Clinical Practice
Comprehensive treatment of temporomandibular joint disorders Leosˇ Navra´til1,2, Vaclav Navratil1, Simona Hajkova1,2, Petra Hlinakova3, Tatjana Dostalova3, Jana Vranova´1 1
Czech Technical University in Prague, Faculty of Biomedical Engineering, Department of Medicine and Humanities, Czech Republic, 2Rehabilitation Center THERAP-TILIA, Prague, Czech Republic, 3Charles University in Prague, 2nd Faculty of Medicine and the Motol University Hospital, Department of Pediatric Stomatology, Czech Republic Aims: Changing lifestyles, decreasing physical activity, which is increasing the number of degenerative joint diseases of various etiology, and certain dental procedures are increasing the number of patients complaining of pain in their temporomandibular joints. The aim of the study was to assess the benefits of comprehensive physiotherapy sessions in order to decrease the number of temporomandibular joint problems, thereby improving the patient’s quality of life. Methodology: An examination by a dentist determined each patient’s treatment plan, which consisted of a medical exam, physical therapy and education. Each form of treatment was applied 10 times at intervals of 7–14 days. The main goal of the therapeutic physical education was to redress the muscle imbalance in the mandibular joint. This was achieved by restoring balance between the masticatory muscles, along with releasing the spastic shrouds found in the masticatory muscles. The aim of education was to teach the patient exercises focused on the temporomandibular joint and masticatory muscles. The intensity of the exercises and their composition were individually adjusted and adapted to their current state. Physical therapy consisted of the application of pulsed magnetic therapy, laser therapy, and non-invasive positive thermotherapy. Results: The above procedure was conducted on a therapeutic group of 24 patients (3 men and 20 women). In the course of therapy, there were no complications, and all patients adhered to the prescribed regime. None reported any side effects. The mean treatment duration was 123666 days. The outcome of the therapy was evaluated as described in the methodology, the degree of pain affecting the joint, and the opening ability of the mouth. In both parameters, there was a significant decline in patient pain. Conclusions: In a study devoted to tactics of rehabilitation treatment for temporomandibular joint disorders, the need for comprehensive long-term therapy, involving education, and learning proper chewing habits was made apparent for recovery and pain reduction. A priority in physical therapy, and combinations of pulsed magnetic therapy and hyperthermia-positive peloids, are also beneficial. Keywords: Jaw joint, Imbalance, Medical rehabilitation, Physiotherapy, Education
Introduction Changing lifestyles, changes in dietary habits, along with declining physical activity, and the increasing number of a variety of degenerative joint disease etiologies, are all factors in the rising number of patients who complain of jaw discomfort.1 In recent years, physiotherapy departments have been overflowing with patients suffering from temporomandibular joint pain. Treating these patients requires a
Correspondence to: L Navratil, Czech Technical University in Prague, na´m., Sı´tna´ 3105, 272 01 Kladno, Czech Republic. Email: leos.navratil@ fbmi.cvut.cz
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ß W. S. Maney & Son Ltd 2014 DOI 10.1179/0886963413Z.0000000002
form of comprehensive physiotherapy care based on physical and manual therapy,2 including the application of therapeutic lasers. The construction of the temporomandibular joint is extremely complex to allow movement for chewing and speaking. In principle, this leads to two types of movements: 1. rotational movement (rotational); 2. translational movement (sliding).
There are numerous possible causes of temporomandibular articulation pain. In the great majority of cases, this ailment occurs from a convergence of
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multiple factors happening simultaneously (multifactorial theory). These factors can be broken down into the following groups:
N N N N N N N
inflammatory diseases; degenerative disease of articular cartilage; changes in the position of the articular disc (dislocation); extra capsular affected by extra-articular structures, along with the chewing muscles and ligaments; movement disorders such as hypermobility; changes in the cervical spine associated with cervical muscle spasm; accidents and/or random injuries.
Causes of overloading the joint involve:
N N N N
faults in the mouth; missing teeth; articulatory constraints; inappropriately sized prosthetics.
