Department of Stomatology and Maxillo-Facial Surgery, Catholic University of Louvain, Bruxelles, Belgium b

Transcription

1 Mædica - a Journal of Clinical Medicine EDITORIAL Current recommendations for the diagnosis of temporo-mandibular joint disorders Review paper Part two Herve REYCHLER a, MD, PhD; Serban Tovaru b, DDS, PhD a Department of Stomatology and Maxillo-Facial Surgery, Catholic University of Louvain, Bruxelles, Belgium b Department of Oral Medicine Oral Pathology, Faculty of Dental Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania ABSTRACT The present paper reviews current literature on evidence-based treatment guidelines for TMJ disorders. Treatment of TMJ disorders may be non-invasive and/or surgical. Key words: TMJ disorders, treatment guidelines, conservative treatment, surgical treatment INTRODUCTION T he disorders of the temporomandibular joint (TMJ) form a special group of problems, with a large number of symptoms which cause complex painful syndromes, characterized by a developing self-limiting stage of stable ostheoarthrosis, with a powerful psychological component (1), a special pathology and therapeutic measures which should be focused on the patient s own situation. The present diagnostic recommendations are mainly based on clinical evidence, because the complementary examinations only have a limited value due to the obvious lack of sensitivity and specificity. An MRI can be used to provide information, being the only technique which is able to show abnormalities of position and especially of mobility of the intra-articular disc. The part played by dental occlusion, previously controversial, has been settled as an ethiologic factor favoring but certainly not a determining element. This fact is crucially important for the therapeutic measures. The question that must be answered prior to any form of treatment is: what should be Address for correspondence: Serban Tovaru, DDS, MD, Department of Oral Medicine-Oral Pathology, Faculty of Dental Medicine, Carol Davila University of Medicine and Pharmacy, 19 Calea Plevnei, Zip Code , Bucharest, Romania address: serban.tovaru@gmail.com 130 Mædica A Journal of Clinical Medicine, Volume 3 No

2 done and especially what should not be done? The different forms of treatment, ranging from drug treatment, behavioral and kinetic treatments, to orthopedic and/or mechanical treatments by occlusal bite-guards and surgical treatment, should be taken into account. MEDICAL TREATMENTS Several drugs can be prescribed with good results, for their antialgic or muscular relaxing effects. Whereas analgesics are useful in the acute stages, the non-steroid antiinflammatory drugs, especially COX-2 (Celocoxib) (2) have proven to be particularly efficient in acute arthralgias. Muscle relaxant drugs have a certain, though limited, effect: in case of a chronic stage or of a relapse, the relaxing effect of anxiolytics will be beneficial. For the same reasons, some specialists recommend antidepressants in the above mentioned situations; nevertheless, these drugs are certain to have some effects on the patient s behaviour, all risks and benefits must be clearly explained. Local infiltrations are equally recommended in parallel with the general use of drugs. If the intra-joint infiltrations are excluded (especially because of the risk of cartilage lesions and of infections of the joint), recent literature emphasizes more often the excellent effect of intramuscular infiltrations of botulinic toxin. The recommended doses are, most commonly, 30 U in the lateral pterygoid muscle or in the masseter and temporal muscles, depending on the pain and/or the contraction. Due to such infiltrations, two cases (thus anecdotic) of suppression of a slipped disc for one year (5) have been reported. This treatment breaks a cycle (3) and seems useful in diminishing bruxism (66% of the patients reported an improvement) (4). Along with other non-invasive treatment, this medication has the main goal of alleviating the patient s pain, breaking the cycle of paincontractions-functional disability, as well as allowing the patient to complete other treatments kinesitherapy, occlusal bite-guards, for example. In any case, the use of such drugs should be limited to as short a period as possible. BEHAVIORAL TREATMENT Self-management of the therapeutic schemata by the patient is of critical importance: as far as the therapist is concerned, it requires a clear and accurate explanation of the symptoms, reassurance concerning the benign character of and the spontaneous improvement in his or her disorder, advice concering joint and muscle relaxation, awareness of the patient s bad habits, as well as relaxation of the musclejoint apparatus. If such a treatment is familiar to any therapist, it is, nevertheless, clear, that the kinesitherapist is the specialist best prepared to manage it. The kinesitherapist s advice will have a favourable impact during other forms of treatment, which are mentioned in the following paragraph. KINETHIC TREATMENT The principles of kinesytherapy used in the treatment of TMJ disorders are the following: a muscle relaxation (through thermotherapy and manual therapy: massage stretching trigger point) of the masticatory muscles as well as the muscles of the neck and the backside of the neck, the muscular chains that are further away but connected to the agonist and antagonist muscles, active and passive exercises (kinetic, noises, proprioceptors, re-programming, paradoxical breathing, lingual dysfunctions), exercises to correct cervical posture, teaching relaxation and selfrelaxation techniques. The effects of kinesytherapy are particularly beneficial in cases of miofascial pains through considerable reduction in the level of pain and a clear improvement in movement (6, 8). In case of non-reducible meniscal displacement the patient has less pain and a wider open mouth. In case of reducible displacement of the disc, an improvement in function was obtained (in 11% of cases, noises disappeared after 6 months) (9). The effect of kinesytherapy on the accufenes is random, hard to foresee and has no guarantee of success in the long run. OCCLUSAL BITE-GUARDS The aims of so-called mechanical therapy by means of occlusal bite-guards are the following: mandibular relaxation, suppression of Mædica A Journal of Clinical Medicine, Volume 3 No

