Medikamentöse Therapie bei Kiefergelenkschmerzen

Transcutaneous auricular vagus nerve stimulation for the treatment of myoarthropatic symptoms in patients with craniomandibular dysfunction - a protocol for a randomized and controlled pilot trial

BACKGROUND

Temporomandibular disorders (TMD) are a collective term for pain and dysfunction of the masticatory muscles and the temporomandibular joints. The most common types of TMD are pain-related, which may impact the psychological behavior and quality of life. Currently, the most popular methods for the treatment of TMD patients are occlusal splint therapy, often in combination with physical- and/or pharmacotherapy. However, due to the complexity of etiology, the treatment of chronic TMD remains a challenge. Recently, CE-certified systems for non-invasive VNS (transcutaneous auricular vagus nerve stimulation, taVNS) have become available and show positive effects in the treatment of chronic pain conditions, like migraine or fibromyalgia, with which TMD shares similarities. Therefore, it is the main purpose of the study to evaluate the feasibility of daily taVNS against chronic TMD and to assess whether there is an improvement in pain severity, quality of life, and kinetic parameters.

METHODS

This study is designed as a single-blinded, double-arm randomized controlled trial (RCT) in a 1:1 allocation ratio. Twenty adult patients with chronical TMD symptoms will be enrolled and randomized to stimulation or sham group. In the stimulation group, taVNS is performed on the left tragus (25 Hz, pulse width 250 µs, 28 s on/32 s off, 4 h/day). The sham group will receive no stimulation via a non-functional identical-looking electrode. Validated questionnaire data and clinical parameters will be collected at the beginning of the study and after 4 and 8 weeks. The compliance of a daily taVNS of patients with chronical TMD will be evaluated via a smartphone app recording daily stimulation time and average intensity. Additionally, the treatment impact on pain severity and quality of life will be assessed with different questionnaires, and the effect on the mandibular mobility and muscle activity will be analyzed.

DISCUSSION

This is the first clinical trial to assess the feasibility of taVNS in patients with chronic TMD symptoms. If taVNS improves the symptoms of TMD, it will be a significant gain in quality of life for these chronic pain patients. The results of this pilot study will help to determine the feasibility of a large-scale RCT.

TRIAL REGISTRATION

This study has been registered in the DRKS database (DRKS00029724).

Condylar dysfunctional remodeling and recortication: a case-control study

BACKGROUND

Temporo-mandibular disorders (TMD) is a collective term comprehending different clinical issues involving masticatory muscles, temporo-mandibular joint (TMJ) and other associated structures. TMD diagnosis is not made for its pathogenesis or etiology, but mainly on clinical symptoms. Primary dysfunction develops mostly on four factors: individual predisposition, high psychomotor activity (due to stress or parafunction), occlusal instability and low or absent tissue adaptation capability. On the other hand, secondary disorders can be caused by hereditary or congenital diseases, rheumatic inflammatory diseases, autoimmune and tumoral diseases. During their function, the condyles undergo a structural adaptive and physiological remodeling, but when mechanical stress exceeds adaptive capability, dysfunctional remodeling phenomena may occur. It is characterized by significant condylar morphological modifications at the level of the head of the condyle (smaller condyle), break of cortical integrity and reduced mandibular ramus height with subsequent mandibular retrusion and articular function alteration. The aim of this study is to compare condylar recortication amount, and pain reduction after two different therapeutic protocols.

METHODS

This is a case-control study. Twenty TMD patients were chosen and each of them underwent a documentation protocol including extraoral and intraoral photographs, dental casts, casts mounting on the articulator to evaluate CPI (CO-CR discrepancy index) and cone beam computed tomography (CBCT) of the mandibular condyles taken in closed mouth position. For the radiographic evaluation, a Planmeca ProMax 3D Mid system was utilized with an acquiring volume of 80×80 mm dimension, exposition 90 kV, 10.0 mA, 12 seconds with a DAP (Dose Area Product) of 1094 mGy·cm2 for each condyle. The acquired volume was elaborated by the Planmeca Romexis software v. 3.2.0.R and TMJ module. Seven coronal cuts and 10 sagittal cuts were performed on the head of the condyle to highlight the amount of cortication, before and after the application of two different therapeutic protocols. Protocol number 1 (N.=10 patients) included the exclusive use of a splint, while protocol number 2 (N.=10 patients) included the use of a splint associated with pharmacological therapy (NSAIDs, antioxidant, omega 3). The revaluation was performed on asymptomatic patient after a period of 6-8 months. The pain for each patient was assessed by a Visual Analogue Scale (VAS) from 0 to 10, 0 meaning no pain and 10 the worst pain ever felt. The VAS was evaluated after 10 days from the beginning of the treatment, after 3 months and after 8 months at the end of the treatment. Statistical analyses were carried using a χ2 test (P value <0.05).

RESULTS

No significant differences in the amount of cortication were found in the radiographic revaluation between the two different therapeutic protocols, even though it was noticed that the use of medicaments brought to a resolution of the symptoms in a shorter period of time (P=0.00001 after 10 days; P=0.0251 after 3 months).

CONCLUSIONS

According to this study, pharmacological protocol in the therapy of TMD does not seem to affect condylar cortication. Medicaments although seem to accelerate the disappearance of clinic symptomatology, but more researches are needed to valid these findings.