Previous analysis has shown that up to 75% of the adult population are affected with temporomandibular joint pain. Of that 75%, only 7% will see a doctor.3 The most common cause for sufferers to seek treatment is pain (in 90% of cases) and acoustic phenomena (65%).2 The ratio of affected men to women in different studies varies, but usually falls close to a ratio of 3 : 1, with predominance in women.4 It is interesting to note that 75% of men and 52% of women claim that the pain and difficulties in joint movement do not affect their personal lives.1 This leads to varying times of patient diagnoses, as patients sometimes seek medical help as soon as problems occur, and in other cases, they may wait for up to several months or years. Treatment options for temporomandibular disorders combine manual therapy and long-term monitoring of rehabilitation treatments, including dental techniques, described by Hammad et al.5 A review article, which also notes biomechanical analysis of temporomandibular joint disorders, was published by Ingawale´ and Goswami.6 In addition, good experiences with combined treatments using acupuncture and manual therapy in 49 patients are described by Shin et al.7 de Laat et al.8 showed increased positive effects on pain, using these treatment modalities. The same effects were also found by Furto et al.9 Owing to differing methodologies used, it is not possible to make a proper comparison in order to determine an optimal therapeutic approach. An integral part of the authors’ approach to therapy was the application of therapeutic lasers. Views on its benefits in the treatment of temporomandibular joint disorders are inconsistent, however. Positive results with laser therapy in the
Comprehensive treatment of TMJ disorders
treatments of a number of diagnoses in the temporomandibular joint were obtained by Cavalcanti et al.,10 where a team of authors from the University of Bursa demonstrated that the function of temporomandibular disorders achieved better results after application of the laser (904 nm, 17 mW, 3 J) than in the control group. A similar result was found by a group of dentists and physiotherapists in Ankara (780 nm, 3.6 J) who applied lasers combined with manual therapy, therapeutic ultrasound, and phonophoresis.11 The positive, statistically significant results gained after using low-level laser therapy were also documented by the staff of Gazi University.12 The use of laser therapy for chronic pain in temporomandibular joints (with involvement on the basis of a joint or myofascial etiology) was recommended by Fikackova et al.1,13 Strong, statistically significant analgesic effects were described in 29 patients with chronic temporomandibular articulation as per Dincher,14 where a combination of three laser wavelengths (660, 810, and 850 nm) was used. Patients were irradiated five times during a time period of 2–3 weeks. Further use of lasers for significant analgesic effects in chronic joint pain was recommended, based on a number of literary source studies, such as Bjordal et al.15 On the other hand, statistically insignificant improvement in using a laser with a wavelength of 780 nm and 30 mW (energy density: 6.3 J/cm2) with involvement of the temporomandibular articulation was observed by a double-blind group conducted by Venancio Rde et al.16 The effect on muscular pain caused by the dysfunction of the temporomandibular joint from the application of a therapeutic laser wavelength of 790 nm at an energy density of 1.5 J/cm2 was evaluated by a Brazilian electromyography team. Better results were found with laser therapy than with electrotherapy, according to Medlicott and Harris.17 Kulekcioglu et al.18 had similar results, using only non-invasive laser therapy as an alternative form of treatment. A number of clinical effects have been described in connection with treatments using therapeutic lasers. For example, tables done with colleagues from Mexico and Cuba demonstrated laser thermal effect of more than z5uC at 100 mW/cm2 power density.19 Dias 8 and colleagues demonstrated that this effect occurs depending on the absorbed laser energy density and the intracellular immunohistochemical changes in muscle cells,20 and a significant increase in oxidative metabolism.21 A Brazilian team of authors demonstrated a stimulatory effect of therapeutic lasers with a wavelength of 830 nm for collagen I and III.22 Not all those observations were positive. Emshoff et al.23 at
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Innsbruck Medical University, found no improvement in the treatment of temporomandibular joint using a helium-neon laser. A team of authors from the University Estadual Paulista Ju´lio de Mesquita Filho in Brazil, assessed the analgesic effects of the laser (830 nm, 500 mW, 4 J), and even then they did not observe a statistically significant improvement.24 Carrasco et al.25 found similar results, with significantly higher energy density reached. The following statement is primarily focused on the methodology the authors modified for physiotherapy care to the temporomandibular joint, along with other joints, to treat significant specifics given, as well as localization and biomechanical differences.
Method Twenty-four patients (mean age: 25.67612.52 years), consisting of 20 women (mean age: 26.56613.30 years) and 4 men (mean age: 17.3360.58 years) participated in the study. Each patient was examined before treatment at the Children’s Dental Clinic at the Second Faculty of Medicine, Charles University, in Prague, Czech Republic. Graduated targeted medical examinations were undergone, with pain levels determined (pain assessment criteria are listed in Table 1, according to Farrar et al.26), and the extent of mouth opening was measured with a goniometer. The same test was carried out to assess the effect of treatment after its completion. None of the patients used in the experiment had an anterior bite splint. Part of the follow-up treatment was done at the Clinic THERAPY-TILIA Prague (Physiotherapy & Physical Therapy) and consisted of:
N N N
postizometric relaxation, mobilization, distraction, and automobilization exercises to improve cognitive and motor skills of the patient; the goal of restoring the balance between biting and mimic spastic muscles and relax the jaw muscles insertions (sternocleidomastoidenus, styloglosseus, and stylothyroideus) (Fig. 1); repeated practice of individual exercises leading to the recall and subsequent assignment of beneficial effects persisting, and the gradual improvement or disappearance of symptoms (Fig. 2);
Figure 1 Correction of the muscle imbalance found in the mandibular joint
Figure 2 Patient instruction of proper jaw movements
N N
magnetic pulse (disc applicator used (Fig. 3) (10 mT magnetic field, electric current frequency 10 Hz, duration 30 minutes). This study uses a device DIMAP (DIMAP, Kladno, Czech Republic); non-invasive laser therapy (laser source with a wavelength of the diode power of 200 mW). The temporomandibular joint area was illuminated with a point probe, J/cm2 energy density (Fig. 4). This study
Table 1 Criteria for assessment of severity of pain. Degree of pain 0 1 2 3 4 5
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Characteristic No pain Sporadic pain Mild pain not requiring analgesics Occasional pain fully responsive to analgesics Chronic pain temporarily responding to analgesics Excruciating pain without possibility of analgesics correction
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Figure 3 Disk applicator
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Figure 4 Laser application
N
N
Comprehensive treatment of TMJ disorders
Figure 5 The application of pulsed magnetic fields, and peloids
uses the device BTL 4100 (BTL, Brno, Czech Republic); positive thermotherapy. Peat peloids were used. A peloid denotes a natural substance that is extracted and is a mixture of inorganic and organic compounds in varying proportions. In proportion to the composition of these substances, it is divided into mud and humus. Mud, understood to be mainly inorganic matter, is mixed with dead bodies of algae and plankton. Humus is a mixture of mainly organic compounds, having at least 30% of the proportion of humic substances. In the current study, the authors used peat that forms decay of different grass species under water and contains a number of chemical elements, especially iron, calcium, and sulfur. It was mined near Frantisˇkovy La´zneˇ (Soos National Natural Reserve, Czech Republic). The peloids were sealed in a special permeable film, which was preheated prior to application in a water bath (at 37uC). The duration of treatment was 30 minutes (Fig. 5). education (training autorelaxation, breathing exercises, and modification work, so that the neck muscles relax). The purpose of education was to teach the patient exercises focused on the temporomandibular joint and the masticatory muscles and the use of facial muscles, especially in the mouth area. An important component of the education aspect was done through the catering of food, which provided a framework for the patient to measure the degree of chewing/grinding that should be done.
