biofeedback: The patient first is educated about the contribution of stress and muscular hyperactivity to pain. An EMG monitor provides instant feedback to patients about the state of their muscle activity and allows the patient to easily correlate pain with hyperactivity of the muscles and decrease in pain with relaxation.
Friction massage: The hypothesis is that temporary ischemia and resultant hyperemia, produced by firm cutaneous pressure during massage, helps inactivate trigger points. Friction massage also may help disrupt small fibrous adhesions in the muscle formed as a result of surgery, injury, or prolonged restricted motion.
Ultrasonic treatment: ultrasonic waves produce tissue heating at a deeper level than moist heat; this increase in local tissue temperature leads to increase in blood flow and removal of metabolic byproducts responsible for pain and may help decrease adhesions by disrupting collagen cross-linkage. It also may help decrease intra-articular inflammation. To be effective, ultrasonic treatment should be done every other day, using about 1 watt/cm2 for approximately 10 minutes over the affected muscles and joints.
Transcutaneous electronic nerve stimulation: Electronic stimulation of superficial nerve fiber overrides the pain input from mastication muscles and TMJ, causing release of endogenous endorphins. In some patients it provides longer duration of pain relief than the time during which the stimulation is actually applied.
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Cognitive-behavioral treatment: This consists of hypnosis, cognitive coping skills, and relaxation. Hypnotic susceptibility correlates with reductions in reported pain.
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Psychology: Chronic painful conditions worsen any preexisting anxiety or depression. In appropriate settings, psychological counseling may provide benefit.
