Cooper, B: The Journal of Craniomandibular Practice. July 2011, vol 29,No.3, pp. 237-244
ABSTRACT:
Purpose: Two principal schools of thought regarding the etiology and optimal treatment of temporomandibular disorders exist; one physical/functional, the other biopsychosocial. This position paper establishes the scientific basis for the physical/functional.
The ICCMO Position: Temporomandibular disorders (TMD) comprise a group of musculoskeletal disorders, affecting alterations in the structure and/or function of the temporomandibular joints (TMJ), masticatory muscles, dentition and supporting structures. The initial TMD diagnosis is based on history, clinical examination and imaging, if indicated. Diagnosis is greatly enhanced with physiologic measurement devices, providing objective measurements of the functional status of the masticatory system: TMJs, muscles and dental occlusion. The American Alliance of TMD organizations represent thousands of clinicians involved in the treatment of TMD. The ten basic principles of the Alliance include the following statement: Dental occlusion may have a significant role in TMD; as a cause, precipitant and /or perpetuating factor. Therefore, it can be stated that the overwhelming majority of dentists treating TMD believe dental occlusion plays a major role in predisposition, precipitation and perpetuation. While our membership believes that occlusal treatments most frequently resolve TMD, it is recognized that TMD can be multi faceted and may exist with co-morbid physical or emotional factors that may require therapy by appropriate providers. The International College of Cranio-Mandibular Orthopedics (ICCMO), composed of academic and clinical dentists, believes that TMD has a primary physical/functional basis. Initial conservative and reversible TMD treatment employing a therapeutic neuromuscular orthosis that incorporates relaxed, healthy masticatory muscle function and a stable occlusion is most often successful. This is accomplished using objective measurement technologies and ultra low frequency transcutaneous electrical neural stimulation (TENS).
Conclusion:
Extensive literature substantiates the scientific validity of the physical/functional basis of TMD, efficacy of measurement devices and TENS and their use as aids in diagnosis and in establishing a therapeutic neuromuscular dental occlusion. Clinical Implications: A scientifically valid basis for TMD diagnosis and treatment is presented aiding in therapy.
The overwhelming majority of dentists worldwide, treating thousands of patients annually, and whose patients had not previously experienced resolution of their painful and/or dysfunctional symptoms support the conclusions reached by a large number of studies that TMD is a physical/functional disorder most often resulting from the mal-relationship among the dental occlusion, masticatory muscles, and TM joint function.11-34,39,164 They find that their patients are most often conservatively and successfully treatable initially with reversible occlusal orthosis therapy. Members of ICCMO adhere to this principal and treat to establish a healthy craniomandibular relationship through the use of a physiologically balanced neuromuscular occlusion that is in harmony with relaxed, healthy masticatory muscles with improved function and properly functioning TM joints. This achieves a stable, physiologically sound dental and craniomandibular position that does not cause noxious neural input to the central nervous system with resultant adaptive/accommodative function and behavior. In addition to its use in the treatment of patients with TMD, the neuromuscular occlusal philosophy can be successfully applied to all forms of dental treatment that involve major alteration of dental occlusion, including orthodontics, full arch or full mouth reconstruction and complete dentures. Successful treatment of temporomandibular disorders using neuromuscular occlusion techniques is directed towards elimination of the cause of the disease, not just symptom relief. If the cause is not successfully identified and treated, the acute physical/physiological form of TMD may unfortunately degenerate into a chronic pain condition, rarely cured, and at best, attempted to be managed with pharmacologic and other medical/ behavioral therapies. Such symptom- only oriented treatment can adversely affect the patients’ ability to work or have normal social interactions, resulting in an overall reduction in quality of life. Published research data demonstrate that the establishment of a neuromuscular therapeutic occlusion provides improved mandibular and masticatory function in a large group of TMD patients with notably significant reduction or resolution of symptoms.39,152
The International College of Cranio- Mandibular Orthopedics supports the consensus among its members and thousands of neuromuscular dentists worldwide that TMD has a primary physical/functional component that is most often successfully treated with neuromuscular dental occlusion therapy, based on objective measurements.
Wednesday, August 24, 2011
Occlusion and Temporomandibular Disorders (TMD): Still Unsolved Question?
