Eduardo Januzzi

Temporo-mandibular disorders are an important comorbidity of migraine and may be clinically difficult to distinguish them from tension-type headache

UNLABELLED Clinical differentiation between the primary headaches and temporomandibular disorders (TMD) can be challenging. OBJECTIVES To investigate the relationship between TMD and primary headaches by conducting face to face assessments in patients from an orofacial pain clinic and a headache tertiary center. METHOD Sample consists of 289 individuals consecutively identified at a headache center and 78 individuals seen in an orofacial pain clinic because of symptoms suggestive of TMD. RESULTS Migraine was diagnosed in 79.8% of headache sufferers, in headache tertiary center, and 25.6% of those in orofacial pain clinic (p<0.001). Tension-type headache was present in 20.4% and 46.1%, while the TMD painful occurred in 48.1% and 70.5% respectively (p<0.001). CONCLUSION TMD is an important comorbidity of migraine and difficult to distinguish clinically from tension-type headache, and this headache was more frequent in the dental center than at the medical center.

Mandibular Manipulation for the Treatment of Temporomandibular Disorder

AbstractThe aim of this study was to conduct a systematic review to identify the randomized clinical studies that had investigated the following research question: Is the mandibular manipulation technique an effective and safe technique for the treatment of the temporomandibular joint disk displacement without reduction? The systematic search was conducted in the electronic databases: PubMed (Medical Publications), LILACS (Latin American and Caribbean Literature in Health Sciences), EMBASE (Excerpta Medica Database), PEDro (Physiotherapy Evidence Database), BBO (Brazilian Library of Odontology), CENTRAL (Library Cochrane), and SciELO (Scientific Electronic Library Online). The abstracts of presentations in physical therapy meetings were manually selected, and the articles of the ones that meet the requirements were investigated. No language restrictions were considered. Only randomized and controlled clinical studies were included. Two studies of medium quality fulfilled all the inclusion criteria. There is no sufficient evidence to support the effectiveness of the mandibular manipulation therapy, and therefore its use remains questionable. Being minimally invasive, this therapy is attractive as an initial approach, especially considering the cost of the alternative approaches. The analysis of the results suggests that additional high-quality randomized clinical trials are necessary on the topic, and they should focus on methods for data randomization and allocation, on clearly defined outcomes, on a priori calculated sample size, and on an adequate follow-up strategy.

Ortodontia baseada em evidência científica: incorporando ciência na prática clínica

The aim of this article is to warn the orthodontist about the importance of making decision based on scientific evidence when taking care of the patients. It describes the main steps for the Dentistry practices based in evidence (EBD) as well as the science and research principles. There are adequate ways for the search of quality information. While selecting the scientific articles, the first step would be defining its design, since for each question there is an adequate delineation able to answer it. Questions about treatment, etiology, diagnostic, prognostic or prevention could be answered in the article if it has been delineated for that. Understanding the meaning of randomized allocation, blinding and control group is essential for a critical reading; selecting those articles that deserve credibility. Among so many publications one needs to identify precisely about what must be incorporated to his knowledge as well as to the clinical practices.

Review articleDiagnosis of temporomandibular joint disorders: indication of imaging examsDiagnóstico das disfunções da articulação temporomandibular: indicação dos exames por imagem☆

Introduction Knowledge of the different imaging tests and their appropriate indications is crucial to establish the diagnosis of temporomandibular disorders, especially in patients with overlapping signs and symptoms.INTRODUCTION Knowledge of the different imaging tests and their appropriate indications is crucial to establish the diagnosis of temporomandibular disorders, especially in patients with overlapping signs and symptoms. OBJECTIVE To present and assess the main diagnostic imaging tests for temporomandibular disorders and rationally discuss their indication criteria, advantages, and disadvantages. METHODS Literature review in the Web of Knowledge, PubMed and SciELO databases, as well as manual search for relevant publications in reference lists of the selected articles. RESULTS Computed tomography and magnetic resonance imaging were considered the gold standard assessments for the temporomandibular joint to evaluate hard and soft tissues, respectively. Each diagnostic method exhibited distinct sensitivity and specificity for the different subtypes of joint dysfunction. CONCLUSION Selecting an evaluation examination based on its accuracy, safety, and clinical relevance is a rational decision that can help lead to an accurate diagnosis and an optimum treatment plan.