Each of these forms of treatment was applied 10 times, at an interval of 14 days. The total duration of treatment was four months (Table 2).
Statistical analysis To compare the observed variables before and after treatment, paired tests were conducted. For the normally distributed variable (the ability to open the mouth), the paired t-test was used, and for skewed data (degree of pain), the non-parametric Wilcoxon paired signed-rank test was used. Statsoft’s STATISTICA version 9 was used for statistical analysis. A P value less than 0.05 was considered to be statistically significant.
Results Specified therapeutic procedures were carried out on a group of 24 patients (mean age: 25.67612.52 years), consisting of 4 men (mean age: 17.3360.58 years) and 20 women (mean age: 26.56613.30 years). This ratio is consistent with the literature, which also shows prevalence of this type of disease in women.27 During the therapy, there were no complications. All of the patients adhered to the prescribed regimen, and did not report any side effects. The average length of treatment was 123 days.
Table 2 Treatment protocol Type of therapy
n
Method
Methodology
Therapeutic exercise Physical therapy
10 10
Manual Pulse magnetotherapy
Correcting muscle imbalance in the area of mandibular joint to balance Magnetic induction 10 mT, frequency of 10 Hz, duration of application of 30 minutes 830 nm, power of 200 mW point probe meandering method, the energy density of 4 J/cm2 Peloids (peat) from the region of Spa Frantiskovy Lazne of Czech Republic sealed in a special permeable foil, heated in a water bath at a temperature 37uC, 30 minutes Education focused on the muscle imbalance in the area of the mandibular joint to correct the balance
Non-invasive laser therapy Positive thermotherapy
Education of movement habits
10
Training
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Table 3 Mean values and standard deviations (SDs) of the extent of mouth opening, count, and percentage of degrees of pain before and after treatment. P values of paired t-test and Wilcoxon signed-rank test Pre-treatment
Post-treatment
Mean6SD
Mean6SD
Paired t-test
Extent of the mouth opening (mm)
34.0065.92
41.9665.17
P,0.0001
Degree of the pain 0 1 2 3 4
N; % 0 3; 12.50% 6; 25.00% 9; 37.50% 6; 25.00%
N; % 15; 62.50% 8; 33.33% 1; 4.17% 0 0
Wilcoxon paired signed-rank test P,0.0001
In recent years, the authors have seen a significant increase in the number of patients with pain in one or both jaw joints. The cause of these difficulties and pain, in addition to disorders involving improper bite techniques, poorly sized articulation prosthesis, inadequate diet composition (if mushy consistency, which reduces the need for involvement of masticatory muscles), and stress, are disorders of the spine, including cervical paravertebral muscle spasm.3,28,29
In line with other departments,11 the authors demonstrated the necessity of complex physiotherapy, by completing the necessary education. Treatment was focused on correcting muscle imbalances in the mandibular joint, as described in the methodology section, along with the restoration of the physiological mobility of the temporomandibular joint. The authors chose mobilization techniques, especially the method of muscle facilitation and inhibition, namely, the isometric contraction of muscles in spasm, followed by isometric relaxation. The anti-gravity method (method based on maximum muscle relaxation during joint movement from one extreme position to another in the joint)30 was also used in the current study. In the treatment, the authors used an active, repetitive movement, which the patient performed in the direction of their particular impairment, in order to prevent the development of resistance in the joint. The results of this reciprocal movement led to the easement of antagonistic muscles. Proper breathing methods were also found to be imperative, as breath has the effect of dampening the facilitating skeletal muscles. Combining the above-mentioned procedures has proved to be effective.8 The biggest advantage of this
Graph 1
Graph 2
The mean values of the pre-treatment and posttreatment extent of the mouth opening were 34.0065.92 and 41.9665.17 mm, respectively (P,0.0001). A high statistically significant improvement in ability to open the mouth after the laser treatment was found (Table 3 and Graph 1). Before the treatment, three patients declared the degree of pain 1, six patients degree 2, nine patients degree 3, and six patients degree 4. After the treatment, only 1 patient suffered pain of degree 2, 8 patients suffered degree 1, and 15 patients declared that they felt no pain (see Table 3 for details). The strong, statistically significant analgesic effects were confirmed using the non-parametric Wilcoxon paired signed-rank test (P,0.0001) (Table 3 and Graph 2).