Journal of Dental Research, Vol. 81, No. 8, 518-519 (2002)
DOI: 10.1177/154405910208100803
Pentti Alanen Institute of Dentistry, University of Turku, Lemminkäisenkatu 2, SF 20520 Turku, Finland; pealan@utu.fi
DOI: 10.1177/154405910208100803
Pentti Alanen Institute of Dentistry, University of Turku, Lemminkäisenkatu 2, SF 20520 Turku, Finland; pealan@utu.fi
The discussion about TMD etiology may be the longest debate in dentistry. Why does this debate still continue? I believe an answer can be found by analyzing the design of TMD studies against the principles of etiological epidemiology (Rothman and Greenland, 1998).
Both parties of the debate refer to empirical evidence. High-quality studies of occlusal adjustment in TMD patients are still too few to permit firm conclusions to be drawn (Forssell et al., 1999; Tsukiyama et al., 2001), but the use of occlusal splints seems to relieve TMD symptoms (Forssell et al., 1999). Success in therapy, however, is proof neither for nor against an etiological theory.
Where is the Evidence Suggesting that Occlusion and TMD are not Associated?
The observation that many subjects have "occlusal abnormality" without TMD has clearly encouraged reviewers to conclude that occlusal factors have no significant etiological role (Clark, 1991; DeBoever et al., 2000). Results of experimental interference studies are also seen as strong evidence for the same conclusion (Tsukiyama et al., 2001).
It is possible, however, that the reviews by Clark (1991), Clark et al. (1999), DeBoever et al. (2000), and Tsukiyama et al. (2001) have overlooked some methodological errors in studies on TMD etiology: (1) use of data which are not suitable for etiological generalizations, (2) confusion between the concepts "sufficient cause" and "causal factor", and (3) confounders in studies of artificial interference.
Generalizations
There are two types of generalizations in epidemiology. Rothman and Greenland (1998) have pointed out that studies aiming at generalization to the target population require representative samples, whereas powerful tests of competing hypotheses require selected samples. The majority of the epidemiological studies of association between occlusal factors and TMD have not made this decisive distinction but have used samples representing non-selected populations. It is therefore possible that the variation has been insufficient for effective comparisons between subjects with and those without a certain trait. For a critical study design, one must select subjects with occlusion totally free from any kind of interference, and compare them with subjects with interference. If this is impractical by selection, the needed variation can be produced by adjustment (Kirveskari et al., 1992, 1998).
Sufficient Cause vs. Causal Factor
Clark’s (1991) comment that "a high percentage of patients who have a naturally occurring ‘occlusal abnormality’ do not exhibit TM disorder" discloses that a distinction between the concepts "sufficient cause" and "causal factor" has not been made. This criticism applies also to the review by DeBoever et al. (2000). The conclusion should have read: "The literature does not give strong support for the opinion that occlusion is a sufficient cause for TMD." (emphasis added)
All diseases and disorders are multifactorial in practice. The most common example in dentistry is dental caries. Not mutans streptococci alone and not a sugar-rich diet alone lead to dental decay; they are both needed in addition to a certain weakness in host resistance. Analogously, if both stress and occlusal factors are needed for TMD to develop, then occlusal factors are a causal factor but not a sufficient cause for TMD. Occlusion could be excluded as a causal factor if the absence or presence of occlusal interferences does not affect the incidence rate of TMD in longitudinal studies (Kirveskari et al., 1998).
Confounder in Artificial Interference Studies
The trials with experimental interference are considered powerful (Tsukiyama et al., 2001). Interestingly, the usually virtuous principle of including only subjects healthy at baseline can be a confounder in the present case. Healthy adult subjects have demonstrated the ability to tolerate their natural interferences. Therefore, they can also be expected to adapt to artificial interference. What would happen if the study subjects were former TMD patients? In the trial by LeBell et al. (2002), the former patients did not adapt to the artificial interference as well as did healthy controls.
Conclusion
To conclude, studies which have not disclosed associations between occlusion and TMD may not have fulfilled sound methodological criteria. Lack of evidence has been interpreted as evidence of lacking association. In spite of the fact that it has been much more difficult for the occlusal hypothesis to survive in the trials by Kirveskari et al. (1992 (1998) and Le Bell et al. (2002), these studies have not succeeded in finding evidence against the occlusal hypothesis. Therefore, the rejection of the occlusal hypothesis cannot be justified with the present empirical evidence.
