Treating temporomandibular disorders with permanent mandibular repositioning: is it medically necessary?

Prognostic and predictive biomarkers in head and neck cancer: something old, something new, something borrowed, something blue and a sixpence in your shoe

A biomarker is a measurable indicator of biological or pathological processes or the response to an exposure or intervention and is used to guide management decisions. In head and neck pathology, biomarkers are assessed by histological criteria and immunohistochemical and molecular studies. Surgical resection remains the mainstay of management of many head and neck malignancies. Adjuvant radiotherapy and/or systemic therapy may be administered depending on the presence of adverse prognostic factors identified on histopathological or immunohistochemical examination. In this review, we outline the clinically relevant prognostic and predictive factors in head and neck malignancies including conventionally recognised factors such as tumour size, depth of invasion, lymphovascular and perineural invasion and margin status as well as novel evolving factors such as recurrent genetic rearrangements and assessment of immune checkpoints. Practical issues are discussed to assist with recognising and reporting of these factors. A summary of useful tools such as structured pathology report formats is also included to assist with comprehensive reporting of all clinically relevant parameters, minimise risk and improve workflow efficiencies.

A clinical trial: Aqualizer ™ therapy and its effects on myopathies or temporomandibular dysfunctions. Part I: Objective parameters

OBJECTIVE

Symptoms of temporomandibular dysfunction (TMD) may include pain in the muscles or restrictions opening the mouth. The aim of this study was to assess the effects of initial Aqualizer™ therapy.

METHODS

Group 1 received initial Aqualizer™ therapy before definitive hard splint; Group 2 received no initial therapy. Patients with arthrosis, partial/total prosthesis or undergoing splint therapy were excluded. Objective (temporomandibular joint palpation, temporomandibular joint auscultation, palpation of the chewing muscles, and mobility of the lower jaw) parameters were evaluated. The level of statistical significance was 5% (p < 0.05).

RESULTS

In 53 patients (Group 1 n = 25; Group 2 n = 28), a significant improvement (p < 0.001) was found in Group 1 in pain on palpation (masseter muscle, temporal muscle, post-mandibular region, lateral pterygoid muscle, and suboccipital region), but no significant differences in jaw mobility were found.

CONCLUSION

Aqualizer™ therapy produces significant improvement of primary symptoms.

Chewing performance of patients with worn dentition before and after restorations: A scoping review

BACKGROUND

Tooth wear is a multifactorial complex process related to the loss of dental tissue, due to chemical or mechanical processes, by abrasion, attrition, erosion. Restorative treatment represents an attempt to rebuild and recreate the lost structure.

OBJECTIVE

This scoping review aims to investigate whether restorative treatment of worn dentition (either with direct or indirect adhesive composite adhesive procedures or with prosthetic techniques) can have an impact on the masticatory performance parameters.

METHODS

A scoping review was conducted on multiple databases (Pubmed, Medline CENTRAL, ICTRP), following the PRISMA guidelines. Abstracts of research papers were screened for suitability, and full-text articles were obtained for those who satisfied the inclusion and exclusion criteria.

RESULTS

Only one article meet the inclusion criteria of the review. Restorative treatment of worn dentition although have a positive impact on the self-report ability to chew, has no effect on the masticatory performance test.

CONCLUSION

At the moment, not enough evidence to comment on the actual therapeutic role of restorative treatment on tooth wear is available. Clinicians, before taking any clinical decision, should carefully discuss with patients the needs and expectations of the treatment plan.

A clinical trial: Aqualizer ™ therapy and its effects on myopathies or temporomandibular dysfunctions. Part II: Subjective parameters

OBJECTIVE

Temporomandibular dysfunction (TMD) reduces patients' quality of life (QoL). The aim was to assess the effects of initial Aqualizer™ therapy.

METHODS

Group 1 (initial Aqualizer™ therapy) before definitive splint therapy or Group 2 (no initial therapy). Patients with arthrosis, partial/total prosthesis, or were undergoing splint therapy were excluded. Subjective parameters were evaluated: duration and intensity of pain, influence on wellbeing, changes in the head/neck area, handling and improvement of the Aqualizer™, improvement in QoL. The statistical significance level was 5% (p < 0.05).

RESULTS

In 53 patients (Group 1 n = 25; Group 2 n = 28), the improvement in patients' well-being and intensity of pain in both groups was significant (p < 0.001). An improvement in QoL was found in 84% of patients in Group 1 and 75% in Group 2.

