Impact of Ibruprofen Medication and Prosthetic Esthetical Treatment in Elderly Patients with Temporal Mandibular Joint Disorders and Deppresion

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1 Impat of Ibruprofen Mediation and Prostheti Esthetial Treatment in Elderly Patients with Temporal Mandibular Joint Disorders and Deppresion LAURA ELISABETA CHECHERITA 1, LUCIAN STEFAN BURLEA 2 *, OVIDIU STAMATIN 3 *, DANIELA MANUC 4 1 Grigore T. Popa University of Mediine and Pharmay, Faulty of Dental Mediine, Department of Odontology, Periodontology and Fixed Prosthesis, 16 Universitãii Str., , Iasi, Romania 2 Grigore T. Popa University of Mediine and Pharmay, Faulty of Dental Mediine, Department of Oro-Maxillo-Faial Surgery, 16 Universitãii Street, , Iasi, Romania 3 Carol Davila University of Mediine and Pharmay, Faulty of Dental Mediine, Department of Publi Health, 8 Eroii Sanitari Str., , Buharest, Romania Affetions of temporomandibular joint (TMJ) an lead to imbalanes and disfuntions named temporomandibular desorders (TMDs). Elderly people with TMDs are experiening more severe phenomena due to instability entri relationship, edentation, hypotonia, and ranio-mandibular malrelations, neurologi and hroni diseases. The aim of this study is to investigate the effiieny of the anti-inflamatory treatment followed by prostheti, estethi and gnathologi treatment in elderly. This is a prospetive study, based on data obtained from 410 elderly people, 74 female and 33 male gender subjets. In the studied group we found a high prevalene of pain (42.99%) and artiular affetation (25.23%) whih is due both to the grade of edentation and to ompliations of it, also the musular affetation, headahe, modifiation of the ranialmandibular relations, psyhologial affetation. The prevalene of depressive manifestations was high (35.51%) and after the ibuprofen treatment in assoiation with prostheti treatment was ompleted dereased (at 23.36%) in the elderly subjets. In onlusion, the anti-inflamatory treatment followed by prostheti treatment and also esthetial one determined the improved outomes of the TMDs in elderly patients, not only in terms of pain and depression but also linially, meaning at the TMJ funtion and in all the intraoral and faial aspets. Keywords: publi health, dysfuntional syndrome of stomatognati system (SDSS), the temporal-mandibular joint (TMJ), prostheti treatment, temporomandibular disorders (TMDs) Population aging is an undeniable fat people aged over 65 representing 10-15% of the population for most of the European ountries [1]. In Romania, the demographi data on 1 January 2012 showed that the share of persons aged 60 years and over was 21% of the total population. The geriatri population inrease and their speifi pathology explain the high onsumption of medial servies and mediines registered in the last 10 years [2]. Temporal-mandibular disorders (TMDs) has been desribed as a luster of disorders haraterized by pain in the preauriular area, in the jaw and fae, mastiatory musles and other musles of the head and nek, limitation or deviations in mandibular range of motion, and liking of the TMJ during mandibular funtion [3]. Elderly people are experiening more severe phenomena due to instability entri relationship, edentation, hypotonia, and raniomandibular altered relationships, neurologi and hroni diseases [3]. Affetions of TMJ an lead to imbalanes and disfuntions named algo-disfuntional syndrome (SDSS). A person is onsidered to have a temporalmandibular disorder only if pain or limitation of motion is enough severe to make them seek professional are. Experimental part Iasi County had, at 1 January 2016, 919,049 inhabitants, of whih 19.8% were people aged 60 and over (60+). Extrapolating the prevalene of TMJ affetions (ode K 07.6 in the International Classifiation of Diseases ICD-10, 2013), this population would result in an estimated number of 48,313 elderly people affeted by this pathology, only in Iasi County [4]. Therefore, the sientifi interest in elderly TMJ disorders and the onsideration of this pathology as * luianburlea@yahoo.om, stamatinovidiu@yahoo.om the priority publi health issue in dentistry, whih requires speial attention from professionals in the field, is justified. Aim and objetive of the study The aim of this study is to investigate the effiieny of the anti-inflamatory drug treatment (fig. 1) vs. Prostheti estethial and gnathologi treatment of the TMJ disorder in elderly patients. One of the affetions that we will take into onsideration in this study is the temporal-mandibular arthrosis, whih is, in fat, the most frequent pathology at this level in the elderly patients, and to whih we will measure the pain before and after the administration of the anti-inflammatory therapy. To relieve pain and inflammation of the TMJ and musles was used ibuprofen (fig. 1). Ibuprofen is a non-steroidal analgesi and antipyreti anti-inflammatory drug and anti-platelet; is reommended for mild and moderate pain. It is administered orally, analgesi mg per day; as anti-inflammatory mg daily, divided into 3-4 outlets. Fig. 1. Chemial formula for Ibuprofen Materials and methods This is a prospetive study, based on data obtained from 410 elderly persons, between and from Iasi County, who were addressed at two private dental offies and at the Mihail Kogalnieanu Clinial Eduation REV.CHIM.(Buharest) 69 No