REFERENCES
- Clark GT (1991). Etiologic theory and the prevention of temporomandibular disorders. Adv Dent Res 5:60–66.[Abstract/Free Full Text]
- Clark GT, Tsukiyama Y, Baba K, Watanabe T (1999). Sixty-eight years of experimental occlusal interference studies: what have we learned? J Prosthet Dent 82:704–713.[Medline] [Order article via Infotrieve]
- DeBoever J, Carlsson G, Klineberg I (2000). Need for occlusal therapy and prosthodontic treatment in the management of temporomandibular disorders. Part I. Occlusal interferences and occlusal adjustment. J Oral Rehabil 27:367–379.[Medline] [Order article via Infotrieve]
- Forssell H, Kalso E, Koskela P, Vehmanen R, Puukka P, Alanen P (1999). Occlusal treatments in temporomandibular disorders: a qualitative systematic review of randomised controlled trials. Pain 83:549–560.[CrossRef][Medline] [Order article via Infotrieve]
- Kirveskari P, Alanen P, Jämsä T (1992). Association between craniomandibular disorders and occlusal interferences in children. J Prosthet Dent 67:692–696.[Medline] [Order article via Infotrieve]
- Kirveskari P, Jämsä T, Alanen P (1998). Occlusal adjustment and the incidence of demand for temporomandibular disorder treatment. J Prosthet Dent 79:433–438.[Medline] [Order article via Infotrieve]
- Le Bell Y, Jämsä T, Korri S, Niemi P, Alanen P (2002). The effect of artificial occlusal interferences depends on previous experience of temporomandibular disorders. Acta Odontol Scand (in press).
- Rothman K, Greenland S (1998). Modern epidemiology. 2nd edition. Philadelphia: Lippincott–Raven, pp. 133-134.
- Tsukiyama Y, Baba K, Clark GT (2001). An evidence-based assessment of occlusal adjustment as a treatment for temporomandibular disorders. J Prosthet Dent 86:57–66.[CrossRef][Medline] [Order article via Infotrieve]
Tuesday, June 21, 2011
Is Occlusion A Primary Cause of TMD?
By Karen McCloy, DDS
Occlusion is the act of the teeth coming together.
A primary cause is a factor that if present will reliably initiate the pathological changes that lead to tmd in a patient that did not previously have tmd
TMD is a state of chronic pain in the tmj and the soft tissues supporting it. Chronic pain implies the presence of neural plasticity, so we are talking about a state of central sensitization involving the trigeminal nerve. There is no rule that says that tmd patients may not have similar changes in other areas of the central nervous system. Saying that someone has chronic pain does not address it's etiology, and someone with a clicking joint does not have tmd unless they have pain.
If you ask me is occlusion an important pain producing factor in patients with tmd the answer is a definite yes. In normal patients, without plastic changes, occclusal dsiharmony may be nociceptive, but that means it is not pain. Once there are neural changes it becomes pain, a form of allodynia where a nonpainful stimulus causes pain, like when you have a headache and touching your skin or brushing your hair hurts, and controlling it is key to calming down that nervous system.
But our treatment has multiple modes of action, besides occlusion.
It has a placebo effect, becasue we believe, and because of that our patients believe they will improve. Plus the decision to seek treatment also changes someones mindset and makes them more in control
Our orthotics are a form of CBT - cognitive behavioral therapy. We insert them and say lips together teeth apart, and the plastic reminds the patient what the correct oral posture is.
Orthotics provide an occlusal effect, because they provide stable and even point occlusion around the arch.
Orthotics have an orthopedic effect because the realign the mandible to the cranial base and cervical structures.
So we are back to Larry's the chicken or the egg. We only see the pain patients, and in them pain is correlated with occlusion, but that is not the same thing as causation. Our 1st study on nonpain patients showed that most of them had some form of occlusal issue, but they did not have pain. So I think something else has to happen.
Occlusion is the act of the teeth coming together.
A primary cause is a factor that if present will reliably initiate the pathological changes that lead to tmd in a patient that did not previously have tmd
TMD is a state of chronic pain in the tmj and the soft tissues supporting it. Chronic pain implies the presence of neural plasticity, so we are talking about a state of central sensitization involving the trigeminal nerve. There is no rule that says that tmd patients may not have similar changes in other areas of the central nervous system. Saying that someone has chronic pain does not address it's etiology, and someone with a clicking joint does not have tmd unless they have pain.
