Edward F. Wright

Management and Treatment of Temporomandibular Disorders: A Clinical Perspective

Abstract A temporomandibular disorder (TMD) is a very common problem affecting up to 33% of individuals within their lifetime. TMD is often viewed as a repetitive motion disorder of the masticatory structures and has many similarities to musculoskeletal disorders of other parts of the body. Treatment often involves similar principles as other regions as well. However, patients with TMD and concurrent cervical pain exhibit a complex symptomatic behavior that is more challenging than isolated TMD symptoms. Although routinely managed by medical and dental practitioners, TMD may be more effectively cared for when physical therapists are involved in the treatment process. Hence, a listing of situations when practitioners should consider referring TMD patients to a physical therapist can be provided to the practitioners in each physical therapists region. This paper should assist physical therapists with evaluating, treating, insurance billing, and obtaining referrals for TMD patients.

Bowel training in spina bifida: importance of education, patient compliance, age, and anal reflexes.

Bowel incontinence is a major social impairment for 90% of patients with spina bifida. This study assess the bowel continence of children and young adults with spina bifida before and after a toileting intervention that emphasized patient/family education and a regular, consistently timed, reflex-triggered bowel evacuation. Bowel continence defined as one or fewer incontinent stools per month, rose from 13% (5/40) to 60% (24/40) following intervention. Twenty-four of the 35 initially incontinent patients were compliant. Seventy-nine percent (19/24) of the compliant subjects achieved continence whereas 0/11 of the noncompliant subjects achieved continence p < 0.0001). Presence of the bulbocavernosus (BC) and anocutaneous (AC) reflexes correlated significantly with achieving continence (either vs none p < .02, AC vs no AC p < .01). Instituting bowel training before age 7 correlated with improved outcomes by means of better compliance. Excluding noncompliant subjects, 83% (24/29) of the original sample of 40 patients satisfied our strict definition of bowel continence after this simple low technology intervention.

Headache Improvement Through TMD Stabilization Appliance and Self-management Therapies

Abstract The purpose of this study was to assess headache response of unselected neurology clinic chronic headache patients to TMD stabilization appliance and self-management therapies, and to identify features of patients whose headaches are more likely to improve from these therapies. Twenty chronic headache patients in a nontreatment control period were provided appliance and self-management therapies, evaluated five weeks after therapy, and those who chose to continue using their appliances were evaluated three months later. The mean pretreatment Headache Disability Inventory (HDI) score of 64.5 suggested the headaches were severe. After five weeks, the mean HDI score decreased by 17 percent (p<0.003), headache medication consumption dropped by 18 percent (p<0.0001), and headache symptoms decreased by 19 percent (p<0.002). Comparing the three months with pretreatment follow-up, the fourteen participants who chose to continue using their appliances had a mean HDI score decrease of 23 percent (p<0.003), headache medication consumption drop of 46 percent (p<0.001), and headache symptom decrease of 39 percent (p<0.001). There was no correlation between response and headache type (p=0.722). These results suggest appliance and self-management therapies can be beneficial for many severe headache patients, irrespective of the headache type (tension-type, migraine without aura, and migraine with aura).

Efficacy of group cognitive behavior therapy for the treatment of masticatory myofascial pain

The purpose of this investigation was to evaluate the reduction in perceived pain in patients with myofascial pain (MFP) using a group cognitive behavior therapy (CBT) course. Twenty-six participants diagnosed as having MFP were enrolled. Each CBT session had a small-group format, where participants received instruction in habit reversal, stress management, and progressive relaxation. Participants served as their own control subjects and were surveyed for pain intensity, duration, and frequency at study enrollment, before attending the CBT course, and 2 to 3 weeks after course completion. Wilcoxon signed-rank tests revealed that changes in intensity, frequency, and duration were significant (p < 0.001 to p < 0.045). Thirty-three percent of the participants showed improvement with home care instructions before CBT course start, whereas 65% of the participants showed improvement after the CBT course. Participants attending CBT group training exhibited significant improvements in MFP intensity, frequency, and duration, compared with levels reported at the initial evaluation.

A simple questionnaire and clinical examination to help identify possible non-craniomandibular disorders that may influence a patient's CMD symptoms.

A patient with craniomandibular disorder (CMD) symptoms may have CMD, a local or systemic disorder that mimics CMD, or CMD superimposed with a local or systemic disorder that exacerbates the CMD symptoms. When evaluating a patient with CMD symptoms, the practitioner needs to determine whether local or systemic problems contribute to the patients symptoms. The author presents a simple questionnaire that can help identify some non-CMD problems that may contribute to the patients symptoms. A discussion of each question and examples of possible non-CMD disorders are provided. The author also describes a clinical examination that may be used in conjunction with the questionnaire to help identify some non-CMD conditions.

In vitro wear of various orthotic device materials.

