Evaluation of iontophoretically applied dexamethasone for painful pathologic temporomandibular joints

Temporomandibular disorders. Part 2: conservative management

Appropriate management of temporomandibular disorders (TMD) requires an understanding of the underlying dysfunction associated with the temporomandibular joint (TMJ) and surrounding structures. A comprehensive examination process, as described in part 1 of this series, can reveal underlying clinical findings that assist in the delivery of comprehensive physical therapy services for patients with TMD. Part 2 of this series focuses on management strategies for TMD. Physical therapy is the preferred conservative management approach for TMD. Physical therapists are professionally well-positioned to step into the void and provide clinical services for patients with TMD. Clinicians should utilize examination findings to design rehabilitation programs that focus on addressing patient-specific impairments. Potentially appropriate plan of care components include joint and soft tissue mobilization, trigger point dry needling, friction massage, therapeutic exercise, patient education, modalities, and outside referral. Management options should address both symptom reduction and oral function. Satisfactory results can often be achieved when management focuses on patient-specific clinical variables.

Clinical Use of Iontophoresis to Treat Facial Pain

Iontophoresis is a modality that assists with the entry of certain therapeutic medications into injured sites. Medications, such as anesthetics, vasoconstrictors, and some corticosteroids, when dissolved in water, separate into positive and negative ions. When an electric current is passed through an ionized solution, the ions of these agents carry the electric current from the positive to the negative electrode. The above medications have been shown to be beneficial in the treatment of TMD. These agents in liquid form are placed in meditrode pads that are attached to skin or mucosal surface over the sites that are to be treated. The treating (active) meditrodes and a larger ground (dispersive or return) meditrode are attached to an iontophoretic unit by wire leads to form a closed circuit. With iontophoresis, the treating medications can be placed in the target areas in high concentrations.

Interventions for the management of temporomandibular joint osteoarthritis

BACKGROUND

Osteoarthritis (OA) is the most common form of arthritis of the temporomandibular joint (TMJ), and can often lead to severe pain in the orofacial region. Management options for TMJ OA include reassurance, occlusal appliances, physical therapy, medication in addition to several surgical modalities.

OBJECTIVES

To investigate the effects of different surgical and non-surgical therapeutic options for the management of TMJ OA in adult patients.

SEARCH METHODS

We searched the following databases: the Cochrane Oral Health Group Trials Register (to 26 September 2011); CENTRAL (The Cochrane Library 2011, Issue 3); MEDLINE via OVID (1950 to 26 September 2011); EMBASE via OVID (1980 to 26 September 2011); and PEDro (1929 to 26 September 2011). There were no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing any form of non-surgical or surgical therapy for TMJ OA in adults over the age of 18 with clinical and/or radiological diagnosis of TMJ OA according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) guideline or compatible criteria.Primary outcomes considered were pain/tenderness/discomfort in the TMJs or jaw muscles, self assessed range of mandibular movement and TMJ sounds. Secondary outcomes included the measurement of quality of life or patient satisfaction evaluated with a validated questionnaire, morphological changes of the TMJs assessed by imaging, TMJ sounds assessed by auscultation and any adverse effects.

DATA COLLECTION AND ANALYSIS

Two review authors screened and extracted information and data from, and independently assessed the risk of bias in the included trials.

MAIN RESULTS

Although three RCTs were included in this review, pooling of data in a meta-analysis was not possible due to wide clinical diversity between the studies. The reports indicate a not dissimilar degree of effectiveness with intra-articular injections consisting of either sodium hyaluronate or corticosteroid preparations, and an equivalent pain reduction with diclofenac sodium as compared with occlusal splints. Glucosamine appeared to be just as effective as ibuprofen for the management of TMJ OA.

AUTHORS' CONCLUSIONS

In view of the paucity of high level evidence for the effectiveness of interventions for the management of TMJ OA, small parallel group RCTs which include participants with a clear diagnosis of TMJ OA should be encouraged and especially studies evaluating some of the possible surgical interventions.