If you ask me is occlusion an important pain producing factor in patients with tmd the answer is a definite yes. In normal patients, without plastic changes, occclusal dsiharmony may be nociceptive, but that means it is not pain. Once there are neural changes it becomes pain, a form of allodynia where a nonpainful stimulus causes pain, like when you have a headache and touching your skin or brushing your hair hurts, and controlling it is key to calming down that nervous system.
But our treatment has multiple modes of action, besides occlusion.
It has a placebo effect, becasue we believe, and because of that our patients believe they will improve. Plus the decision to seek treatment also changes someones mindset and makes them more in control
Our orthotics are a form of CBT - cognitive behavioral therapy. We insert them and say lips together teeth apart, and the plastic reminds the patient what the correct oral posture is.
Orthotics provide an occlusal effect, because they provide stable and even point occlusion around the arch.
Orthotics have an orthopedic effect because the realign the mandible to the cranial base and cervical structures.
So we are back to Larry's the chicken or the egg. We only see the pain patients, and in them pain is correlated with occlusion, but that is not the same thing as causation. Our 1st study on nonpain patients showed that most of them had some form of occlusal issue, but they did not have pain. So I think something else has to happen.
Wednesday, November 10, 2010
Establishment of a Temporomandibular Physiological State with Neuromuscular Orthosis Treatment Affects Reduction of TMD Symptoms in 313 Patients
Barry C. Cooper, D.D.S.; Israel Kleinberg, Ph.D., D.D.S., D.Sc.
THE JOURNAL OF CRANIOMANDIBULAR PRACTICE, APRIL 2008, VOL. 26, NO. 2, pp. 104-117.
ABSTRACT:
The objective of this investigation was to test the hypothesis that alteration of the occlusions of patients suffering from temporomandibular disorders (TMD) to one that is neuromuscularly, rather than anatomically based, would result in reduction or resolution of symptoms that characterize the TMD condition. This hypothesis was proven correct in the present study, where 313 patients with TMD symptoms were examined for neuromuscular dysfunction, using several electronic instruments before
and after treatment intervention. Such instrumentation enabled electromyographic (EMG) measurement of the activities of the masticatory muscles during rest and in function, tracking and assessment of various movements of the mandible, and listening for noises made by the TMJ during movement of the mandible. Ultra low frequency and low amplitude, transcutaneous electrical neural stimulation (TENS) of the mandibular division of the trigeminal nerve (V) was used to relax the masticatory muscles and to facilitate location of a physiological rest position for the mandible. TENS also made it possible to select positions of the mandible that were most relaxed above and anterior to the rest position when the mandible was moved in an arc that began at rest position. Once identified, the neuromuscular occlusal position was recorded in the form of a bite registration, which was subsequently used to fabricate a removable mandibular orthotic appliance that could be worn continuously by the patient. Such a device facilitated
retention and stabilization of the mandible in its new-found physiological position, which was confirmed by follow up testing. Three months of full-time appliance usage showed that the new therapeutic positions achieved remained intact and were associated with improved resting and functioning activities of the masticatory muscles. Patients reported overwhelming symptom relief, including reduction of headaches and other pain symptoms. Experts consider relief of symptoms as the gold standard for assessment of effectiveness of TMD treatment. It is evident that this outcome has been achieved in this study and that taking patients from a less to a more physiological state is an effective means for reducing or eliminating TMD symptoms, especially those related to pain, most notably, headaches.
THE JOURNAL OF CRANIOMANDIBULAR PRACTICE, APRIL 2008, VOL. 26, NO. 2, pp. 104-117.
ABSTRACT:
The objective of this investigation was to test the hypothesis that alteration of the occlusions of patients suffering from temporomandibular disorders (TMD) to one that is neuromuscularly, rather than anatomically based, would result in reduction or resolution of symptoms that characterize the TMD condition. This hypothesis was proven correct in the present study, where 313 patients with TMD symptoms were examined for neuromuscular dysfunction, using several electronic instruments before
and after treatment intervention. Such instrumentation enabled electromyographic (EMG) measurement of the activities of the masticatory muscles during rest and in function, tracking and assessment of various movements of the mandible, and listening for noises made by the TMJ during movement of the mandible. Ultra low frequency and low amplitude, transcutaneous electrical neural stimulation (TENS) of the mandibular division of the trigeminal nerve (V) was used to relax the masticatory muscles and to facilitate location of a physiological rest position for the mandible. TENS also made it possible to select positions of the mandible that were most relaxed above and anterior to the rest position when the mandible was moved in an arc that began at rest position. Once identified, the neuromuscular occlusal position was recorded in the form of a bite registration, which was subsequently used to fabricate a removable mandibular orthotic appliance that could be worn continuously by the patient. Such a device facilitated
retention and stabilization of the mandible in its new-found physiological position, which was confirmed by follow up testing. Three months of full-time appliance usage showed that the new therapeutic positions achieved remained intact and were associated with improved resting and functioning activities of the masticatory muscles. Patients reported overwhelming symptom relief, including reduction of headaches and other pain symptoms. Experts consider relief of symptoms as the gold standard for assessment of effectiveness of TMD treatment. It is evident that this outcome has been achieved in this study and that taking patients from a less to a more physiological state is an effective means for reducing or eliminating TMD symptoms, especially those related to pain, most notably, headaches.
