Development of Core Outcome Sets for Clinical Trials in Temporomandibular Disorders

Background Temporomandibular Disorder (TMD) is a generic term applied to describe musculoskeletal disorders that affect the temporomandibular joint (TMJ), the masticatory muscles and the related structures. TMD comprises two groups of disorders, namely intra-articular TMD and masticatory muscle disorders. There is still difficulty in establishing the effectiveness of different therapeutic modalities for TMD with robust evidence, despite the large volume of publications in the area. The lack of outcomes standardization may represent a limiting factor in the search for scientific evidence. Objective This study aims to develop a core outcome sets (COS) for clinical trials in intra-articular TMD and masticatory muscle disorders. Methods The protocol for determining the COS-TMD will consist of three phases: 1. Synthesis of TMD Management Intervention Outcomes. The identification of outcomes will be carried out through a systematic review, which will include randomized clinical trials that evaluated the effectiveness of interventions used in TMD management. 2. Through a two-round international Delphi survey, the list of outcomes will be scored by three panels of stakeholders. 3. A representative sample of key stakeholders will be invited to participate in a face-to-face meeting where they can discuss the results of the Delphi survey and determine the final core set. Conclusions The implementation of this protocol will determine the COS-TMD, which will be made available for use in all TMD clinical studies. The use of COS when planning and reporting TMD clinical trials will reduce the risk of publication bias and enable proper comparison of results found by different studies.

Experience of using an integrated approach in the diagnosis of temporomandibular joint dysfunction

The article presents a clinical case of the diagnostics and treatment of the temporomandibular joint dysfunction (TMJ) in patient after orthodontic treatment. The hypertonia of masticatory muscles, limit of mouth opening and deviation of the jawbone to the right were observed during physical examination. Adhesion of the disk to the articular tubercle of the right temporal bone was detected on MRI. Hyperrotation of the articular head and the deviation of the jawbone to the right were observed on the charts during axiography. Disappearing of the feeling of heaviness in the right TMJ, free mouth opening, absence of deviation symptom, and the reduction of the rigidity of the masseter muscles were observed on the basis of diagnostic examinations after treatment. Presented clinical experience lets us make a conclusion that it is necessary to prescribe taking axiography and MRI during diagnosing and treating temporomandibular joint dysfunction.

The effectiveness of orthodontic and osteopathic correction in patients with dental anomalies and musculoskeletal dysfunction of the temporomandibular joint in the presence of concomitant somatic dysfunctions and without it

Introduction. The influence of the dental apparatus on the balance of the body in an upright position has been widely discussed in the literature for several decades. Examination of the patient taking into account his postural balance makes it possible to clarify the reasons for the low effectiveness of pain syndromes treatment of the craniocervical region caused by malocclusion, as well as ineffective correction of musculoskeletal dysfunction of the temporomandibular joint (MSD TMJ) associated with posture disorders.The aim of the study is to evaluate the effectiveness of treatment of patients with dental anomalies and musculoskeletal dysfunctions of the temporomandibular joint and concomitant somatic dysfunctions (if any) by methods of orthodontic and osteopathic correction.Materials and methods. The study involved 102 patients aged from 18 to 45 years with TMJ. All patients underwent orthodontic and osteopathic examination. 3 groups of patients were formed: № 1 — exclusively with dental anomalies TMJ (occlusive dysfunction), who received only orthodontic treatment, № 2 with concomitant somatic (extra-occlusive) dysfunctions, who received only orthodontic treatment, and №3 with concomitant somatic (extra-occlusive) dysfunctions, who received both orthodontic and osteopathic treatment. Orthodontic treatment of musculoskeletal dysfunction of the TMJ consisted of the occlusive kappa manufacturing. Osteopathic correction was carried out individually, taking into account the identified somatic dysfunctions, on average 3 sessions. Patients also received drug therapy, and they performed myohymnastics for the masticatory muscles. The clinical dysfunction index (Helkimo M.) was used to control the elimination dynamics of the TMJ's musculoskeletal dysfunction symptoms. The assessment of the pain dynamics in the TMJ was carried out by a visual-analog scale (VAS). The evaluation of the osteopathic treatment effectiveness was carried out on the basis of computer stabilometry data and osteopathic examination data. A stabilometric study was performed on the «ST-150» («Biomera») stabiloplatform in the Romberg sample (European foot installation) with open and closed eyes in two positions of the lower jaw: 1) in a state of physiological rest (tooth rows are separated); 2) in the kappa with closed tooth rows.Results. The MSD TMJ symptoms were eliminated 10 weeks after the start of treatment in all (100 %) patients of group № 1 and group № 3. Among the patients in group № 2, only 12,1 % of patients had complete absence of MSD TMJ symptoms, while all patients in this group had a statistically significant decrease in the clinical index of Helkimo dysfunction. In one third of the group № 2 patients on the 12th week of orthodontic treatment, headaches and/or pains in other parts of the musculoskeletal system (neck, back, shoulders, arms) prevailed among complaints and which were previously indicated in the anamnesis. This occurred after the elimination of the MSD TMJ symptoms. The absolute majority of patients in group № 3 (97,1 %) noted the complete disappearance of headaches and/or pains in other parts of the musculoskeletal system (neck, back, shoulders, arms). Also, in patients of this group, stabilometric indicators were normalized in a state of physiological rest and in the kappa.Conclusion. Patients with somatic dysfunctions need complex treatment with the participation of an osteopath and a dentist. When assessing the osteopathic status of a patient, it is important to determine whether the patient has only occlusive dysfunctions or there are also extra-occlusive ones. Additional osteopathic correction is recommended for patients with extraocclusive dysfunctions in order to achieve treatment results comparable in effectiveness and timing.