2 Base, of Iasi. We lost from the study, 7 (1.71%) elderly people by hanging their domiile (5 persons) or death (2 persons), the final response rate being 98.29%. The studied group involved 403 elderly people (161 men and 242 women). Of these, 107 elderly people aged years (mean age: ± 8.37 years) were diagnosed with TMDs: 74 female and 33 male subjets. Data onerning physial and mental health were retrieved from patients with painful TMDs aording to the researh diagnosti riteria [5]. The inlusion riteria for the patients in our study were: all patients had to have experiened pain omplaints in the temporal-mandibular region, the presene of musular tonus and musular ontration alterations, musular dysfuntion (pain at the level of stomatognati system and ephali extremity, limitation of mouth opening, and deviation of mandible from the medial line during the opening, fatigue of ephali extremity musles and funtional alteration of stomatognati system). Partiipants admitted or keeping follow-up appointments were also inluded. The exlusion riteria of the patients were represented by the presene of TMJ afflition, trauma [6, 7], rheumatoid arthritis [8] and neoplasm [9, 10]. Exlusion riteria were also: refuse of the patient to partiipate, unooperative patients or those who did not respet the presribed treatment. We start the evaluation with the questionnaires for: a) subjetive symptoms of TMD [5, 11]; b) pain (Graded Pain Sale, version 2.0) [11-13]; ) depression [14, 15]. The elderly patients answered at questions related to TMDs symptoms, whih afforded a lassifiation of eah subjet regarding the presene and severity of suh dysfuntions [11]. For this study there were taken into onsideration the symptoms of the patients, whih determined their addressing to the dotor. Symptoms Questionnaire of TMJ disorders were assessed aording to the 1-4 Likert sale whih has: 1 = no symptoms, 2= mild TMJ hanges (suh as TMJ sounds, feeling of fatigue in the jaws, and feeling of stiffness in the jaws on awakening or on movement of the lower jaw), type 3=moderate TMJ hanges (like diffiulties in opening the mouth wide) and type 4=severe TMJ hanges (suh as loking, subluxations, pain on movement of the lower jaw, pain in the region of the mandible or in the musles in the last 30 days). Nowadays, it is reognized that pain is influened by a dynami interation between physial, psyhologial and soial fators. The most ommon TMD symptom is the pain, whih appears in front of the ear or near to it, with propagation towards the heeks, nek or shoulder. In elderly people, the TMJ hroni pain is disabling and an impair ognitive funtions suh as onentration and memory, disrupt the sleep yle, produe hanges in personality, lead to a derease in ativities of daily living and stop people to partiipate in soial ativities [16]. Depression is defined as a state of low mood and aversion to ativity whih have a negative effet on a person s thoughts, behavior, feelings and sense of well-being [17]. Geriatri Depression Sale (GDS) - is a depression sreening test for the elderly persons [18]. It is a simple test in whih the elderly (with and without a history of depression) has to answer (affirmative/ negative) to a set of questions that explore the presene of symptoms that our to depressed people. Over 5 sores indiating the presene of depression, and a sore above 11 requires a speialist assessment. We mention that the diagnosis of depression in the elderly remains a problem beause often the symptoms are masked, negated by the patient or entourage, there are frequent somatization of the disease or ognitive disorder as its main manifestation [14, 15]. The seond step of our study was a TMJ objetive examination for linial signs and a musular examination. Diagnosti of TMD are based on a standardized linial examination [5]. All 107 elderly patients were introdued in the Mihail Kogalnieanu Clinial Eduation Base, of Iasi for prostheti estethial and gnathologi treatment. The methodology of linial and paralinial examination was applied, inluding the TMJ and olusion examination, as well as TMJ tomography. An objetive examination of the TMJ has been realized by inspetion, palpation and ausultation. Pretragienial areas are statial and dynamial examined, both of the TMJs, firstly separate and then simultaneously for omparison. Any stati or dynami deformation of the unilateral or bilateral pretragienial area has been registered both, in mandibular rest or in olusion and movement. During the artiular examination, the patient was ordered to exeute losing movements, opening movements, aperture movements, laterality, protrusion with a frequeny that shall not be tiring and whih permits the areful observation. The presene of liks in the TMJ during opening and losing of the mouth was observed with the aid of a stethosope plaed near the external ear [5]. The examination of the musles is made by inspetion and palpation in order to determine the painful points and the irradiation areas. Any painful areas, trigger areas with determinations at distane, as they are noted in the observation paper, irumsribing the painful area at diret palpation, trigger area, irradiation area. The examination of the musles in dynami aims to detet the pain provoked by ontration, symmetri and equal partiipation in the realization of the mandibular dynami. In our study, we administered antiinflammatories frequently used in the TMJ treatment as ibuprofen mg/day, aording to reent studies, for a period of 7 days (maximum 14 days). For all patients, we used the lowest effetive dose and shortest treatment duration to ontrol the symptoms. Variables In our study, the demographi and soio-eonomi fators, onsidered as independent variables was: age, gender (male/female), soial environment (rural/urban), marital status and the personal monthly inome. As dependent variables has been taken: the general health indiators (pain and depression), the symptoms of TMJ disorders, the results of objetive examination for linial signs and a musular examination and the use of dental prosthesis. The statistial analysis was performed with the SPSS software pakage for Windows [19]. The obtained data allowed for the lassifiation of patients with respet to gender distribution, age groups, area of origin, linial aspets, type of treatment instituted and appreiation of pain and depression. To assess the signifiane of the identified differenes we performed the Chi-squared test (Pearson χ 2 ); p values 0.05 were onsidered to be statistially signifiant [20, 21]. Patients were informed about the study and the ontent of the questionnaire. When patients were willing to partiipate, they were requested to fill an informed onsent. The study was approved by Institutional Committee of Researh Ethis. REV.CHIM.(Buharest) 69 No

3 Results and disussions General harateristis In our study were inluded 107 elderly patients: 74 (69.16%) female and 33 (30.84%) male gender (fig. 2). The elderly patients are divided depending on the soial environment. Thus, in our study there were 58 (54.21%) patients from the rural area and 49 (45.79%) patients from the urban area (fig. 3). Thereby, we lassified the elderly patients on age groups (table 1). Fig. 2. Gender distribution Fig. 3. Distribution based on soial environment Table 1 GENERAL CHARACTERISTICS OF STUDIED GROUP Table 2 SYMPTOMATOLOGY OF TMJ DISORDERS IN ELDERY- BEFORE TREATMENT REV.CHIM.(Buharest) 69 No

4 Table 3 SYMPTOMATOLOGY OF TMJ DISORDERS IN ELDERY- AFTER TREATMENT The alulated prevalene of TMDs was 26.55% in the studied group: 20.49% in male and 30.58% in female gender (between the two gender being a statistially signifiant differene, χ 2 =5.039, GL=1, p= ), the gender ratio being F/M=74/33= 2.24/1 (tables 2,3). Making a proper medial history of the elderly patient we revealed that a history of loal infetion is present in 9.35% (10) of patients, osteoporosis 19.63% (21) of the ases, depression in 9.35% (10) of the ases and arthritis in 10.28% (11) of the ases (fig. 4). TMD symptomatology in elderly patients before versus after treatment was presented in figure 5. The holisti vision, the unitary, systemi oneption, supports the dis-homeostati theory in the generation of TMDs, the idea of the onjugate ation of triggering fators. Thus, we desribe the fators: artiular, musular, dental, periodontal and funtional [16]. It is a disorder of the temporal-mandibular artiulation, whih frequently determines patients to ask for treatment, beause the elderly persons usually do not realize the existene of the rakles or other funtional disorders. Fig. 4. Personal pathologial anteedents- in elderly patients Fig. 5. TMDs symptomatology prevalene in the elderly patientsbefore and after treatment Pain and the TMJ affetation Pain and TMJ funtion disorder reflet intra-artiular problems. In the studied