Monday, September 6, 2010
Postural loads during walking after an imbalance of occlusion created with unilateral cotton rolls
Simona Tecco*1, Antonella Polimeni2, Matteo Saccucci3 and Felice Festa1: Tecco et al. BMC Research Notes 2010, 3:141
http://www.biomedcentral.com/1756-0500/3/141.
Abstract
Background: It was showed that stomatognathic functions correlate with alterations in locomotion, that are detectable through the analysis of loading during walking. For example, subjects with symptoms of Temporomandibular disorders (TMDs) showed a significant higher load pressure on the two feet, respect to health subjects, when cotton rolls were inserted. This previous study appeared to suggest that the alteration of postural loads associated to a particular alteration of stomatognathic condition (in this case, the cotton rolls inserted between the two dental arches) is detectable only in TMD's subjects, while it resulted not detectable in health subjects, because in that study, health subjects did not show any significant alteration of postural loads related to the different stomatognathic tested conditions. In other words, in that previous study, in the group of health subjects, no significant difference in postural loads was observed among the different test conditions; while TMD subjects showed a significant higher load pressure on the two feet when cotton rolls were inserted, respect to all the other tested conditions. Thus, the aim of this study was to better investigate these correlations in health subjects without TMD's symptoms, testing other different intra-oral conditions, and to verifywhether an experimentally induced imbalance of occlusion, obtained putting an unilateral cotton roll, could cause an alteration of postural loading on feet during
walking.
Findings:
In a sample of thirty Caucasian adult females (mean age 28.5 ± 4.5), asymptomatic for TMDs, when a cotton roll was positioned on the left or the right sides of dental arches, so causing a lateral shift of the mandible, the percentage of loading and the loading surface of the ipsi-lateral foot, left or right, were found to be significantly lower than in habitual occlusion (p < 0.05). Males were not included because of their different postural attitude respect to females. Further studies in a sample of males will be presented.
Conclusions:
This study showed that in health subjects without TMD's symptoms, an experimentally induced imbalance of the occlusion, obtained through an unilateral cotton roll, is associated to detectable alterations in the distribution of loading on feet surface, during walking.
http://www.biomedcentral.com/1756-0500/3/141.
Abstract
Background: It was showed that stomatognathic functions correlate with alterations in locomotion, that are detectable through the analysis of loading during walking. For example, subjects with symptoms of Temporomandibular disorders (TMDs) showed a significant higher load pressure on the two feet, respect to health subjects, when cotton rolls were inserted. This previous study appeared to suggest that the alteration of postural loads associated to a particular alteration of stomatognathic condition (in this case, the cotton rolls inserted between the two dental arches) is detectable only in TMD's subjects, while it resulted not detectable in health subjects, because in that study, health subjects did not show any significant alteration of postural loads related to the different stomatognathic tested conditions. In other words, in that previous study, in the group of health subjects, no significant difference in postural loads was observed among the different test conditions; while TMD subjects showed a significant higher load pressure on the two feet when cotton rolls were inserted, respect to all the other tested conditions. Thus, the aim of this study was to better investigate these correlations in health subjects without TMD's symptoms, testing other different intra-oral conditions, and to verifywhether an experimentally induced imbalance of occlusion, obtained putting an unilateral cotton roll, could cause an alteration of postural loading on feet during
walking.
Findings:
In a sample of thirty Caucasian adult females (mean age 28.5 ± 4.5), asymptomatic for TMDs, when a cotton roll was positioned on the left or the right sides of dental arches, so causing a lateral shift of the mandible, the percentage of loading and the loading surface of the ipsi-lateral foot, left or right, were found to be significantly lower than in habitual occlusion (p < 0.05). Males were not included because of their different postural attitude respect to females. Further studies in a sample of males will be presented.