Bruxismo Infantil: Uma Revisão de Literatura / Children's Bruxism: A Literature Review

Resumo: O objetivo do presente estudo foi discutir aspectos do bruxismo infantil através de uma revisão de literatura, abordando os fatores etiológicos bem como sinais, sintomas e características clínicas desta condição. É de grande importância o domínio dos sinais e sintomas para um diagnóstico mais preciso pelos profissionais da odontopediatria. O tratamento é multidisciplinar para esta condição parafuncional. Os resultados demonstraram ser o bruxismo um hábito não funcional da função mastigatória, que se caracteriza , pelo ato de apertar ou ranger os dentes, ocorrendo tanto durante o dia como no momento do sono. A etiologia é multifatorial e a literatura apresenta diversos, tais como fatores associados: dentário, fisiológico, psicológico e neurológico. O sinal mais comum é um certo desgaste nas faces incisais, principalmente dos dentes anteriores e, oclusais nos dentes posteriores. Também tende a ocasionar hipersensibilidade dentária, fratura de cúspides e restaurações e hipertonicidade dos músculos mastigatórios. Concluiu-se que conhecer os fatores etiológicos e as características clínicas do bruxismo na infância é importante para um diagnóstico o mais rápido possível, permitindo um tratamento precoce que favoreça o bem-estar da criança. Palavras-chave: bruxismo; crianças; odontopediatria. Abstract: The aim of this study was to discuss aspects of childhood bruxism through a literature review, addressing the etiological factors as well as signs, symptoms and clinical characteristics of this condition. It is very important to master the signs and symptoms for a more accurate diagnosis by pediatric dentistry professionals. Treatment is multidisciplinary for this parafunctional condition. The results showed that bruxism is a non-functional habit of the masticatory function, which is characterized by the act of squeezing or grinding the teeth, occurring both during the day and during sleep. The etiology is multifactorial and the literature presents several, such as associated factors: dental, physiological, psychological and neurological. The most common sign is some wear on the incisal surfaces, especially on the anterior teeth, and occlusal on the posterior teeth. It also tends to cause tooth hypersensitivity, fracture of the cusps and restorations, and hypertonicity of masticatory muscles. It was concluded that knowing the etiological factors and clinical characteristics of bruxism in childhood is important for a diagnosis as quickly as possible, allowing an early treatment that favors the child's well-being.Keywords: bruxism; kids; pediatric dentistry.