Discussion
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method is that from the very beginning, the therapy can be done by the patient himself, several times a day. Given physiotherapy treatments, the authors added pulse magnets and hyperthermia (peloids heated to 37uC). The use of this combination was a priority in the current study, as its therapeutic benefit is shown in analgesic and anti-inflammatory effects of a pulsed magnetic field, and peloids, which have a relaxant effect on the tissue (positive thermotherapy).27 In the current study, the authors used one of the best peloids in the world, from the site of the National Nature Reserve SOOS, Franzensbad, Czech Republic. The combination of peloids and pulsed magnetic field reduces muscle spasms of masticatory muscles and has a strong anti-inflammatory and regenerative effect. Hyperthermia peloids are natural for the human body, and are therefore more effective than hyperthermia induced by shortwave diathermy.31 To amplify the analgesic effect, the authors used noninvasive lasers. When selecting the energy density (4 J/ cm2) the authors used the recommended values based on the Arndt–Schultz Law.11,32 To ensure an objective evaluation of the effect of the therapy, the authors selected two independent units, listing the appropriate doctor or dentist, and verified input and output values gathered throughout treatment. Physicians focused on treating musculoskeletal issues. Observed values measured before the start and the end of treatment (level of pain and range of mouth opening, as described above) are simple, and objectively verify the benefits of rehabilitation care.
Conclusion In this study, dedicated to tactics of rehabilitation treatment in disorders of temporomandibular articulation, the authors have demonstrated the need for comprehensive long-term therapy that plays an important role in education and in learning good eating and exercising habits. In invasive procedures, the authors used a combination that was considered to bring positive effects, as with pulse magnetic hyperthermia peloids, which were not used in this indication.
Acknowledgements The study was supported by the IGA of Ministry of Health of the Czech Republic (no. 9902-4).
References 1 Fikackova H, Dostalova T, Navratil L, Klaschka J. Effectiveness of low-level laser therapy in temporomandibular joint disorders: a placebo-controlled study. Photomed Laser Surg. 2007;25:297–303.
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2 Machon V. [Treatment of temporomandibular joint disease]. Prague: Grada Publishing; 2008. Czech. 3 Machon V, Lukasova V. Prˇ´ıspeˇvek k etiologii onemocneˇnı´ temporomandibula´rnı´ho kloubu. Prakt zubnı´ le´karˇ. 2005;53: 111–4. Czech. 4 Gray RJM, Davies SJ, Quayle AA. A clinical approach to temporomandibular disorders: classification and functional anatomy. Br Dent J. 1994;176:429–34. 5 Hammad IA, Nassif NJ, Salameh ZA. Full-mouth rehabilitation following treatment of temporomandibular disorders and teeth-related signs and symptoms. J Craniomandib Pract. 2005;23:289–96. 6 Ingawale´ S, Goswami T. Temporomandibular joint: disorders, treatments, and biomechanics. Ann Biomed Eng. 2009;37: 976–96. 7 Shin BC, Ha CH, Song YS, Lee MS. Effectiveness of combining manual therapy and acupuncture on temporomandibular joint dysfunction: a retrospective study. Am J Chin Med. 2007;35:203–8. 8 de Laat A, Stappaerts K, Papy S. Counseling and physical therapy as treatment for myofascial pain of the masticatory system. J Orifac Pain. 2003;17:42–9. 9 Furto ES, Cleland JA, Whitman JM, Olson KA. Manual physical therapy interventions and exercise for patients with temporomandibular disorders. J Craniomandib Pract. 2006;24: 283–91. 10 Cavalcanti ET, Pinheiro TI, Alves MJ, Miranda ER, de Quevendo AS, Manzi CT, et al. Study user therapy is an important tool to treat disorders of the maxillofacial region (TMJ). Med Surg. 1998;16:223–6. ¨ , Babadag˘ M, Du¨lgerog˘lu D, O ¨ zel S, 11 Kaya K, Delialiog˘lu SU C ¸ ulha C, et al. Combined physiotherapy in patients with arthrogenous pain of temporomandibular joint. J PMR Sci. 2010;13:6–14. 12 C ¸ etiner S, Kahraman SA, Yu¨cetas¸ S¸. Evaluation of low-level therapy in the treatment of temporomandibular disorders. Photomed Laser Surg. 2006;24:637–41. 13 Fikackova H, Dostalova T, Vosicka R, Peterova V, Navratil L, Lesak J. Arthralgia of the temporomandibular joint and lowlevel laser therapy. Photomed Laser Surg. 2006;24:522–7. 14 Dincher M. Efficacy of low level laser therapy (LLLT) for the reduction of pain in chronic temporomandibular disorder (TMD) [dissertation]. Boston (CA): Tufts University School of Dental Medicine; 2011. 15 Bjordal JM, Couppe´ C, Chow RT, Ljunggren EA. A systematic review of low level laser therapy with location-specific doses for pain from chronic joint disorders. Aust J Physiother. 2003;49: 107–16. 16 Venancio Rde A, Camparis CM, Lizarelli Rde F. Low intensity laser therapy in the treatment of temporomandibular disorders. a double-blind study. J Oral Rehabil. 2005;32:800–7. 17 Medlicott MS, Harris SR. A systematic review of the effectiveness of exercise, manual therapy, electrotherapy, relaxation training, and biofeedback in the management of temporomandibular disorder. Phys Ther. 2006;86:955–73. 18 Kulekcioglu S, Sivrioglu K, Ozcan O, Parlak M. Effectiveness of low-level laser therapy in temporomandibular disorder. Scand J Rheumatol. 2003;32:114–8. 19 Stolik S, Delgado JA, Anasagasti L, Perez AM. Effective thermal penetration depth in photo-irradiated ex vivo human tissues. Photomed Laser Surg. 2011;29:669–75. 20 Dias FJ, Issa JP, Barbosa AP, de Vasconcelos PB, Watanabe IS, Mizusakiiyomasa M. Effects of low-level laser irradiation in ultrastructural morphology, and immunoexpression of VEGF and VEGFR-2 of rat masseter muscle. Micron. 2012;43:237–44. 21 Dias FJ, Issa JP, Vicentini FT, Fonseca MJ, Lea˜o JC, Sie´ssere S, et al. Effects of low-level laser therapy on the oxidative metabolism and matrix proteins in the rat masseter muscle. Photomed Laser Surg. 2011;29:677–84. 22 Neves MA, Pinfildi CE, Wood VT, Gobbato RC, da Silva FM, Parizotto NA, et al. Different power settings of LLLT on the repair of the calcaneal tendon. Photomed Laser Surg. 2011;29:663–8. 23 Emshoff R, Bo¨sch R, Pu¨mpel E, Scho¨ning H, Strobl H. Lowlevel laser therapy for treatment of temporomandibular joint pain: a double-blind and placebo-controlled trial. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;105:452–6.