group (table 2 and 3), we found a high prevalene of pain (42.99%) and artiular affetation (25.23%), whih is due both to grade of edentation (ompliations of it) and the haoti, unoordinated, funtioning of the stomatognathi musle system, espeially of the external pterygoid. Artiular pain is of variable intensity, starting with dull vivid pains, up to real uni- or bilateral pain, it appears at rest and an be exaerbated in motion, usually in the morning, disappearing after a few moves. It an also appear after lunh, as a result of the fatigue and joint soliitation. After the treatment with Ibuprofen it an be noted, in male gender, a derease (from to 21.21%) in the prevalene of artiular affetation, but it is statistially insignifiant (χ 2 =0.42, GL=4, p= ). After REV.CHIM.(Buharest) 69 No

5 treatment with Ibuprofen in female gender subjets is also a derease (from 24.32% to 17.57%) in the prevalene of joint damage, but it is statistially insignifiant (χ 2 =0.414, GL=4, p= ). Headahe attributed to TMJ disorders In male gender subjets, after a treatment with Ibuprofen, it an be noted a derease (from 36.37% to 15.15%) of headahe prevalene attributed to TMDs, it is a statistially signifiant derease (χ 2 =3.882, GL=1, p= ). Similarly to female gender subjets, was observed a derease (from 28.38% to 12.16%) of the TMDs headahe prevalene attributable to Ibuprofen treatment, statistially signifiant also (χ 2 =6.041, GL=2, p= ). The musular pain and affetation Signs and musular symptoms are predominant in the linial table, in elderly patients being almost impossible to learly establish the ause of the signs and symptoms, suh as TMJ patology or as a onsequene of edentulous. In our study, the prevalene of pain in mastiatory musles reported by elderly patients was high (32.71%). After treatment with Ibuprofen, it an be noted a derease (from to 12.12%) in the prevalene of musle pain reported by elderly male patients, statistially insignifiant (χ 2 =0.94, GL=1, p= ). Also, at female gender elderly subjets, after treatment with Ibuprofen, there was a derease (from 12.16% to 9.46%) in the prevalene of musle pain reported by the patient, it was a statistially signifiant derease (χ 2 =7.194, GL=1, p= ). The lear influene ould be studied after prostheti estetial and gnathologi treatment, when the influene would remain only in patients with TMDs. Affetation of the musular fator, important milestone in the orretitude of the ranial-mandibular fundamental relations will impliitly generate the installation of ranialmandibular relations. Psyhologially affetation Patients with persistent TMDs problems may suffer psyhologially and soially beause of pain and dysfuntion [22]. Failed treatments and reurrent pain episodes ontribute to stresses with a pattern of frustration and even depression [23]. At the beginning of our study, the prevalene of depressive manifestations was higher (33.33%), statistially signifiant (χ 2 =4.486, GL=1, p= ) in elderly males subjets with TMDs versus those without TMDs linially manifest (20.18%). After treatment with Ibuprofen followed by prostheti esthetial treatment, TMDs prevalene dereased to 21.22% [OR=1.9452, CI 95%= ( ), p=0.2393], the risk attributable to depression being Ar=48.59%. At the beginning of our study, the prevalene of depressive manifestations was high (36.47%) and in elderly women with TMDs versus those without TMDs (28.48%), but it was statistially insignifiant (χ 2 =2.258, GL=1, p= ). After treatment with Ibuprofen followed by prostheti estetial and gnathologi treatment, TMDs prevalene dereased (at 24.32%), [OR=1.1702, CI95%=( ), p=0.6216], the risk attributable to depression being in this ase low, Ar=14.54%. We mention that musular pain is the symptom that most ommonly assoiates with depression, leading to a viious irle by whih one auses it then maintains the other. Modifiation of the ranial-mandibular relations The relationship between TMD and malolusion is an extremely ritial issue in dentistry. Elderly people are the most affeted group of altered ranio-mandibular relationships. In male gender group, was observed a signifiant derease in the prevalene of modifiations of olusion after treatment with Ibuprofen followed by prostheti treatment (χ 2 =8.852, GL=2, p= ). And in female gender, there was a signifiant derease in the prevalene of modifiations of olusion after treatment with Ibuprofen followed by prostheti treatment (χ 2 =21.256, GL=2, p= ) inrease the olusion riteria. The ranio-mandibular relationships an be altered as a result of ation, frequently simultaneous and onjugated, of risk fators that an be orrelated with stomatologi system elements. This situation an also our due to the hypotoniity of the mosquito musles, a phenomenon