The role of elastic bands (kinesiotapes) in complex therapy of patients with temporomandibular joint osteoarthrosis

Introduction. Temporomandibular joint (TMJ) arthrosis is a chronic disease, characterized by dystrophic and degenerative changes in TMJ with aseptic inflammatory process. The prevelence of TMJ arthrosis in patients with a history of other TMJ disorders varies between 32-39 % of cases. Complex treatment of TMJ arthrosis includes pharmacotherapy, physiotherapy, exercise therapy for TMJ and massage of the masticatory muscles, manual therapy, prosthodontics, but these treatment methods are not always lead to a desired result.The aim of the study is to improve the traditional treament method of patients suffering from TMJ arthrosis by using elastic tapes (kinesiotapes).Materials and methods. 68 patients were examined at the «Galaxy» Beauty Institute Clinic (St. Petersburg) and FSBEI HE SamSMU MOH Russia (Samara). Comparison group of patients was prescribed pharmacotherapy, exercise therapy for TMJ and massage of masticatory muscles, while for the main group of patients the same therapy was enhanced by elastic bands. The effectiveness of therapy was evaluated using a visual-analog pain scale (VAS), mouth opening width and electromyography of the masticatory muscles.Results. Noticeable positive effect in the main group of patients was observed on the 21th day of treatment. By this time patients noticed significant decrease in pain intensity from 8,77±0,8 to 5,19±0,5 (Z1-4=-5,88; p1-4=0,0015) points as well as increase in mouth opening width from 21-23 to 33-35 mm. Similar changes in the comparison group of patients were achieved only by the beginning of fifth week of treatment (Z1-6=-5,58; p1-6=0,0015). The range of mouth opening width increased from 21-23 to 27-29 mm. Amplitude of masticatory muscles biopotentials in maximum intercuspation in patients of the main group almost approached to the normal results by the beginning of the fourth week. In patients of the comparison group the amplitude of masticatory muscles biopotentials remained reduced even by the end of observations (42 day of the study).Conclusion. Thus, the combination of elastic bands applications with conventional treatment methods of TMJ arthrosis greatly increases the effectiveness of therapy and allows to relief pain and normalize bioelectric activity of masticatory muscles in a relatively short time. Due to the simplicity of elastic bands application it is possible to teach patients the technique of self-applying bands and recommend to use them as a prevention of relapse of TMJ arthrosis.

Effectiveness of Physical Therapy in the Correction of the Functional Status of the Temporomandibular Joint in Arthrosis

The purpose of the study was to evaluate the effect of a physical therapy program on the state of functioning of the maxillofacial region in patients with arthrosis of the temporomandibular joint. Materials and methods. The study involved 33 people with arthrosis of the temporomandibular joint of the II-III degrees, which were divided into 2 groups – control and main. The control group consisted of 18 people who received arthrosis therapy only with non-steroidal anti-inflammatory drugs. The main group consisted of 15 people who additionally underwent the developed program of physical therapy (therapeutic exercises, massage, post-isometric relaxation, kinesiotaping of the masticatory muscles, neck muscles, cervical-collar zone; paraffin therapy course for the temporomandibular joint area, patient education). Complaints of patients, the intensity of pain in the temporomandibular joint on a visual analogue scale, the amount of mouth opening were determined, and auscultation of the joint was performed. Results and discussion. After the completion of the treatment course (for patients of the control group) and physical therapy (for the patients of the main group), pain in the temporomandibular joint did not manifest itself at rest and during movement. This is explained, in particular, by the fact that the basis of conservative treatment of arthrosis is the use of non-steroidal anti-inflammatory drugs with analgesic effects. At the same time, the usage of physical therapy, in comparison with medications, in the main group was statistically significant (p <0.05) in relation to control patients, it improved the functional activity of the jaw area and the functioning of the temporomandibular joint, which was manifested by a decrease in the number of persons with complaints of pathological sounds during jaw movements and their auscultatory detection, discomfort when chewing, as well as an increase in the magnitude of opening the mouth. Restoration of the condition of patients with diseases of the maxillofacial region, and, in particular, the temporomandibular joint, is an urgent problem not only for dentists, but also for specialists in the field of rehabilitation, in particular, physical therapists. The objectives of physical therapy in patients with arthrosis of the temporomandibular joint are to reduce the load on the joint, eliminate and reduce pain, synovitis, myalgia, improve joint function, stimulate and activate metabolic processes in cartilaginous and bone tissues, normalize blood flow, and thus improve quality of life. Conclusion. Physical therapy means improve the functional ability of the temporomandibular joint in the complex recovery of patients with arthrosis statistically significantly better than monotherapy with non-steroidal anti-inflammatory drugs