CONCLUSION

Initial Aqualizer™ therapy can decrease the intensity of pain and increase patients'.

Recommendations on the Use of Oral Orthotic Occlusal Appliance Therapy for Temporomandibular Joint Disorders: Current Evidence and Clinical Practice

Background

'Temporomandibular joint disorders (TMDs)' denote an umbrella term that includes arthritic, musculoskeletal and neuromuscular conditions involving the temporomandibular joint, the masticatory muscles, and the associated tissues. Occlusal devices are one of the common treatment modalities utilized in the conservative management of TMDs. The indications for the available 'oral splints' or 'oral orthotic occlusal devices' remain ambiguous.

Methods

A joint international consortium was formulated involving the subject experts at TMJ Foundation, to resolve the current ambiguity regarding the use of oral orthotic occlusal appliance therapy for the temporomandibular joint disorders based on the current scientific and clinical evidence.

Results

The recommendations and the conclusion of the clinical experts of the joint international consort has been summarized for understanding the indications of the various available oral orthotic occlusal appliances and to aid in the future research on oral occlusal orthotics.

Conclusion

The use of the oral orthotic occlusal appliances should be based on the current available scientific evidence, rather than the archaic protocols.

Treatment of severe open bite and mandibular condyle anterior displacement by mini-screws and four second molars extraction: A case report

BACKGROUND

Temporomandibular joint (TMJ) disorders are closely related to high-angle and skeletal Class II malocclusion. Sometimes pathological changes in the mandibular condyle can cause open bite to occur after growth is complete.

CASE SUMMARY

This article is about the treatment of an adult male patient with a severe hyperdivergent skeletal Class II base, an unusual and gradually occurring open bite and an abnormal mandibular condyle anterior displacement. Because the patient refused surgery, four second molars with cavities and root canal therapy were extracted, and four mini-screws were used for intrusion of the posterior teeth. The treatment duration was 22 mo, and after the treatment, the open bite was corrected and the displaced mandibular condyles were seated back to the articular fossa as shown by cone-beam computed tomography (CBCT). Based on the patient’s open bite history, the result of clinical examinations and CBCT comparisons, we believe it is possible that the occlusion interference was eliminated after the four second molars were extracted and the posterior teeth were intruded, and the patient's condyle spontaneously returned to its physiologic position. Finally, a normal overbite was established, and stable occlusion was achieved.

CONCLUSION

This case report suggested that identifying the cause of open bite is essential, and the TMJ factors for hyperdivergent skeletal Class II cases should be particularly examined. For these cases, intruding posterior teeth may place the condyle in a more appropriate position and provide an environment suitable for TMJ recovery.

Temporomandibular Disorders: Implications in Restorative Dentistry and Orthodontics

Over the past several decades, the science of restorative/reconstructive dentistry and orthodontics has evolved tremendously, following sound principles passed down from robust literature and scientific rationale. These principles have been solid and instrumental in enhancing dentistry, from a single tooth restoration to complex full-mouth rehabilitations. However, it must be noted that some of the principles and philosophies followed over these decades have been questioned based on the advances in science, technology, and evidence-based medicine. The scenario became complex when clinicians were faced with the question of guidance for optimum joint and muscle health as related to restorative dentistry and orthodontics.

Decellularized small intestine submucosa device for temporomandibular joint meniscus repair: Acute timepoint safety study

Temporomandibular joint (TMJ) Meniscus removal is an option for the patient to regain full range of motion if the disc is irreversibly damaged or unable to be reduced. However, this procedure leaves the joint vulnerable to condylar remodeling and degeneration. We have shown that extracellular matrix (ECM) scaffolds remodel into a tissue with near native TMJ meniscus in previous studies. The next step towards clinical translation is to manufacture the ECM scaffold as a device under good manufacturing practices (GMP) and test it in a pre-clinical animal study under good laboratory practices (GLP). The primary objective of this study was to evaluate the in-vivo histopathological response to a Prototype GMP manufactured device made of decellularized porcine small intestinal submucosa (SIS), by observing for signs of surrounding tissue reaction to the device that are indicative of an adverse host response in comparison to an empty control at 21 days post-surgical implantation in a canine TMJ meniscus removal and implant model in a GLP setting. The conclusive findings were that the ECM device is safe for placement in the TMJ. After 21 days post implantation, histology of tissue surrounding the device and draining lymph nodes showed that the Prototype GMP device had no negative effects compared to the empty site (as evaluated by the board-certified veterinary pathologist). Furthermore, there was a lack of negative findings for clinical pathology (hematology and clinical chemistry), mortality, and body weight/weight change. Future studies will go to one year after implantation to show that the remodel device remains as a viable tissue with near native mechanical properties.