espeially enountered in elderly peoples with neurologial and/or hroni diseases. The disturbane of tone and musle ontration will in time involve artiular, odontal, periodontal stress, all aggravating the altered ranio-mandibular relationships. Examination of the entri relation has a major impat in establishing the diagnosis of the stomatognathi system s dysfuntions. Interarh reports registered in entri relation will serve to detet the premature ontats (where appliable) in entri relation or at fitting models in the simulator. Modifiation of the main funtions: mastiatory, deglutition, physiognomi, phoneti and lathing ours in the whole group of patients, eah patient being total or subtotal edentulous, showing damage physiognomy, a selfmaintaining iruit, speaking problems, mastiatory issues or dysphagia for liquids and solids. In ase of dynami olusion the testing movement is realized, testing position with ontat at the level of all the inisors (normal) and a distal olusion (Cristhensen sagittal). It is observed the way in whih dynami olusion is in ompliane with mandibular dynami, artiular dynami or musular ontration [28]. Another variable taken into onsideration is the artiular mobility, and the third obvious sign are the rakles produed when using the artiulation, whih an be heard by the patient and also by the ones around him, but whih are not signifiant in the absene of the pain and artiular immobility. In our study, after Ibuprofen treatment, from the mobility point of view, artiular hypermobility an be found in 31 (28.97%) elderly patients, whih is muh more frequent that the limitation of the mandible movements, whih is present in 19 (17.76%) patients (fig. 6). Between the two parameters it is a statistially signifiant differene (χ 2 =3.758, GL=1, p=0.05). Fig. 6. Mobility in the TMJ REV.CHIM.(Buharest) 69 No

6 The improved health outomes of the elderly patients was not only in terms of pain and depression but also linially, meaning at the TMJ funtion. In elderly patients, the noninvasive therapies are learly preferred for most TMDs problems. Fig. 7. The prostheti and gnathologi treatment of the elderly patients They were questioned and evaluated after treatment about the pain threshold aording to VAS (Visual Analogue Sale) [8]. The effet of Ibuprofen is moderate at this time. The last evaluation was onduted after prostheti treatment ompletion. The effets of the antiinflammatories were preserved throughout the time of administration, without any signifiant hanges. It an also be mentioned that improved outomes was not only in terms of pain but also in terms of linial funtion of the TMJ [25, 26]. Another important parameter that we took into onsideration was the side effets of the antiinflammatories. They ause side effets inluding gastrointestinal (GI) disorders (from minor dyspepsia through to major ulers and bleeding), kidney effets and ardiovasular effets. In our study there were no usual side effets during the administration of any of the used drugs, with the ondition of respeting the basi rules. In onsidering the risk assoiated with non-presription use of the antiinflammatories, it is important to onsider three fators: safety at low doses, with short durations of treatment, and in populations with a low bakground risk of events [8]. Patients have been applied, simultaneously, different fix prostheti treatments, mobile, as well as relaxation mouth guards (fig. 7), an improvement of the quality of life of these patients being registered, as it follows: in 67.29% were applied aryli prostheses and in the rest, both fixed and mobile, in 2 (1.87%) ases being used the method of relaxation mouth guards. Only 11 patients (10.28%) rejet any kind of prostheti treatment. At the faial level, the appearane of the teeth and oral avity as a whole is of partiular importane, and by its morphology and omplexity of funtions, its physial and psyhologial signifiane is the dominant faial element. Psyhiatri disorders are seondary to body shape hanges (faial features, faet level, golden proportions and intraoral signs) due to the projetion of one s own body morphology, whih determines the degree of omfort of the individual in the report with the normal body omposition. Intraoral signs of edentation no longer orrespond to the normal image reated by induing onfusion that an ause psyhologial imbalane or depression [27]. Conlusions Our study found a high prevalene of TMD, onsidering the geriatri population studied and the results of other studies. Referenes 1.***. World report on ageing and health. WHO, Geneva, 2015, p. 14. ISBN: (PDF). 2. UNTU, I.; CHIRITA, R.; BULGARU-ILIESCU, D.; CHIRILA, B.D.; CIUBARA, A.; BURLEA, S.L. (2015). 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