3 control of the intermaxillary relations through the existing dental occlusion, suppresion of muscular contraction, disappearance of joint pain and rehabilitation of the position of the mandible (10, 11, 12). For this particular type of treatment, rigid or soft bite-guards can theoretically be used. Soft bite-guards are hardly ever used in the treatment of TMJ disorders because of their potential to change shape, difficulty of being polished, difficulty in getting an even, constant pressure and of the unconscious tensions they cause determined by fragility of the occlusal bite; on the other hand, they are frequently recommended in the treatment of nighttime bruxism. Rigid bite-guards have all the features for beneficial treatment of TMJ disorders. There are several types, only the most important will be discussed further the so-called Michigan bite-guards, the meniscal reduction guards and the retroincisive guide. The so-called Michigan bite-guard, placed on all the teeth on the upper maxilla, is made of hard, translucent resin, having neat occlusal surfaces and allows lateral and frontal canine guidance, but no incisive guidance; it must ensure good occlusal stability, with a minimum vertical size of the occlusion and a minimum oral crowding, for the patient s comfort; its only disadvantage is the fact that it must be made on an articulator (Figure 1). The guards for the repositioning of the mandible are different, according to the reducibility or non-reducibility of the meniscus. The guards for the repositioning of the mandible in the case of a reducible displaced meniscus (Figure 2) can be placed on the upper maxilla or on the mandible, in a therapeutic position on the TMJ level so as to obtain a more frontal and lower position of the condyle capitulum, which means an edge to edge incissor Figure 1. The Michigan byte-guard Figure 2. Repositioning bite-guard in case of reducible condylar luxation bite, with a consequent posterior inocclusion supported by the guard. The occlusal surfaces are indented. This type of guard must be worn permanently for 4 to 6 months. It results, at the end of the treatment, is a posterior dental inocclusion; its compensation is obtained in most of cases by prosthetic and rarely by orthodontic or by surgical means. Guards for repositioning the mandible in case of a non-reducible meniscal displacement disc is known decompression guard, which reduces the symptoms of a recent and/ or acute displaced disc. In theory, the posterior occlusal obstacle allows decompression of unilateral TMJ, which should, in turn, enable the disc to return to its correct position. Due to the lack of tissue elasticity which is characteristic of this stage, it must be admitted that the disc will most often remain in an incorrect anterior position and that the disc-ligament apparatus can be reshaped, leading to near-normal functioning of the mandible and to an asymptomatic stage. The retro-incissive guide (Figure 3) is an interocclusal device, conceived as a retroincisive plan from one upper canine connect to another, allowing only lower incisives and canines to have connection to the guide. This plan must be parallel to the bipupil ligne and the Camper treatment; it also creates a disocclusion of the posterior teeth. It is generally worn around the clock and adjustment is achieved by adding or removing resin in the lateral zones. 132 Mædica A Journal of Clinical Medicine, Volume 3 No