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24 da Cunha LA, Firoozmand LM, da Silva AP, Camargo SE, Oliveira W. Efficacy of low-level laser therapy in the treatment of temporomandibular disorder. Int Dent J. 2008;58:213–7. 25 Carrasco TG, Mazzetto MO, Mazzetto RG, Mestriner W, Jr. Low intensity laser therapy in temporomandibular disorder: a phase II double-blind study. J Craniomandib Pract. 2008;26: 274–81. 26 Farrar JT, Young JP, Jr, LaMoreaux L, Werth JL, Poole RM. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain. 2001;94:149–58. 27 Benda J. [Peloids in balneotherapy]. Rehabil Fyz Lek. 2000;7:82–91. Czech. 28 Silveira EB, Rocabado M, Russo AK, Cogo JC, Osorio RA. Incidence of systemic joint hypermobility and temporomandibular
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joint hypermobility in pregnancy. J Craniomandib Pract. 2005;23:138–43. von Piekartz H, Lu¨dtke K. Effect of treatment of temporomandibular disorders (TMD) in patients with cervicogenic headache: a single-blind, randomized controlled study. J Craniomandib Pract. 2011;29:43–56. Zbojan L. [Anti-gravity relaxation, its principle and application]. Prakt Lek. 1992;68:147–9. Czech. Stamenkovic´ B, Stankovic´ A, Nedovic´ J, Stojanovic´ S, Dimic´ A, Djordjevic´ D, et al. [Effects of balneotherapy on the reactants of acute inflammation phase in ankylosing spondylitis]. Srp Arh Celok Lek. 2009;137:255–8. Serbian. Lubart R, Lavi R, Friedmann H, Rochkind S. Photochemistry and photobiology of light absorption by living cells. Photomed Laser Surg. 2006;24:179–85.
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Comprehensive treatment of temporomandibular joint disorders Leosˇ Navra´til1,2, Vaclav Navratil1, Simona Hajkova1,2, Petra Hlinakova3, Tatjana Dostalova3, Jana Vranova´1 1
Czech Technical University in Prague, Faculty of Biomedical Engineering, Department of Medicine and Humanities, Czech Republic, 2Rehabilitation Center THERAP-TILIA, Prague, Czech Republic, 3Charles University in Prague, 2nd Faculty of Medicine and the Motol University Hospital, Department of Pediatric Stomatology, Czech Republic Aims: Changing lifestyles, decreasing physical activity, which is increasing the number of degenerative joint diseases of various etiology, and certain dental procedures are increasing the number of patients complaining of pain in their temporomandibular joints. The aim of the study was to assess the benefits of comprehensive physiotherapy sessions in order to decrease the number of temporomandibular joint problems, thereby improving the patient’s quality of life. Methodology: An examination by a dentist determined each patient’s treatment plan, which consisted of a medical exam, physical therapy and education. Each form of treatment was applied 10 times at intervals of 7–14 days. The main goal of the therapeutic physical education was to redress the muscle imbalance in the mandibular joint. This was achieved by restoring balance between the masticatory muscles, along with releasing the spastic shrouds found in the masticatory muscles. The aim of education was to teach the patient exercises focused on the temporomandibular joint and masticatory muscles. The intensity of the exercises and their composition were individually adjusted and adapted to their current state. Physical therapy consisted of the application of pulsed magnetic therapy, laser therapy, and non-invasive positive thermotherapy. Results: The above procedure was conducted on a therapeutic group of 24 patients (3 men and 20 women). In the course of therapy, there were no complications, and all patients adhered to the prescribed regime. None reported any side effects. The mean treatment duration was 123666 days. The outcome of the therapy was evaluated as described in the methodology, the degree of pain affecting the joint, and the opening ability of the mouth. In both parameters, there was a significant decline in patient pain. Conclusions: In a study devoted to tactics of rehabilitation treatment for temporomandibular joint disorders, the need for comprehensive long-term therapy, involving education, and learning proper chewing habits was made apparent for recovery and pain reduction. A priority in physical therapy, and combinations of pulsed magnetic therapy and hyperthermia-positive peloids, are also beneficial. Keywords: Jaw joint, Imbalance, Medical rehabilitation, Physiotherapy, Education
Introduction Changing lifestyles, changes in dietary habits, along with declining physical activity, and the increasing number of a variety of degenerative joint disease etiologies, are all factors in the rising number of patients who complain of jaw discomfort.1 In recent years, physiotherapy departments have been overflowing with patients suffering from temporomandibular joint pain. Treating these patients requires a
Correspondence to: L Navratil, Czech Technical University in Prague, na´m., Sı´tna´ 3105, 272 01 Kladno, Czech Republic. Email: leos.navratil@ fbmi.cvut.cz
24
ß W. S. Maney & Son Ltd 2014 DOI 10.1179/0886963413Z.0000000002
form of comprehensive physiotherapy care based on physical and manual therapy,2 including the application of therapeutic lasers. The construction of the temporomandibular joint is extremely complex to allow movement for chewing and speaking. In principle, this leads to two types of movements: 1. rotational movement (rotational); 2. translational movement (sliding).