Conclusions:
This study showed that in health subjects without TMD's symptoms, an experimentally induced imbalance of the occlusion, obtained through an unilateral cotton roll, is associated to detectable alterations in the distribution of loading on feet surface, during walking.
Friday, July 30, 2010
Systematic Review and Meta-analysis of Randomized Controlled Trials Evaluating Intraoral Orthopedic Appliances for Temporomandibular Disorders
James Fricton, DDS, MS/John O. Look, DDS, PhD/Edward Wright, DDS, MS/Francisco G. P. Alencar, Jr, DDS, MS/Hong Chen, DDS, MS/Maureen Lang, DDS, MS/Wei Ouyang, DDS, PhD/Ana Miriam Velly, DDS, PhD. J OROFAC PAIN 2010;24:237–254.
Aims: To conduct a systematic review with meta-analysis of randomized controlled trials (RCTs) that have assessed the efficacy of intraoral orthopedic appliances to reduce pain in patients with temporomandibular disorders affecting muscle and joint (TMJD) compared to subjects receiving placebo control, no treatment, or other treatments. Methods: A search strategy of MEDLINE, the Cochrane Library, the Cochrane CENTRAL Register, and manual search identified all English language publications of RCTs for intraoral appliance treatment of TMJD pain during the years of January 1966 to March 2006. Two additional studies from 2006 were added during the review process. Selection criteria included RCTs assessing the efficacy of hard and soft stabilization appliances, anterior positioning appliances, anterior bite appliances, and other appliance types for TMJD pain. Pain relief outcome measures were used in the meta-analyses, and the QUORUM criteria for data abstraction were used. A quality analysis of the methods of each RCT was conducted using the CONSORT criteria. The review findings were expressed both as a qualitative review and, where possible, as a mathematical synthesis using meta-analysis of results. Results: A total of 47 publications citing 44 RCTs with 2,218 subjects were included. Ten RCTs were included in two meta-analyses. In the first meta-analysis of seven studies with 385 patients, a hard stabilization appliance was found to improve TMJD pain compared to non-occluding appliance. The overall odds ratio (OR) of 2.46 was statistically significant (P = .001), with a 95% confidence interval of 1.56 to 3.67. In the second meta-analysis of three studies including 216 patients, a hard stabilization appliance was found to improve TMJD pain compared to no-treatment controls. The overall OR of 2.15 was positive but not statistically significant, with a 95% confidence interval of 0.80 to 5.75. The quality (0 to 1) of the studies was moderate, with a mean of 55% of quality criteria being met, suggesting some susceptibility to systematic bias may have existed. Conclusion: Hard stabilization appliances, when adjusted properly, have good evidence of modest efficacy in the treatment of TMJD pain compared to non-occluding appliances and no treatment. Other types of appliances, including soft stabilization appliances, anterior positioning appliances, and anterior bite appliances, have some RCT evidence of efficacy in reducing TMJD pain. However, the potential for adverse events with these appliances is higher and suggests the need for close monitoring in their use.
Aims: To conduct a systematic review with meta-analysis of randomized controlled trials (RCTs) that have assessed the efficacy of intraoral orthopedic appliances to reduce pain in patients with temporomandibular disorders affecting muscle and joint (TMJD) compared to subjects receiving placebo control, no treatment, or other treatments. Methods: A search strategy of MEDLINE, the Cochrane Library, the Cochrane CENTRAL Register, and manual search identified all English language publications of RCTs for intraoral appliance treatment of TMJD pain during the years of January 1966 to March 2006. Two additional studies from 2006 were added during the review process. Selection criteria included RCTs assessing the efficacy of hard and soft stabilization appliances, anterior positioning appliances, anterior bite appliances, and other appliance types for TMJD pain. Pain relief outcome measures were used in the meta-analyses, and the QUORUM criteria for data abstraction were used. A quality analysis of the methods of each RCT was conducted using the CONSORT criteria. The review findings were expressed both as a qualitative review and, where possible, as a mathematical synthesis using meta-analysis of results. Results: A total of 47 publications citing 44 RCTs with 2,218 subjects were included. Ten RCTs were included in two meta-analyses. In the first meta-analysis of seven studies with 385 patients, a hard stabilization appliance was found to improve TMJD pain compared to non-occluding appliance. The overall odds ratio (OR) of 2.46 was statistically significant (P = .001), with a 95% confidence interval of 1.56 to 3.67. In the second meta-analysis of three studies including 216 patients, a hard stabilization appliance was found to improve TMJD pain compared to no-treatment controls. The overall OR of 2.15 was positive but not statistically significant, with a 95% confidence interval of 0.80 to 5.75. The quality (0 to 1) of the studies was moderate, with a mean of 55% of quality criteria being met, suggesting some susceptibility to systematic bias may have existed. Conclusion: Hard stabilization appliances, when adjusted properly, have good evidence of modest efficacy in the treatment of TMJD pain compared to non-occluding appliances and no treatment. Other types of appliances, including soft stabilization appliances, anterior positioning appliances, and anterior bite appliances, have some RCT evidence of efficacy in reducing TMJD pain. However, the potential for adverse events with these appliances is higher and suggests the need for close monitoring in their use.