4 Figure 3. Retroincisive guide All the above mentioned non-surgical treatments have an 89% success rate after 10 months; success being measured in terms of pain, joint mobility, and buccal opening (6). Patients who do not respond to these conservative treatments have as a characteristic a painless limited buccal opening, of under 30 mm, also known as stuck disc (7). SURGICAL TREATMENT These involve arthrocentesis or joint rinsing, arthroscopy or arthrotomy with discpexis or discectomy. Unfortunatelly, literature is not very rigorous in the analysis of surgical results, so there are very few evidencebased scientific facts. Nevertheless, there are evaluation questionnaires which allow the Figure 4. Left TMJ arthrocentesis comparison of results in patiens from different countries and cultures (British, German, Japanese). Culture seems to play an important part in the way patients report symptoms of TMJ disfunctions: an even more important role seems to be the patients response to conservative treatment. There are some reports in literature emphasizing the correlation between the composition of synovial fluid (collected during surgery) and clinical TMJ disfunction. Thus, clinical symptoms are correlated with cytokins (15) (IL-1, TNF-alfa), Beta-glucorodinase (16), values of IgG and IgA. Arthrocentesis or joint rinsing (Fig. 4), is efficient in 90% of the patients after one year (17), but only in 26% of patients after 5 years (20). The procedure must be done under high pressure: the high pressure ensures better results than lower pressure (18). Three hundreed (300) ml are necessary to remove the inflammation products (19). The main indication remains non-responsiveness to conservative treatment (21). Surgical treatments (22) is only recommended in cases with the following pathologic situations: if and only if, severe pain is present after having tried, for at least 6 months, well controlled conservative treatment; if and only if functional disability persists; if and only if organic intraarticulary or peri-articulary pathology is also present. At present there is no consensus on the use of a particular articular prosthesis. If TMJ resection becomes necessary following non disfunctional pathology but of an organic nature, reconstruction with a chondro-costal graft is the method of choice. Unfortunately, there are no random studies on surgical treatments of TMJ disorders and, at the same time, all the studies that have already been published have a low methodological standard; by the end of 2006, 32 studies, reporting results for 11 to 237 patients can be reviewed; only 54% of these studies are prospective, with a follow-up period of 2 to 111 months for surgery performed for reducible and non-reducible disc displacements, as well as surgery performed for temporal-mandibular ostheoarthrosis sequellae. Analyzing the entire range of reported results, it can be pointed out that arthroscopy has the same results as a condylectomy, a discectomy better than a Mædica A Journal of Clinical Medicine, Volume 3 No

5 discopexy (23), except for a slight advantage because of mandible mobility (24). In case of non reducible disc displacement, a maximum of 10% of cases become reducible through surgery, although the disc generally remains stuck on the temporal structures (the roof of the glenoid cavity or the anterior temporal tubercle), which MRI results show very well bearing in mind that 60% of patients have no symptoms (25). In case of discectomy, the results after 5 years are encouraging: 85% (26) to 87% (27) good results given by the disppearance of pain, better mobility and a buccal opening of 40 mm. OUR THERAPEUTIC RECOMMENDATIONS In view of recent specific literature, which was briefly reviewed in this article the findings of which were supported by our experience of more than 25 years, we consider that the following therapeutic recommendations can be proposed: in case of myalgia: kinesytherapy, prescription of mio-relaxing drugs, and infiltrations with botulinic toxine. If the patient is not satisfied, our suggestion is a retro-incissive occlusal guard; in case of arthralgy: prescription of nonsteroid anti-inflammatory drugs along with kinesytherapy. If this treatment proves unsuccessful (less than 10% of cases), the mechanical treatment retroincissive occlusal guard is introduced; in case of reducible disc displacement: kinesytherapy is extremely efficient. The guard is not recommendable in our opinion; in case of non-reducible disc displacement: kinesytherapy is very efficient for treatment of pain and mandible mobility. The occlusal guard is only the second choice; in case of osteoarthrosis: non-steroid anti-inflamatory drugs are prescribed, followed by kinesytherapy; in case of treatment failure, the occlusal guard can efficiently alleviate the patient s discomfort. At the same time, the long term effect of guards on dental occlusion generally should be remebered at all times. Only after failure of well-controlled conservative treatment for at least 6 months is surgery recommended: in case of arthralgy: arthrocentesis under high pressure will relieve the patient, but its effect is limited over time (often 6 to 12 months); in case of reducible disc displacement: a discopexy can have good results after 5 and even after 10 years; in case of non-reducible disc displacement: an arthrocentesis, a discopexy, or even a discectomy can be suggested with caution; in case of osteoarthrosis: an arthrocentesis is chosen first. If symptoms reappear and cannot be controlled through conservative treatment, we suggest an arthrotomy and, most often, a temporal muscular flap. REFERENCES 1. Suvinen TI et al. Review of etiological concepts of TM pain disorders: towards a biopsychosocial model for integration of physical disorder factors with psychological and psychosocial illness impact factors. Eur J Pain 2005; 9: Ta LE et al. Treatment of painful TMJ with a cyclooxygenase-2 inhibitor: a randomized placebocontrolled comparison of celocoxib to naproxen. Pain 2004; 111: Nixdorf DR et al. Randomized controlled trial of botulinic toxin A for chronic myogenous orofacial pain. Pain 2002; 99: Chikhani L et al. Bruxism, TM dysfunction and botulinic toxin. Ann Readapt Med Phys 2003; 46: Bakke M et al. Treatment of severe TMJ clicking with botulinic toxin in the lateral pterygoid muscle in two cases of anterior disc displacement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005; 100: Mc Neely ML, Armijo OS, Magee DJ A systematic review of the effectiveness of physical therapy interventions for temporomandibular disorders. Phys Ther 2006; 86: Cleland J, Palmer J Effectiveness of manual physical therapy, therapeutic exercise and patient education on bilateral disc displacement without reduction of the temporomandibular joint: a single-case design. J Orthop 134 Mædica A Journal of Clinical Medicine, Volume 3 No