Questionnaire-Based Assessment of the Masticatory Function and Facial Nerve Recovery Post Pterional Approach in Brain Tumors Surgery

Background: The pterional approach for craniotomy, one of the most used surgical intervention in neurosurgery, results in a series of postoperative changes that, if they persist, affect the patient’s life, social reintegration, and his/her physical and mental recovery. The aim of the present study was to develop and validate a questionnaire for indicating directly affected masticatory muscles groups and facial nerve branches, in patients undergoing the pterional approach in neurosurgery, so that the recovery therapy can be monitored and personalized. Methods: A self-reporting questionnaire consisting of 18 items (12 for postoperative masticatory status and 6 for facial nerve branches involvement), validated on fifteen patients, following three steps: items development, scale development, and scale evaluation, was prospectively applied twice, at a one-year interval (T0 and T1), with thirty-two patients suffering from vascular or tumoral pathology and surgically treated through a pterional approach. Results: No statistically significant correlation could be found between postoperative outcomes and age or gender. Facial nerve branch involvement could not be correlated with any of the assessed variables. Pathology and time elapsed from surgery were statistically significantly correlated to preauricular pain on the non-operated side (p = 0.008 and p = 0.034, respectively). Time elapsed from surgery was statistically significantly correlated to the ability to chew hard food, pain while yawning, and preauricular pain during back and forward jaw movements and gradual mouth opening. Conclusions: We created and validated a valuable patient-centered questionnaire that can be employed as a tool for postoperative assessment of directly affected masticatory muscles and groups of facial nerve branches.

CONTRIBUIÇÕES DA TERAPIA COGNITIVO-COMPORTAMENTAL NO TRATAMENTO DA DISFUNÇÃO TEMPOROMANDIBULAR (DTM)

Resumo: A Disfunção Temporomandibular (DTM) é um distúrbio que afeta as articulações temporomandibulares e os músculos mastigatórios, entre outras estruturas da face. Os sintomas podem gerar dores nessas articulações e músculos, bem como dores na cabeça, orelha, ruídos nas articulações, zumbidos, dores no ouvido, limitação na abertura da boca, entre outros. Sua etiologia é multifatorial. Entre os fatores que podem influenciar a DTM encontram-se os psicológicos. Assim, este estudo teve como objetivo identificar as principais estratégias da terapia cognitivo-comportamental (TCC) utilizadas para o tratamento de indivíduos diagnosticados com DTM. Por método, adotou-se a revisão da literatura. Os bancos de dados utilizados foram PePSIC, SCIELO, PubMed e BVS, em inglês e português. Os descritores utilizados em todos os bancos foram: DTM e terapia cognitiva-comportamental; Disfunção temporomandibular e terapia-cognitiva comportamental, Disfunção temporomandibular e terapia-cognitiva, TMD and cognitive behavioral therapy; Temporomandibular disorder and cognitive behavioral therapy, Temporomandibular disorder and cognitive therapy. Os filtros utilizados para inclusão dos estudos foram artigos sobre intervenções em TCC, em português e/ou inglês e com datas de publicação dos últimos três anos. Seis artigos foram analisados, após a passagem dos filtros. Os resultados apontam que as principais estratégias de TCC utilizadas no tratamento da DTM são a restruturação cognitiva, a autogestão, a psicoeducação e o relaxamento. Sugerem, também, que a TCC pode trazer contribuições positivas para os casos de DTM, porém a amostra deste estudo foi pequena. Os artigos analisados apontam que o tratamento multidisciplinar deve incluir intervenções cognitivas e comportamentais. Sendo assim, fica evidenciada a necessidade de realização de mais pesquisas com o objetivo de verificar os efeitos da TCC em pacientes com DTM, principalmente, estudos com ensaios clínicos.Palavras-chave: Terapia cognitiva-comportamental. Disfunção temporomandibular. DTM. Estresse. Ansiedade. Abstract: Temporomandibular Disorder (TMD) is a disorder that affects the temporomandibular joints and masticatory muscles, among other facial structures. Symptoms can generate pain in these joints and muscles, as well as pain in the head, ear, noise in the joints, tinnitus, ear pain, limitation in opening the mouth, among others. Its etiology has multifactorial causes. Among the factors that can influence TMD are psychological. Objective: This study aimed to identify cognitive behavioral therapy (CBT) strategies used to treat individuals diagnosed with TMD. Method: Literature review. The databases used were PePSIC, SCIELO, PubMed and BVS, in English and Portuguese. The descriptors used in databases were: TMD and cognitive-behavioral therapy; Temporomandibular disorders and cognitive behavioral therapy, Temporomandibular disorders and cognitive therapy, TMD and cognitive behavioral therapy; Temporomandibular disorder and cognitive behavioral therapy, Temporomandibular disorder and cognitive therapy. The filters used to include the studies were: articles on CBT interventions, articles in Portuguese and/or English and with publication dates in the last three years. Results: Six articles were analyzed, after passing the filters. Discussion: The results show that the main CBT guidelines used in the treatment of TMD are: cognitive restructuring, self-management, psychoeducation and relaxation training. They also suggest that a CBT can bring positive contributions to TMD cases, but the sample in this study was small. The articles point out that multidisciplinary treatment must include cognitive and behavioral interventions. Thus, the need for further research to verify the effects of CBT in patients with TMD is evidenced, especially, studies with clinical trials.Keywords: Cognitive behavioral therapy. Temporomandibular disorder. TMD. Stress. Anxiety.