Thursday, July 22, 2010
Is Occlusion A Primary Cause to TMD?
A Multiple Logistic Regression Analysis of the Risk and Relative Odds of Temporomandibular Disorders as a Function of Common Occlusal Features
A.G. Pullinger (Section of Orofacial Pain and Occlusion, UCLA, School of Dentistry, 10833 Le Conte Avenue, Los Angeles, California 90024-1668), D.A. Seligman (Section of Orofacial Pain and Occlusion, UCLA, School of Dentistry, 10833 Le Conte Avenue, Los Angeles, California 90024-1668), J.A. Gornbein (UCLA Department of Biomathematics, Los Angeles, California 90024). Journal of Dental Research.
A multiple logistic regression analysis was used to compute the odds ratios for 11 common occlusal features for asymptomatic controls (n = 147) us. five temporomandibular disorder groups: Disc Displacement with Reduction (n = 81), Disc Displacement without Reduction (n = 48), Osteoarthrosis with Disc Displacement History (n = 75), Primary Osteoarthrosis (n = 85), and Myalgia Only (n = 124). Features that did not contribute included: retruded contact position (RCP) to intercuspal position (ICP) occlusal slides < 2 mm, slide asymmetry, unilateral RCP contacts, deep overbite, minimal overjet, dental midline discrepancies, ≤ 4 missing teeth, and maxillo-mandibular first molar relationship or cross-arch asymmetry. Groupings of a minimum of two to at most five occlusal variables contributed to the TMD patient groups. Significant increases in risk occurred selectively with anterior open bite (p < 0.01), unilateral maxillary lingual crossbite (p < 0.05 to p < 0.01), overjets > 6-7 mm (p < 0.05 to p < 0.01), ≥5-6 missing posterior teeth (p < 0.05 to p < 0.01), and RCP-ICP slides > 2 mm (p < 0.05 to p < 0.01). While the contribution of occlusion to the disease groups was not zero, most of the variation in each disease population was not explained by occlusal parameters. Thus, occlusion cannot be considered the unique or dominant factor in defining TMD populations. Certain features such as anterior open bite in osteoarthrosis patients were considered to be a consequence of rather than etiological factors for the disorder.
By Karen McCloy, DDS
Discussion:
Definitions
Occlusion is the act of the teeth coming together.
A primary cause is a factor that if present will reliably initiate the pathological changes that lead to tmd in a patient that did not previously have tmd.
TMD is a state of chronic pain in the tmj and the soft tissues supporting it. Chronic pain implies the presence of neural plasticity, so we are talking about a state of central sensitization involving the trigeminal nerve. There is no rule that says that tmd patients may not have similar changes in other areas of the central nervous system. Saying that someone has chronic pain does not address it's etiology, and someone with a clicking joint does not have tmd unless they have pain.
If you ask me is occlusion an important pain producing factor in patients with tmd the answer is a definite yes. In normal patients, without plastic changes, occclusal dsiharmony may be nociceptive, but that means it is not pain. Once there are neural changes it becomes pain, a form of allodynia where a nonpainful stimulus causes pain, like when you have a headache and touching your skin or brushing your hair hurts, and controlling it is key to calming down that nervous system.
But our treatment has multiple modes of action, besides occlusion.
It has a placebo effect, becasue we believe, and because of that our patients believe they will improve. Plus the decision to seek treatment also changes someones mindset and makes them more in control.