Nonsurgical treatment of class III malocclusion with temporomandibular disorder comorbidity: A clinical report

The treatment of a 57-year-old woman with combined skeletal and pseudo-class III malocclusion who was also suffering from chronic myofascial orofacial pain is described. The challenge was to treat the patient's malocclusion while simultaneously managing the temporomandibular disorder. After a successful 3-month occlusal device therapy, which substantially reduced the patient's discomfort, a nonsurgical therapy by using complete-mouth fixed restorations was planned. The treatment was first tested by using printed interim restorations before monolithic zirconia restorations were provided. Stable occlusion and a pain-free outcome were observed at the 3-month follow-up.

Transitioning to chronic temporomandibular disorder pain: A combination of patient vulnerabilities and iatrogenesis

Background

Based on a variety of studies conducted in recent years, some of the factors that might contribute to the negative treatment responses of some TMD patients have been elucidated.

Methods

This paper describes known vulnerability factors that make individuals susceptible to developing temporomandibular disorders (TMDs), as well as those that contribute to the perpetuation of such problems. In addition, the topic of iatrogenesis is discussed as a major contributor to the negative outcomes that can be seen in this field.

Results

At the patient level, anatomical, psychosocial and genetic factors may contribute to individual vulnerability. The anatomy and pathophysiology of muscles, joints, disc and nerves may all be involved in predisposing to TMD symptoms, especially when the patients have pain elsewhere in the body. Among the psychosocial factors, some features may be elucidated by the DC/TMD axis II, while others (eg illness behaviour, Munchausen syndrome, lack of acceptance of non‐mechanical approaches) require careful evaluation by trained clinicians. Genetic predisposition to first onset TMDs and to chronification of symptoms has been identified for individuals with certain psychological traits, presence of comorbid conditions and certain abnormal clinical manifestations. Regarding iatrogenesis, sins of omission may influence the clinical picture, with the main ones being misdiagnosis and undertreatment. Joint repositioning strategies, occlusal modifications, abuse of oral appliances, use of diagnostic technologies, nocebo effect and complications with intracapsular treatments are the most frequent sins of commission that may contribute to chronification of TMDs. The patients who present with massive occlusal and jaw repositioning changes combined with persistent severe orofacial pain are not a rarity within TMD and orofacial pain canters; these patients are the most difficult ones to manage because of this horrific combination of negative factors.

Conclusions

The information presented in this paper will help clinicians to understand better why some individuals develop temporomandibular disorders, why some of them will progress to becoming chronic patients, and what the appropriate responses may be.

Neuro-Muscular Dentistry: the "diamond" concept of electro-stimulation potential for stomato-gnathic and oro-dental conditions

Oro-Pharyngeal Dysphagia - or simply dysphagia - is the difficulty (persistent) in swallowing/passing food and/or liquid from the mouth to the pharynx into the esophagus and finally the stomach; a deglutition disorder (a symptom, by definition, often due to neuro-degenerative/−muscular, drug-induced or localized structural pathologies such as head and neck tumors, lesions and associated surgical and/or radiation injuries) linked to severe consequences on Quality of Life (QoL), including malnutrition, dehydration, and even sudden death. Likewise, Temporo-Mandibular Jaw and Joint disorder(s) – or simply TMD – is a multifactorial etiological condition, regularly encountered in the dental office. Whether due to malocclusion, bruxism, stress and/or trauma, TMD destabilizes the whole cranio-mandibular system structurally and functionally, via affecting mastication, teeth, supporting structures, comfort and aesthetics, and thus, QoL, again. While several treatment regimens do exist for such conditions, some of which have been standardized for use over the years, most continue to lack proper evidence-based literature support. Hence, (1) caution is to be exercised; and (2) the need for alternative therapeutic strategies is amplified, subsequently, the door for innovation is wide open. Indeed, neuromuscular electrical stimulation or “NMES”, is perhaps a fine example. Herein, we present the interested oro-dental health care provider with an up-dated revision of this therapeutic modality, its potential benefits, risks and concerns, to best handle the dysphagic patient: an intra-disciplinary approach or strategy bridging contemporary dentistry with speech and language therapy; a rather obscure and un-discovered yet critical allied health profession. A pre-clinical and clinical prospectus on employing inventive NMES-based regimens and devices to manage TMD is also highlighted.

Evaluation of prolotherapy in comparison with occlusal splints in treating internal derangement of the temporomandibular joint - A randomized controlled trial

PURPOSE

The aim of this study was to compare the efficacy of dextrose prolotherapy with that of occlusal splints in treating internal derangement of the temporomandibular joint.

PATIENTS AND METHODS

A total of 34 patients with temporomandibular joint internal derangement classed as Wilkes stages II or III were recruited for the study, and were randomly divided into study and control groups with 17 patients each. The patients in these control and study groups were treated with splints and prolotherapy, respectively. Outcome parameters, such as pain, mouth opening, clicking and deviation, were assessed using the Helkimo clinical dysfunction index for a review period of 1 year.

RESULTS

Nine patients in the study group had complete absence of pain, compared with only one patient in the control group. The results showed that patients who received prolotherapy demonstrated improvement in pain (p < 0.001), mouth opening (p = 0.032), and clicking (p < 0.001), but no significant difference in deviation was observed between the groups after 1 year (p = 0.862).

CONCLUSION

Prolotherapy was found to be superior in providing long-term clinical relief, with reduction in pain and clicking along with improved mouth opening.

Oral rehabilitation following successful TMD treatment with condylar position changes: A case report

BACKGROUND

A 31-year-old woman with crowns, fixed partial prostheses, and dental restorations complained of recurrent pain in the left and right temporomandibular joints during the last 2 years.

CLINICAL PRESENTATION

The symptoms of temporomandibular disorder (TMD) resolved successfully after a 3-month-long treatment with a repositioning splint. Pre- and post-operative cone-beam computed tomography revealed slight changes in the condylar position after splint use. Minimally invasive oral rehabilitation guided by digital design was performed to maintain the acquired stable position. The status of the restorations was good, and the TMD symptoms did not relapse during the 3-year follow-up.

CONCLUSION

This case report demonstrates the importance of a stable adapted condylar position after extensive prosthodontic treatment.

Temporomandibular disorders: improving outcomes using a multidisciplinary approach

Patients with temporomandibular disorders (TMD) can become very complex. This article aims to highlight the importance of the multimodal and multidisciplinary approach in this type of patients to improve clinical outcomes. At present we have innumerable techniques and tools to approach this type of patients from a biopsychosocial model where active and adaptive type treatments are fundamental. There are various health professions that have competence in the treatment of TMD, however, although in the most complex cases should be treated simultaneously, still too many patients receive unique treatments and only from one point of view. This review exposes the treatments available from a clinical-scientific perspective and also emphasizes the importance of working in specialized units with those professionals who have competencies on the different conditions that may occur.

Seeking treatment for temporomandibular disorders: What patients can expect from non-dental health care providers

The dental profession has long been the primary source for clinical management of patients with temporomandibular disorders (TMDs). However, patients with a facial pain problem may seek diagnosis and/or treatment from other health care providers. These providers may be physicians or other professional-level practitioners, or they could be members of various allied groups, such as physical therapists or occupational therapists. However, little has been written about what patients might experience if they seek care outside of the dental profession. This article reports the results of an Internet survey of non-dental professionaland allied health care professionals to learn what they might offer to patients who may be seeking treatment for TMDs. The official organizational websites for all groups, as well as the websites of individual practitioners in each group, were reviewed. Most of the official websites had little or no information about TMDs, but some members of every group surveyed were offering to treat TMDs in their offices. The variety of treatments being offered went far beyond the boundaries of appropriate TMD management in the 21st century. These results are presented with a critical discussion of each concept or practice, as well as advice for both dentists and patients to deal with this situation.

Orthognathic Surgery as a Treatment for Temporomandibular Disorders

Well-controlled clinical trials supporting orthognathic surgery as the primary management for temporomandibular disorders (TMDs) are lacking. Most published studies lack an adequate experimental design to minimize biases. Studies that did minimize some biases do support an overall reduction in the frequency of TMD signs and symptoms in some Class III and Class II patients who had orthognathic surgery. However, Class II correction with counter-clockwise rotation of the mandible increased TMD. Individual variability precludes the ability to predict TMD outcome after surgery. Irreversible therapies such as orthognathic surgery should not be primary treatments in the management or prevention of TMDs.

Do patients with malocclusion have a higher prevalence of temporomandibular disorders than controls both before and after orthognathic surgery? A systematic review and meta-analysis

PURPOSE

The aim of this study was to identify, through meta-analysis, whether patients who require orthognathic surgery have a higher prevalence of temporomandibular disorders (TMDs) than controls, both before treatment and after.