METHODS OF DEPROGRAMMING THE MASTICATORY MUSCLES: LITERATURE REVIEW

Deprogramming of masticatory group muscles is an integral step in determining and fixing the centric jaw relation in the diagnosis and treatment of patients with orthopedic and orthodontic pathology of the maxillary system. The review presents the main methods for determining the centric jaw ratio using deprogramming of masticatory muscles, as well as indications for the use of these methods. In complete adentia, the most acceptable are the method of non-forced control of the mandibular movements, the Dawson method, the Schiler method, the method of recording the Gothic angle, transcutaneous electroneurostimulation. The above-listed methods can be used in partial adentia as well, and in the presence of all teeth in the oral cavity. In the pathology of the temporomandibular joint, deprogramming methods using the Lucia jig, a leaf gauge, Sliding Guide, as well as the method of recording the Gothic angle will also perform a diagnostic function. With the help of these methods, it is possible to change the design of long-wearing deprogrammers and medical devices. The most universal of these methods are the method of electronic recording of the Gothic arch and transcutaneous electroneurostimulation.

Assessment of the bioelectric activity of the masticatory muscles in orthopedic treatment with partial removable plate prostheses

Relevance. According to a number of authors, it is known that full adaptation to complete removable dentures occurs within 3 months [3–5, 9]. The main criterion for patients getting used to removable dentures is the synchronization of the work of the masticatory muscles and, as a consequence, the normalization of the chewing function.The aim of the study was to evaluate the bioelectrical activity of the masticatory muscles in patients using the CSPP.Materials and methods. In patients of the control (n = 23) and main (n = 63) groups, electromyographic examination was performed using the electroneuromyographic system "Synapsis" (Neurotechnology, Russia). Registration of the bioelectric activity of the chewing muscles was carried out directly on the day of applying the prostheses, after 1 and 3 months, respectively.Results and discussion. The electromyographic indices of the masticatory muscles in the patients of the control group decreased within one month after the treatment and amounted to 231 ± 18.2 μV for the right and 229 ± 16.1 μV for the left proper chewing muscles. The values were also reduced for the right and left temporal muscles – 228 ± 15.2 μV and 225 ± 24.1 μV (p < 0.05). It should be noted that the electromyographic parameters in patients of the main group were comparable to the lower limit of the norm and amounted to 269 ± 16.5 μV and 256 ± 20.4 μV, respectively, after one month of treatment.Conclusions. In the treatment of dysfunction of the temporomandibular joint with the use of thermoplastic prostheses, an increase in the biopotentials of the masticatory muscles is observed. In the orthopedic treatment of patients with terminal dentition defects using thermoplastic prostheses, the electromyographic parameters of the masticatory muscles are most close to normal after 3 months of using these prostheses.