Our orthotics are a form of CBT.. cognitive behavioral therapy. We inserrt them and say lips together teeth apart, and the plastic reminds the patient what the correct oral posture is.
Orthotics provide an occlusal effect, because they provide stable and even point occlusion around the arch.
Orthotics have an orthopedic effect because the realign the mandible to the cranial base and cervical structures.
So we are back to Larry's the chicken or the egg. We only see the pain patients, and in them pain is correlated with occlusion, but that is not the same thing as causation. Our 1st study on nonpain patients showed that most of them had some form of occlusal issue, but they did not have pain. So I think something else has to happen.
A.G. Pullinger (Section of Orofacial Pain and Occlusion, UCLA, School of Dentistry, 10833 Le Conte Avenue, Los Angeles, California 90024-1668), D.A. Seligman (Section of Orofacial Pain and Occlusion, UCLA, School of Dentistry, 10833 Le Conte Avenue, Los Angeles, California 90024-1668), J.A. Gornbein (UCLA Department of Biomathematics, Los Angeles, California 90024). Journal of Dental Research.
A multiple logistic regression analysis was used to compute the odds ratios for 11 common occlusal features for asymptomatic controls (n = 147) us. five temporomandibular disorder groups: Disc Displacement with Reduction (n = 81), Disc Displacement without Reduction (n = 48), Osteoarthrosis with Disc Displacement History (n = 75), Primary Osteoarthrosis (n = 85), and Myalgia Only (n = 124). Features that did not contribute included: retruded contact position (RCP) to intercuspal position (ICP) occlusal slides < 2 mm, slide asymmetry, unilateral RCP contacts, deep overbite, minimal overjet, dental midline discrepancies, ≤ 4 missing teeth, and maxillo-mandibular first molar relationship or cross-arch asymmetry. Groupings of a minimum of two to at most five occlusal variables contributed to the TMD patient groups. Significant increases in risk occurred selectively with anterior open bite (p < 0.01), unilateral maxillary lingual crossbite (p < 0.05 to p < 0.01), overjets > 6-7 mm (p < 0.05 to p < 0.01), ≥5-6 missing posterior teeth (p < 0.05 to p < 0.01), and RCP-ICP slides > 2 mm (p < 0.05 to p < 0.01). While the contribution of occlusion to the disease groups was not zero, most of the variation in each disease population was not explained by occlusal parameters. Thus, occlusion cannot be considered the unique or dominant factor in defining TMD populations. Certain features such as anterior open bite in osteoarthrosis patients were considered to be a consequence of rather than etiological factors for the disorder.
By Karen McCloy, DDS
Discussion:
Definitions
Occlusion is the act of the teeth coming together.
A primary cause is a factor that if present will reliably initiate the pathological changes that lead to tmd in a patient that did not previously have tmd.
TMD is a state of chronic pain in the tmj and the soft tissues supporting it. Chronic pain implies the presence of neural plasticity, so we are talking about a state of central sensitization involving the trigeminal nerve. There is no rule that says that tmd patients may not have similar changes in other areas of the central nervous system. Saying that someone has chronic pain does not address it's etiology, and someone with a clicking joint does not have tmd unless they have pain.
If you ask me is occlusion an important pain producing factor in patients with tmd the answer is a definite yes. In normal patients, without plastic changes, occclusal dsiharmony may be nociceptive, but that means it is not pain. Once there are neural changes it becomes pain, a form of allodynia where a nonpainful stimulus causes pain, like when you have a headache and touching your skin or brushing your hair hurts, and controlling it is key to calming down that nervous system.
But our treatment has multiple modes of action, besides occlusion.
It has a placebo effect, becasue we believe, and because of that our patients believe they will improve. Plus the decision to seek treatment also changes someones mindset and makes them more in control.
Our orthotics are a form of CBT.. cognitive behavioral therapy. We inserrt them and say lips together teeth apart, and the plastic reminds the patient what the correct oral posture is.
Orthotics provide an occlusal effect, because they provide stable and even point occlusion around the arch.
Orthotics have an orthopedic effect because the realign the mandible to the cranial base and cervical structures.
So we are back to Larry's the chicken or the egg. We only see the pain patients, and in them pain is correlated with occlusion, but that is not the same thing as causation. Our 1st study on nonpain patients showed that most of them had some form of occlusal issue, but they did not have pain. So I think something else has to happen.
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