STATEMENT OF PROBLEM Orthotic devices are advocated to decrease occlusal attrition caused by bruxism but tend to wear with time. PURPOSE This study investigated the wear rate of various materials used to fabricate orthotic devices. MATERIAL AND METHODS Five experimental groups (n=8) were studied: Splint Biocryl autopolymerized (SBA), Splint Biocryl autopolymerized plus additional heat and pressure (SBHP), Forestacryl autopolymerized (FA), Forestacryl autopolymerized plus additional heat and pressure (FHP), and Quick Splint 15-minute (QS), light-polymerized composite. Specimens were mounted to the base of a universal testing machine. A wear device using steatite balls and a load of 9.1 kg was positioned against the specimens, submerged in a 37 degrees C water bath and subjected to 2500 reciprocal cycles. Wear, in micrometers, was calculated as the maximum peak to valley measurement (Ry) using profilometry. Data were subjected to analysis of variance (ANOVA) and Tukeys HSD (alpha=.05). RESULTS Mean acrylic wear in micrometers was as follows: FA 6.8 +/-3.0; FHP 7.1 +/- 1.8; SBA 20.4 +/- 5.6; SBHP 23.7 +/- 7.8; and QS 23.8 +/- 6.9. One-way ANOVA detected significant differences between groups (P<.001); the Tukey honestly significant difference test determined that FA and FHP specimens were significantly more resistant to wear than all other specimens (P=.007). CONCLUSION Differences in in vitro wear resistance among various orthotic device materials exist. The in vitro wear resistance among other autopolymerizing materials appears to be related to proprietary differences.

Persistent dysesthesia following dental implant placement: a treatment report of 2 cases.

Occasionally, a patient has persistent dysesthesia symptoms (eg spontaneous or evoked painful or unpleasant sensations) following the placement of a dental implant. This disorder may be sufficiently superficial that an anesthetic and steroid mixture can be infiltrated into the region and satisfactorily treat the disorder. If an anesthetic infiltration can significantly reduce the patients pain, this therapy may be beneficial. A 50:50 mixture of local anesthetic and steroid are combined in a dental anesthetic carpule and infiltrated into the painful region. If over the following week, the change in pain is greater than one would expect from an anesthetic infiltration, it suggests that this provided some degree of therapeutic response. A series of these infiltrations can be performed until the patient is symptom free or there is no additional improvement from these infiltrations. Two cases are discussed using this therapy.

Comparison of Moist and Dry Heat Penetration Through Orofacial Tissues

ABSTRACT Application of superficial moist heat has been shown to have a beneficial effect on Temporomandibular Disorder (TMD) symptoms and is often recommended for patients with this disorder. A review of the literature shows that few studies have compared the effects of moist to dry heat. Throughout this study, moist and dry heat were applied through a commercial heating pad alternately for 20 minute intervals. The application sequence was randomized and all individuals received both moist and dry modalities. Intraoral and extraoral thermocouples were positioned on the mid-cheek area of 46 volunteers to record temperature readings. Dry and moist heat applications were equally effective in both maximum tissue temperature rise and the rate of thermal transfer (p > 0.05). However, in a small number of subjects moist heat was preferred. As there seems to be little difference between using moist rather than dry heat, patients may be counseled to employ the superficial heating option that: 1. is an individuals personal preference or 2. improves convenience and optimizes compliance.

Referred orofacial pain from the cervical region

CLINICAL PROBLEM I examined a 40-year-old woman for symptoms of constant bilateral pain in the temple region. This pain had an average intensity of 4 to 6 (on a scale ranging from 0 to 10, in which 0 represented no pain and 10 represented worst pain imaginable) that was worse on awaking and later in the day. The patient reported having had this pain for the past 3 years. Her pain increased with stress but not with eating. Two years ago, her dentist diagnosed her pain as temporomandibular disorder and fabricated a maxillary flat stabilization appliance for this problem, but it had not relieved her pain. Palpation of the patient’s anterior temporalis and masseter muscles and temporomandibular joints revealed slight tenderness of her anterior temporalis muscles but no tenderness in the other structures. Results of the visual oral examination were within normal limits, and the patient related that her dentist told her she had no need for any dental treatments. What could be the true source of this patient’s pain?

Oral pre-trigeminal neuralgia pain: clinical differential diagnosis and descriptive study results

Abstract Aims: To better quantify oral pre-trigeminal neuralgia (PTN) symptoms, attempt to identify PTN symptoms that could reliably differentiate between PTN and odontogenic tooth pain, and determine whether an anesthetic test would reliably differentiate these disorders. Methodology: This was accomplished through a survey of symptom recall for 49 trigeminal neuralgia patients who had PTN tooth and/or gum pain. Results: The variability of oral PTN symptoms, factors that worsened or improved them, and how dental anesthesia affected them, explain the reason for variations found in the literature. A throbbing pain quality is not in the literature, but present for 63% of respondents. Conclusions: No specific PTN symptom would reliably differentiate PTN from odontogenic tooth pain. The results also suggest that an anesthetic test would not be totally reliable for differentiating these disorders. A protocol is provided that should help practitioners identify the tooth pain source when there is no dental pathology.