There are numerous possible causes of temporomandibular articulation pain. In the great majority of cases, this ailment occurs from a convergence of
CRANIOH: The Journal of Craniomandibular & Sleep Practice
2014
VOL.
32
NO.
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Navratil et al.
multiple factors happening simultaneously (multifactorial theory). These factors can be broken down into the following groups:
N N N N N N N
inflammatory diseases; degenerative disease of articular cartilage; changes in the position of the articular disc (dislocation); extra capsular affected by extra-articular structures, along with the chewing muscles and ligaments; movement disorders such as hypermobility; changes in the cervical spine associated with cervical muscle spasm; accidents and/or random injuries.
Causes of overloading the joint involve:
N N N N
faults in the mouth; missing teeth; articulatory constraints; inappropriately sized prosthetics.
Previous analysis has shown that up to 75% of the adult population are affected with temporomandibular joint pain. Of that 75%, only 7% will see a doctor.3 The most common cause for sufferers to seek treatment is pain (in 90% of cases) and acoustic phenomena (65%).2 The ratio of affected men to women in different studies varies, but usually falls close to a ratio of 3 : 1, with predominance in women.4 It is interesting to note that 75% of men and 52% of women claim that the pain and difficulties in joint movement do not affect their personal lives.1 This leads to varying times of patient diagnoses, as patients sometimes seek medical help as soon as problems occur, and in other cases, they may wait for up to several months or years. Treatment options for temporomandibular disorders combine manual therapy and long-term monitoring of rehabilitation treatments, including dental techniques, described by Hammad et al.5 A review article, which also notes biomechanical analysis of temporomandibular joint disorders, was published by Ingawale´ and Goswami.6 In addition, good experiences with combined treatments using acupuncture and manual therapy in 49 patients are described by Shin et al.7 de Laat et al.8 showed increased positive effects on pain, using these treatment modalities. The same effects were also found by Furto et al.9 Owing to differing methodologies used, it is not possible to make a proper comparison in order to determine an optimal therapeutic approach. An integral part of the authors’ approach to therapy was the application of therapeutic lasers. Views on its benefits in the treatment of temporomandibular joint disorders are inconsistent, however. Positive results with laser therapy in the
Comprehensive treatment of TMJ disorders
treatments of a number of diagnoses in the temporomandibular joint were obtained by Cavalcanti et al.,10 where a team of authors from the University of Bursa demonstrated that the function of temporomandibular disorders achieved better results after application of the laser (904 nm, 17 mW, 3 J) than in the control group. A similar result was found by a group of dentists and physiotherapists in Ankara (780 nm, 3.6 J) who applied lasers combined with manual therapy, therapeutic ultrasound, and phonophoresis.11 The positive, statistically significant results gained after using low-level laser therapy were also documented by the staff of Gazi University.12 The use of laser therapy for chronic pain in temporomandibular joints (with involvement on the basis of a joint or myofascial etiology) was recommended by Fikackova et al.1,13 Strong, statistically significant analgesic effects were described in 29 patients with chronic temporomandibular articulation as per Dincher,14 where a combination of three laser wavelengths (660, 810, and 850 nm) was used. Patients were irradiated five times during a time period of 2–3 weeks. Further use of lasers for significant analgesic effects in chronic joint pain was recommended, based on a number of literary source studies, such as Bjordal et al.15 On the other hand, statistically insignificant improvement in using a laser with a wavelength of 780 nm and 30 mW (energy density: 6.3 J/cm2) with involvement of the temporomandibular articulation was observed by a double-blind group conducted by Venancio Rde et al.16 The effect on muscular pain caused by the dysfunction of the temporomandibular joint from the application of a therapeutic laser wavelength of 790 nm at an energy density of 1.5 J/cm2 was evaluated by a Brazilian electromyography team. Better results were found with laser therapy than with electrotherapy, according to Medlicott and Harris.17 Kulekcioglu et al.18 had similar results, using only non-invasive laser therapy as an alternative form of treatment. A number of clinical effects have been described in connection with treatments using therapeutic lasers. For example, tables done with colleagues from Mexico and Cuba demonstrated laser thermal effect of more than z5uC at 100 mW/cm2 power density.19 Dias 8 and colleagues demonstrated that this effect occurs depending on the absorbed laser energy density and the intracellular immunohistochemical changes in muscle cells,20 and a significant increase in oxidative metabolism.21 A Brazilian team of authors demonstrated a stimulatory effect of therapeutic lasers with a wavelength of 830 nm for collagen I and III.22 Not all those observations were positive. Emshoff et al.23 at
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Innsbruck Medical University, found no improvement in the treatment of temporomandibular joint using a helium-neon laser. A team of authors from the University Estadual Paulista Ju´lio de Mesquita Filho in Brazil, assessed the analgesic effects of the laser (830 nm, 500 mW, 4 J), and even then they did not observe a statistically significant improvement.24 Carrasco et al.25 found similar results, with significantly higher energy density reached. The following statement is primarily focused on the methodology the authors modified for physiotherapy care to the temporomandibular joint, along with other joints, to treat significant specifics given, as well as localization and biomechanical differences.