Effectiveness of dexamethasone iontophoresis for temporomandibular joint involvement in juvenile idiopathic arthritis

OBJECTIVE

Temporomandibular joint (TMJ) involvement is common in juvenile idiopathic arthritis (JIA). Dexamethasone iontophoresis (DIP) uses low-grade electric currents for transdermal dexamethasone delivery into deeper anatomic structures. The purpose of this study was to assess the safety and effectiveness of DIP for the treatment of TMJ involvement in JIA, and to delineate variables that are associated with improvement after DIP.

METHODS

Medical records of all JIA patients who underwent DIP for TMJ involvement at a larger tertiary pediatric rheumatology center from 1997-2011 were reviewed. DIP was performed using a standard protocol. The effectiveness of DIP was assessed by comparing the maximal interincisor opening (MIO(TMJ) ) and the maximal lateral excursion (MLE(TMJ) ) before and after treatment.

RESULTS

Twenty-eight patients (ages 2-21 years) who received an average of 8 DIP treatment sessions per involved TMJ were included in the analysis. Statistically significant improvement in the median MIO(TMJ) (P < 0.0001) was observed in 68%. The median MLE(TMJ) (P = 0.03) improved in 69%, and resolution of TMJ pain occurred in 73% of the patients who had TMJ pain at baseline. Side effects of DIP were transient site erythema (86%), skin blister (4%), and metallic taste (4%). Improvement in TMJ range of motion from DIP is associated with lower MIO(TMJ) , lower MLE(TMJ) , and absence of TMJ crepitus at baseline.

CONCLUSION

In this pilot study, DIP appeared to be an effective and safe initial treatment of TMJ involvement in JIA, especially among patients with decreased TMJ measurements. Prospective controlled studies are needed.

Methodological quality of a systematic review on physical therapy for temporomandibular disorders: influence of hand search and quality scales

The validity of a systematic review depends on completeness of identifying randomised clinical trials (RCTs) and the quality of the included RCTs. The aim of this study was to analyse the effects of hand search on the number of identified RCTs and of four quality lists on the outcome of quality assessment of RCTs evaluating the effect of physical therapy on temporomandibular disorders. In addition, we investigated the association between publication year and the methodological quality of these RCTs. Cochrane, Medline and Embase databases were searched electronically. The references of the included studies were checked for additional trials. Studies not electronically identified were labelled as “obtained by means of hand search”. The included RCTs (69) concerning physical therapy for temporomandibular disorders were assessed using four different quality lists: the Delphi list, the Jadad list, the Megens & Harris list and the Risk of Bias list. The association between the quality scores and the year of publication were calculated. After electronic database search, hand search resulted in an additional 17 RCTs (25%). The mean quality score of the RCTs, expressed as a percentage of the maximum score, was low to moderate and varied from 35.1% for the Delphi list to 54.3% for the Risk of Bias list. The agreement among the four quality assessment lists, calculated by the Interclass Correlation Coefficient, was 0.603 (95% CI, 0.389; 0.749). The Delphi list scored significantly lower than the other lists. The Risk of Bias list scored significantly higher than the Jadad list. A moderate association was found between year of publication and scores on the Delphi list (r = 0.50), the Jadad list (r = 0.33) and the Megens & Harris list (r = 0.43).

In vitro optimization of dexamethasone phosphate delivery by iontophoresis

BACKGROUND AND PURPOSE

This study was designed to evaluate the effects of competing ions and electroosmosis on the transdermal iontophoresis of dexamethasone phosphate (Dex-Phos) and to identify the optimal conditions for its delivery.

METHODS

The experiments were performed using pig skin, in side-by-side diffusion cells (0.78 cm(2)), passing a constant current of 0.3 mA via Ag-AgCl electrodes. Dex-Phos transport was quantified for donor solutions (anodal and cathodal) containing different drug concentrations, with and without background electrolyte. Electrotransport of co-ion, citrate, and counterions Na(+) and K(+) also was quantified. The contribution of electroosmosis was evaluated by measuring the transport of the neutral marker (mannitol).