MATERIAL AND METHODS

A systematic review and meta-analysis were conducted based on PRISMA guidelines, to address the study purposes. A search of major databases through PubMed, EMBASE, and Cochrane CENTRAL was performed to locate all pertinent articles published from inception to June 2016. Inclusion criteria were controlled clinical studies, either prospective or retrospective, and case-control studies comparing preoperative and postoperative signs and symptoms of TMDs in patients who undergo orthognathic surgery to those of a healthy volunteer population with no dentofacial deformities. The predictor variables were patients with dentofacial deformities who underwent orthognathic surgery and patients with no dentofacial deformities and with good maxillomandibular relations and normal occlusion. The outcomes variables were the weighted, prevalence rate (proportion) in signs and symptoms of TMDs in patients with dentofacial deformities and risk ratio (RR) of signs and symptoms of TMDs before and after orthognathic surgery, compared to the control group.

RESULTS

A total of 542 patients enrolled in 6 studies were included in this analysis. The overall pooled weighted rate or prevalence of TMDs for orthognathic surgery patients preoperatively was 32.5% (95% CI = 26.7%-38.9%). There was a significant difference between the 2 groups with respect to TMDs before surgery, but no significant difference in TMDs after surgery. The RR for patients who had dentofacial deformities before orthognathic surgery compared with a control group was 1.634 (95% CI = 1.216-2.194; P = 0.001). The RR for patients after orthognathic surgery compared with a control group was 1.262 (0.718; 95% CI = 0.805-1.979; P = 0.311).

CONCLUSION

The results of this study show that patients who are going to have a correction of their malocclusion by orthodontics and orthognathic surgery have a significant incidence of TMDs when compared to a control population, but that after treatment, the incidence of TMDs does not differ from a control population. The reasons for these findings are not clear.

Dental Angle class asymmetry and temporomandibular disorders

OBJECTIVES

The aim of this study was to determine whether there is an association between the presence of asymmetric molar or canine Angle classes on the two sides and the presence of temporomandibular joint dysfunction (TMD).

MATERIALS AND METHODS

Participants to the study were divided into two groups: TMD group (90 patients) or a control group (58 patients). In the TMD group, clinical assessment for TMD was performed according to the Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) guidelines by the same two trained examiners. In both groups, all subjects underwent an assessment of dental occlusion, focusing on the assessment of bilateral canine and molar Angle class relationship. The study protocol was reviewed and approved by the Institutional Review Board of the University of Padova, and each participant gave written consent to take part in the investigation.

RESULTS

TMJ pain was diagnosed in 58, disk displacement in 96, arthrosis in 17, and muscle pain in 46 individuals. Molar Angle class was symmetrical in 86 individuals and asymmetrical in 62 subjects. Molar Angle class was not correlated with any of the TMD diagnoses. Canine Angle class was correlated with TMJ arthrosis. Correlation values with the other TMD diagnoses were low and were not significant.

CONCLUSIONS

It can be suggested that an association between dental Angle class asymmetry and TMDs does not exist and that the role of dental asymmetries as a factor correlated with the presence of TMD signs and symptoms is minimal.

Orthodontics is temporomandibular disorder-neutral

OBJECTIVES

To assess if subjects with a clinical diagnosis of temporomandibular disorders (TMDs) have a similar prevalence of orthodontic history as a population of TMD-free individuals and to assess if those subjects who have a history of ideal orthodontics have fewer symptoms than those with a history of nonideal orthodontics.

MATERIALS AND METHODS

Two groups of age- and sex-matched individuals belonging to either a study ("TMD") or a control group were recruited. Subjects who underwent orthodontic treatment were classified as having a history of ideal or nonideal orthodontics based on the current presence of normal values in five reference occlusal features.

RESULTS

The correlation with a history of orthodontic treatment was not clinically significant for any of the TMD diagnoses (ie, muscle pain, joint pain, disc displacement, arthrosis), with Phi (Φ) coefficient values within the -0.120 to 0.058 range. Within the subset of patients with a history of orthodontics, the correlation of ideal or nonideal orthodontic treatment with TMD diagnoses was, in general, not clinically relevant or was weakly relevant.

CONCLUSIONS

Findings confirmed the substantial absence of clinically significant effects of orthodontics as far as TMD is concerned. The very low correlation values of a negative or positive history of ideal or nonideal orthodontics with the different TMD diagnoses suggest that orthodontic treatment could not have a true role for TMD.