Diagnosis of temporomandibular joint disorders: indication of imaging exams

Introduction Knowledge of the different imaging tests and their appropriate indications is crucial to establish the diagnosis of temporomandibular disorders, especially in patients with overlapping signs and symptoms.INTRODUCTION Knowledge of the different imaging tests and their appropriate indications is crucial to establish the diagnosis of temporomandibular disorders, especially in patients with overlapping signs and symptoms. OBJECTIVE To present and assess the main diagnostic imaging tests for temporomandibular disorders and rationally discuss their indication criteria, advantages, and disadvantages. METHODS Literature review in the Web of Knowledge, PubMed and SciELO databases, as well as manual search for relevant publications in reference lists of the selected articles. RESULTS Computed tomography and magnetic resonance imaging were considered the gold standard assessments for the temporomandibular joint to evaluate hard and soft tissues, respectively. Each diagnostic method exhibited distinct sensitivity and specificity for the different subtypes of joint dysfunction. CONCLUSION Selecting an evaluation examination based on its accuracy, safety, and clinical relevance is a rational decision that can help lead to an accurate diagnosis and an optimum treatment plan.

Ear Acupuncture Therapy for Masticatory Myofascial and Temporomandibular Pain: A Controlled Clinical Trial

Ear acupuncture works by reducing painful sensations with analgesic effect through microsystem therapy and has been demonstrated to be as effective as conventional therapies in the control of facial pain. This clinical trial aimed to evaluate the adjuvant action of auricular acupuncture through an observation of the evolution of temporomandibular and masticatory myofascial symptoms in two groups defined by the therapies elected: auricular acupuncture associated with occlusal splint (study) and the use of the occlusal splint plate alone (control). We have selected 20 patients, who were randomly allocated into two groups of ten individuals. Symptoms were evaluated in five different moments, every seven days. We analyzed the orofacial muscle and joint palpation in order to measure the intensity of the experienced pain. Both groups showed a statistically significant decrease in muscle and joint symptoms (p < 0.05). However, comparisons between the groups showed an expressive and significant reduction of symptomatology in the study group (p < 0.05) already on the first week of therapy. According to the results, to the methodological criteria developed and statistical analysis applied, the conclusion is that auricular acupuncture therapy has synergistic action on conventional occlusal splint treatment. It was demonstrated to be effective in the reduction of symptoms in the short term.

Combined Palliative and Anti-Inflammatory Medications as Treatment of Temporomandibular Joint Disc Displacement Without Reduction: A Systematic Review

Abstract The aim of this study was to evaluate the efficacy of self-care combined with anti-inflammatory medications in the treatment of temporomandibular joint (TMJ) pain associated with disc displacement without reduction (DDWOR). A systematic review of randomized clinical trials was done by the authors. The databases searched were Medline (1966 to July 2012); EMBASE (1980 to July 2012); and LILACS (from 1982 to July 2012). The review authors independently assessed trials for eligibility and methodological quality and also extracted all data. The data was double-checked for accuracy. There was no language restriction in the searches of EMBASE, PubMed, and LILACS databases, or in the manual search. The risk of bias and the heterogeneity of the studies taken into consideration were assessed. Two studies, randomizing 175 patients, were included in this review. The first study (n=106) compared the following interventions: medical treatment, rehabilitation, arthroscopic surgery with postoperative rehabilitation, or arthroplastic surgery with post-operative rehabilitation. The second study (n= 69) compared the use of nonsteroidal anti-inflammatory medications and self-care instructions, nonsteroidal anti-inflammatory medications, occlusal splint, and mobilization therapy. The third group received no treatment; patients were only informed of their prognosis. There is no sufficient evidence regarding efficacy and safety of the palliative treatments associated with anti-inflammatory versus other treatments, or absence of treatment on pain reduction in patients with TMJ DDWOR.