Method Twenty-four patients (mean age: 25.67612.52 years), consisting of 20 women (mean age: 26.56613.30 years) and 4 men (mean age: 17.3360.58 years) participated in the study. Each patient was examined before treatment at the Children’s Dental Clinic at the Second Faculty of Medicine, Charles University, in Prague, Czech Republic. Graduated targeted medical examinations were undergone, with pain levels determined (pain assessment criteria are listed in Table 1, according to Farrar et al.26), and the extent of mouth opening was measured with a goniometer. The same test was carried out to assess the effect of treatment after its completion. None of the patients used in the experiment had an anterior bite splint. Part of the follow-up treatment was done at the Clinic THERAPY-TILIA Prague (Physiotherapy & Physical Therapy) and consisted of:
N N N
postizometric relaxation, mobilization, distraction, and automobilization exercises to improve cognitive and motor skills of the patient; the goal of restoring the balance between biting and mimic spastic muscles and relax the jaw muscles insertions (sternocleidomastoidenus, styloglosseus, and stylothyroideus) (Fig. 1); repeated practice of individual exercises leading to the recall and subsequent assignment of beneficial effects persisting, and the gradual improvement or disappearance of symptoms (Fig. 2);
Figure 1 Correction of the muscle imbalance found in the mandibular joint
Figure 2 Patient instruction of proper jaw movements
N N
magnetic pulse (disc applicator used (Fig. 3) (10 mT magnetic field, electric current frequency 10 Hz, duration 30 minutes). This study uses a device DIMAP (DIMAP, Kladno, Czech Republic); non-invasive laser therapy (laser source with a wavelength of the diode power of 200 mW). The temporomandibular joint area was illuminated with a point probe, J/cm2 energy density (Fig. 4). This study
Table 1 Criteria for assessment of severity of pain. Degree of pain 0 1 2 3 4 5
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Characteristic No pain Sporadic pain Mild pain not requiring analgesics Occasional pain fully responsive to analgesics Chronic pain temporarily responding to analgesics Excruciating pain without possibility of analgesics correction
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Figure 3 Disk applicator
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Figure 4 Laser application
N
N
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Figure 5 The application of pulsed magnetic fields, and peloids
uses the device BTL 4100 (BTL, Brno, Czech Republic); positive thermotherapy. Peat peloids were used. A peloid denotes a natural substance that is extracted and is a mixture of inorganic and organic compounds in varying proportions. In proportion to the composition of these substances, it is divided into mud and humus. Mud, understood to be mainly inorganic matter, is mixed with dead bodies of algae and plankton. Humus is a mixture of mainly organic compounds, having at least 30% of the proportion of humic substances. In the current study, the authors used peat that forms decay of different grass species under water and contains a number of chemical elements, especially iron, calcium, and sulfur. It was mined near Frantisˇkovy La´zneˇ (Soos National Natural Reserve, Czech Republic). The peloids were sealed in a special permeable film, which was preheated prior to application in a water bath (at 37uC). The duration of treatment was 30 minutes (Fig. 5). education (training autorelaxation, breathing exercises, and modification work, so that the neck muscles relax). The purpose of education was to teach the patient exercises focused on the temporomandibular joint and the masticatory muscles and the use of facial muscles, especially in the mouth area. An important component of the education aspect was done through the catering of food, which provided a framework for the patient to measure the degree of chewing/grinding that should be done.
Each of these forms of treatment was applied 10 times, at an interval of 14 days. The total duration of treatment was four months (Table 2).
Statistical analysis To compare the observed variables before and after treatment, paired tests were conducted. For the normally distributed variable (the ability to open the mouth), the paired t-test was used, and for skewed data (degree of pain), the non-parametric Wilcoxon paired signed-rank test was used. Statsoft’s STATISTICA version 9 was used for statistical analysis. A P value less than 0.05 was considered to be statistically significant.
Results Specified therapeutic procedures were carried out on a group of 24 patients (mean age: 25.67612.52 years), consisting of 4 men (mean age: 17.3360.58 years) and 20 women (mean age: 26.56613.30 years). This ratio is consistent with the literature, which also shows prevalence of this type of disease in women.27 During the therapy, there were no complications. All of the patients adhered to the prescribed regimen, and did not report any side effects. The average length of treatment was 123 days.