6 Sports Phys Ther 2004; 34: Nikolakis P, Erdogmus B, Kopf A, et al. Effectiveness of exercise therapy in patients with internal derangement of the temporomandibular joint. J Oral Rehabil 2001; 28: Yoda T, Sakamoto I, Imai H, et al. A randomized controlled trial of therapeutic exercise for clicking due to disc anterior displacement with reduction in the temporomandibular joint. Cranio 2003; 21: Conti PC, dos Santos CN, Kogawa EM, et al. The treatment of painful temporomandibular joint clicking with oral splints: a randomized clinical trial. J Am Dent Assoc 2006; 137: Fricton J Current evidence providing clarity in management of temporomandibular disorders: summary of a systematic review of randomized clinical trials for intraoral appliances and occlusal therapies. J Evid Based Dent Pract 2006; 6: Al-Ani MZ, Davies SJ, Gray RJ, et al. Stabilization splint therapy for temporomandibular pain dysfunction syndrome. Cochrane Database Syst Rev 2004; 1:CD Murakami K et al. Ten-year outcome of nonsurgical treatment for the internal derangement of the TMJ with closed lock. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94: Iwase H et al. Characterization of patients with disc displacement without reduction unresponsive to nonsurgical treatment: a preliminary study. J Oral Maxillofac Surg 2005; 63: Lobbezoo F et al. Topical review: new insights into the pathology and diagnosis of disorders of the TMJ. J Orofac Paint 2004; 18: Chang H et al. Analysis of inflammatory mediators in TMJ synovial fluid lavage samples of symptomatic patients and asymptomatic controls. J Oral Maxillofac Surg 2005; 63: Kunjur J et al. An audit of 405 TMJ arthrocentesis with intra-articular morphise infusion. Br J Oral Maxillofac Surg 2003; 41: Yura S et al. Relationship between effectiveness of arthrocentesis under sufficient pressure and conditions of the TMJ. J Oral Maxillofac Surg 2005; 63: Kaneyama K et al. The ideal lavage volume for removing bradykinin, interleukin-6, and protein from the TMJ by arthrocentesis. J Oral Maxillofac Surg 2004; 62: Alpaslan C et al. Five year retrospective evaluation of TMJ arthrocentesis. Int J Oral Maxillofac Surg 2003; 32: Iwase H et al. Characterization of patients with disc displacement without reduction unresponsive to nonsurgical treatment: a preliminary study. J Oral Maxillofac Surg 2005; 63: Reston JT et al. Meta-analysis of surgical treatments for TM articular disorders. J Oral Maxillofac Surg 2003; 61: Undt G et al. Open versus arthroscopic surgery for ID of the TMJ: A retrospective study comparing two centers results using the Jaw Pain and Function Questionnaire. J Craniomaxillofac Surg 2006;34: Hall HD et al. Prospective multicenter comparison of 4 TMJ operations. J Oral Maxillofac Surg 2005; 63: Ohnuki T et al. Evaluation of the position, mobility, and morphology of the disc by MRI before and after four different treatments for TMJ disorders. Dentomaxillofac Radiol 2006; 35: Eriksson L et al. Discectomy as an effective treatment for painful TMJ ID: a 5-year clinical and radiographic follow-up. J Oral Maxillofac Surg 2001; 59: Nyberg J et al. TMJ discectomy for treatment of unilateral ID a 5 year follow-up evaluation. Int J Oral Maxillofac Surg 2004; 33:8-12 Mædica A Journal of Clinical Medicine, Volume 3 No