Effectiveness of Sequential Viscosupplementation in Temporomandibular Joint Internal Derangements and Symptomatology: A Case Series

Viscosupplementation is a minimally invasive technique that replaces synovial fluid by intra-articular injection of hyaluronic acid (HA). Although effective in some joints, there is not conclusive evidence regarding temporomandibular disorders. This case series described the efficacy of a viscosupplementation protocol in intra-articular temporomandibular disorders. Ten patients with a diagnosis of disc displacement and/or osteoarthritis by Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) were submitted to four monthly injections of low or medium molecular weight HA. Pain, mandibular function, image analysis by tomography and magnetic resonance, and quality of life were assessed at baseline and follow-ups (1 and 6 months). Pain, jaw range-of-motion, mandibular function, and quality of life improved at follow-up evaluations. Osteoarthritis changes decreased, and 20% of patients improved mandibular head excursion after treatment. Resolution of effusion and improvement in disc morphology were observed for most patients. This viscosupplementation protocol reduced pain and symptoms associated with internal derangement of temporomandibular joint, improved quality of life, and showed benefits from both low and medium molecular weight HA in alternate cycles.

The use of dry needling in the treatment of cervical and masticatory myofascial pain

BACKGROUND AND OBJECTIVES: Dry needling is an interventionist, minimally invasive technique, used in the treatment of myofascial pain. The objective of this study was to describe the use of dry needling and to perform a critical literature analysis about the technical aspects of its use by qualified health care professionals. CONTENTS: A search in the literature was carried out for books in English, review articles, randomized controlled or quasi-randomized clinical trials, blind or double-blind and published case studies series in Portuguese or in English. The following databases were used: Cochrane, LILACS, and Pubmed. Articles published from September 1996 to January 2017 were selected according to the following keywords: dry needling versus myofascial pain syndrome versus temporomandibular joint dysfunction syndrome) versus trigger points versus musculoskeletal manipulations versus trapezius muscle, superficial back muscles versus masseter muscle versus secular muscle versus pterygoid muscles versus digastric muscle, neck muscles. Reports of clinical cases, “open-label” studies, studies with animal models and articles not related to DN were excluded. After the matching descriptors and the implementation of inclusion and exclusion criteria, we selected six articles. CONCLUSION: The diagnosis of myofascial pain can be a difficult task since it can simulate different masticatory system pain, from a toothache to a trigeminal neuropathic pain. This can be minimized with proper history taking, clinical examination involving muscle palpation, as well as the own experience and professional training. The deactivation of myofascial trigger points should be a priority in myofascial pain therapy since there is a significant improvement of local and referred pain when we use this approach. Despite the favorable results of studies about the use of dry needling in myofascial pain treatment related to The use of dry needling in the treatment of cervical and masticatory myofascial pain

Sequential infiltration of sodium hyaluronate in the temporomandibular joint with different molecular weights. Case report

BACKGROUND AND OBJECTIVES: Temporomandibular disorders are diseases causing pain and dysfunction in joints and muscles controlling mandibular movements. Their etiology is multifactorial and multidisciplinary approaches are needed to reach a differential diagnosis and an adequate management plan. This case report proposes a management protocol, with monthly sodium hyaluronate infiltrations, with different molecular weights, to control such changes and promote improvement of temporomandibular joint biomechanics and pain. CASE REPORT: This study describes a case of a 48-year old patient with a 10-year history of temporomandibular pain with function loss since 2001. Patient has classified her pain as 9 according to analog visual scale. In addition, history and detailed physical evaluation have shown different signs and symptoms, such as localized pain (right side), and right temporomandibular joint arthralgia with noise. Diagnosis was disc displacement with reduction and possible synovitis/ capsulitis to the right. Right temporomandibular joint osteoarthritis was also diagnosed by cone beam CT-scan. Initially, a flat upper splint with total coverage and contact with all antagonist teeth was used. In the attempt to decrease temporomandibular arthralgia, non-steroid anti-inflammatory drugs and muscle relaxants were used. Since right temporomandibular joint pain was not effectively managed, we decided to use intra-joint sodium hyaluronate injections with different molecular weights, per month, in a total of four applications. At treatment completion, clinical evaluation has shown normal function, no pain with visual analog scale = zero, in addition to adequate interincisal distance. CONCLUSION: This report has suggested that viscosupplementation cycles with sodium hyaluronate of different molecular weights may provide excellent results in the long run, to control joint temporomandibular disorder symptoms. Therapeutic benefits were maintained for four years with no need for annual maintenance cycles.