RESULTS

Electromigration was the dominant mechanism of drug iontophoresis, and reduction in electroosmotic flow directed against the cathodic delivery of Dex-Phos did not improve drug delivery. The Dex-Phos flux from the cathode was found to be optimal (transport number of approximately 0.012) when background electrolyte was excluded from the formulation. In this case, transport of the drug is limited principally by the competition with counterions (mainly Na(+) with a transport number of approximately 0.8) and the mobility of the drug in the membrane.

DISCUSSION AND CONCLUSION

Dex-Phos must be delivered from the cathode and formulated rationally, excluding mobile co-anions, to achieve optimal iontophoretic delivery.

Absorption of dexamethasone sodium phosphate in human connective tissue using iontophoresis

BACKGROUND

Iontophoresis ostensibly facilitates the delivery of medications through the skin to underlying tissues using a direct electrical current. Dexamethasone is the most commonly used medication with iontophoresis to treat a variety of connective tissue disorders.

HYPOTHESIS

Iontophoresis will facilitate the absorption of dexamethasone into connective tissue compared with diffusion.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twenty-nine adults undergoing anterior cruciate ligament reconstructive surgery using the semitendinosus/gracilis autograft were randomly assigned to either a true iontophoresis (TI) or sham iontophoresis (SI). In the TI group, a 40-mA/min dose of iontophoresis using a 0.4% (4 mg/mL) solution of dexamethasone was used targeting the semitendinosus tendon just before surgery. The SI group underwent the same treatment, but the machine was not turned on. Tissue was extracted within 4 hours of treatment and analyzed for dexamethasone. In addition, 2 control samples were sent to the laboratory for analysis.

RESULTS

There was a statistically significant difference in dexamethasone concentrations between the groups (P = .0216). Of the 16 samples in the TI group, 8 had measurable amounts of dexamethasone, with an average concentration of 2.906 ng/g of tendon tissue. In the SI group, 1 of the 13 samples had measurable amounts of dexamethasone with an average concentration of 0.205 ng/g of tendon tissue. The control samples contained no dexamethasone.

CONCLUSION

Iontophoresis facilitates the transmission of dexamethasone to connective tissues in humans.

CLINICAL RELEVANCE

Iontophoresis can deliver dexamethasone to connective tissues in humans.

Therapie bei Arthralgie der Kiefergelenke

Arthralgias of the temporomandibular joint occur rarely in their isolated form, in contrast to myalgias of the jaw muscles. Most often, arthralgias are combined with myofascial pain. Here we define relevant terms (arthralgia, arthropathy, arthritis, osteoarthritis/osteoarthrosis), describe special diagnostic aspects and provide diagnosis-related specifications. We then present current information on the clinical management of temporomandibular joint pain. A systematic literature search revealed that pain reduction or pain relief can be achieved with non-invasive reversible methods for the majority of patients. Results from short and long-term longitudinal studies show that different therapeutic methods are similarly effective. For the management of chronic forms with extensive psychosocial impairment a multidisciplinary approach is essential.

Pharmacologic treatments for temporomandibular disorders

Drugs are widely used in the management of acute and chronic orofacial pain. Whereas the use of analgesics for acute orofacial pain is well documented through hundreds of controlled clinical trials, the use of a broad spectrum of drugs for chronic pain is based on very few studies. In the absence of data supporting a therapeutic benefit for a drug used chronically for pain, toxicity associated with the drug can still occur. It is critical, therefore, to assess the balance between therapeutic benefit and safety. This article reviews current evidence supporting the use of several drug classes for temporomandibular disorders (TMD) and identifies therapeutic controversies in need of further research.

Identifying a neurobiologic basis for drug therapy in TMDs

Emerging results from clinical and basic research indicate that persistent pain results in changes in the central nervous system. These changes may help explain chronic orofacial pain and lead to new therapies. The authors review data that support the use of tricyclic antidepressants for neurogenic or atypical pain, and benzodiazepines for musculoskeletal pain. Dentists must weigh the benefits of the chronic administration of a drug for the management of temporomandibular disorders against the equivocal scientific support for the use of many drug classes and the potential for serious toxicity with prolonged administration.