Table 2 Treatment protocol Type of therapy
n
Method
Methodology
Therapeutic exercise Physical therapy
10 10
Manual Pulse magnetotherapy
Correcting muscle imbalance in the area of mandibular joint to balance Magnetic induction 10 mT, frequency of 10 Hz, duration of application of 30 minutes 830 nm, power of 200 mW point probe meandering method, the energy density of 4 J/cm2 Peloids (peat) from the region of Spa Frantiskovy Lazne of Czech Republic sealed in a special permeable foil, heated in a water bath at a temperature 37uC, 30 minutes Education focused on the muscle imbalance in the area of the mandibular joint to correct the balance
Non-invasive laser therapy Positive thermotherapy
Education of movement habits
10
Training
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Table 3 Mean values and standard deviations (SDs) of the extent of mouth opening, count, and percentage of degrees of pain before and after treatment. P values of paired t-test and Wilcoxon signed-rank test Pre-treatment
Post-treatment
Mean6SD
Mean6SD
Paired t-test
Extent of the mouth opening (mm)
34.0065.92
41.9665.17
P,0.0001
Degree of the pain 0 1 2 3 4
N; % 0 3; 12.50% 6; 25.00% 9; 37.50% 6; 25.00%
N; % 15; 62.50% 8; 33.33% 1; 4.17% 0 0
Wilcoxon paired signed-rank test P,0.0001
In recent years, the authors have seen a significant increase in the number of patients with pain in one or both jaw joints. The cause of these difficulties and pain, in addition to disorders involving improper bite techniques, poorly sized articulation prosthesis, inadequate diet composition (if mushy consistency, which reduces the need for involvement of masticatory muscles), and stress, are disorders of the spine, including cervical paravertebral muscle spasm.3,28,29
In line with other departments,11 the authors demonstrated the necessity of complex physiotherapy, by completing the necessary education. Treatment was focused on correcting muscle imbalances in the mandibular joint, as described in the methodology section, along with the restoration of the physiological mobility of the temporomandibular joint. The authors chose mobilization techniques, especially the method of muscle facilitation and inhibition, namely, the isometric contraction of muscles in spasm, followed by isometric relaxation. The anti-gravity method (method based on maximum muscle relaxation during joint movement from one extreme position to another in the joint)30 was also used in the current study. In the treatment, the authors used an active, repetitive movement, which the patient performed in the direction of their particular impairment, in order to prevent the development of resistance in the joint. The results of this reciprocal movement led to the easement of antagonistic muscles. Proper breathing methods were also found to be imperative, as breath has the effect of dampening the facilitating skeletal muscles. Combining the above-mentioned procedures has proved to be effective.8 The biggest advantage of this
Graph 1
Graph 2
The mean values of the pre-treatment and posttreatment extent of the mouth opening were 34.0065.92 and 41.9665.17 mm, respectively (P,0.0001). A high statistically significant improvement in ability to open the mouth after the laser treatment was found (Table 3 and Graph 1). Before the treatment, three patients declared the degree of pain 1, six patients degree 2, nine patients degree 3, and six patients degree 4. After the treatment, only 1 patient suffered pain of degree 2, 8 patients suffered degree 1, and 15 patients declared that they felt no pain (see Table 3 for details). The strong, statistically significant analgesic effects were confirmed using the non-parametric Wilcoxon paired signed-rank test (P,0.0001) (Table 3 and Graph 2).
Discussion
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method is that from the very beginning, the therapy can be done by the patient himself, several times a day. Given physiotherapy treatments, the authors added pulse magnets and hyperthermia (peloids heated to 37uC). The use of this combination was a priority in the current study, as its therapeutic benefit is shown in analgesic and anti-inflammatory effects of a pulsed magnetic field, and peloids, which have a relaxant effect on the tissue (positive thermotherapy).27 In the current study, the authors used one of the best peloids in the world, from the site of the National Nature Reserve SOOS, Franzensbad, Czech Republic. The combination of peloids and pulsed magnetic field reduces muscle spasms of masticatory muscles and has a strong anti-inflammatory and regenerative effect. Hyperthermia peloids are natural for the human body, and are therefore more effective than hyperthermia induced by shortwave diathermy.31 To amplify the analgesic effect, the authors used noninvasive lasers. When selecting the energy density (4 J/ cm2) the authors used the recommended values based on the Arndt–Schultz Law.11,32 To ensure an objective evaluation of the effect of the therapy, the authors selected two independent units, listing the appropriate doctor or dentist, and verified input and output values gathered throughout treatment. Physicians focused on treating musculoskeletal issues. Observed values measured before the start and the end of treatment (level of pain and range of mouth opening, as described above) are simple, and objectively verify the benefits of rehabilitation care.
Conclusion In this study, dedicated to tactics of rehabilitation treatment in disorders of temporomandibular articulation, the authors have demonstrated the need for comprehensive long-term therapy that plays an important role in education and in learning good eating and exercising habits. In invasive procedures, the authors used a combination that was considered to bring positive effects, as with pulse magnetic hyperthermia peloids, which were not used in this indication.
Acknowledgements The study was supported by the IGA of Ministry of Health of the Czech Republic (no. 9902-4).
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