TMJ/Orofacial James E, Metz, DMProvidte Solutions to Complex

Spring 2010

Dear Colleague:

As always, we wish to thank you for your trust andthe wonderful patients referred to our office.

This quarters newsletter covers the followingtopics...

1 . F i x e d O r t h o d o n t i c T h e r a p y inTemporomandibular Disorder (TMD) Treatment

2. Five Years of Sleep Apnea Treatment with aMandibular Advancement Device

3. Oral Appliance Titration in Patients withObstructive Sleep ApneaInduces the Appearance ofPeriodic Limb Movements

4. Use of a StructuralEquation Model for Predictionof Pain Symptoms inPatients with Orofacial Painand TemporomandibularDisorders

Regards, es E. Metz, D.D.S.

Fixed Orthodontic Therapy inTemporomandibular Disorder(TMD) TreatmentTecco S, Tete S, et al.Cranio. 2010 Jan;28(1):30-42

T his study evaluated the use of a fixed orthodonticappliance in treatment of temporomandibulardisorder (TMD) compared to the use of an intra-

oral splint. Fifty (50) adult patients, with confirmedanterior disk displacement with reduction in at leastone temporomandibular joint (TMJ), were dividedinto three groups: 20 patients treated with ARsplint (Group I); 20 patients treated with a fixedorthodontic appliance (Group ll)and 10 patients who

underwent no treatment (Control Group). Joint pain, jointnoise, muscle pain, and subjective relief were evaluatedmonthly before the treatment began (TO) and for sixmonths thereafter.

Subjects in Group I and Group II displayed a significantdecrease in joint pain from T2 and in muscle pain fromT1 to T6. Subjects in Group I showed a higher decreasein the frequency of joint noise from T1 to T6, comparedwith Group II. At T2 and T3, the patients in Group IIreported a significantly lower discomfort level associatedwith the devices than subjects treated with the AR splint.However, at T5 and T6, this observation was inverted.The use of a fixed orthodontic appliance seems to beas efficacious as the use of an AR maxillary splint inthe treatment of joint pain and muscle pain, but not inthe treatment of joint noise. These results are valid, atleast for the short-term clinical results (first six monthsof treatment). Clinical implications for long-term use arenot clarified by these results.

Five Years of Sleep Apnea Treatmentwith a Mandibular AdvancementDeviceMartinez-Gomis J, Willaert E, et al.Angle Orthod. 2010 Jan;80(1):30-6

T he purpose of this study was to determine thevariation in prevalence of temporomandibulardisorders (TMD), other side effects, and technical

complications during 5 years of sleep apnea treatment witha mandibular advancement device. Forty patients diagnosedwith obstructive sleep apnea received an adjustable applianceat 70% of the maximum protrusion. The protrusion was thenprogressively increased. TMD (diagnosed according to theResearch Diagnostic Criteria for TMD), overjet, overbite,occlusal contacts, subjective side effects, and technicalcomplications were recorded before and a mean of 14, 21,and 58 months after treatment and analyzed with appropriatestatistical analysis.

Fifteen patients still used the oral appliance at the 5-yearfollow-up, and no significant variation in TMD prevalence was

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Sleep Apnea.. .continuedobserved. Subjective side effects were common, and asignificant reduction was found in overjet, overbite, and inthe number of occlusal contacts. Furthermore, the patientsmade a mean of 2.5 unscheduled dental visits per year anda mean of 0.8 appliance repairs/relines per year by a dentaltechnician. The most frequent unscheduled visits wereneeded during the first year and were a result of acrylicbreakage on the lateral telescopic attachment, poorretention, and other adjustments to improve comfort.The authors concluded that five-year oral appliancetreatment does not affect TMD prevalence but isassociated with permanent occlusal changes in mostsleep apnea patients during the first 2 years.

Oral Appliance Titration in Patientswith Obstructive Sleep ApneaInduces the Appearance of PeriodicLimb MovementsGuerrero ML, Kim D, et al.Sleep Breath. 2010 Jan 23

O ral appliance (OA) therapy is considered a firstline choice of therapy for some patients with mildor moderate obstructive sleep apnea (OSA) and

an alternative form of treatment in those intolerant ofcontinuous positive airway pressure (CPAP) use. Accordingto several studies, periodic limb movements (PLM) appearduring effective treatment of OSA with CPAP, but a similarphenomenon has not been described with the use oforal appliance. In this study the authors describe theincidence of PLM in patients with OSA who underwentoral appliance therapy titration. This observational studywas set in a six-bed sleep center in an academic, militaryreferral hospital. Patients with OSA (n = 21; 15 men andsix women; mean age, 43 years; and age range, 25 to53 years) were treated with OA during a 1-year periodwere enrolled. Patients were categorized according tothe severity of sleep apnea and incidence of PLM ondiagnostic polysomnography. Effective treatment of OSAand appearance or disappearance of PLM with arousal onsubsequent oral appliance titration polysomnography wererecorded and compared.

Results found that during baseline polysomnography,three of 21 (14%) patients had five or more PLM witharousal per hour while 11 of 21 (52%) patients had PLM witharousal during the oral appliance titration trial. The authors

concluded that oral appliance therapy for obstructivesleep apnea is an effective treatment and ideal foruse in military recruits. The appearance of periodic limbmovements with arousal during oral appliance useshould be considered as a cause of persistent daytimesleepiness despite effective treatment of obstructivesleep apnea in this subset of patients.

Use of a Structural Equation Modelfor Prediction of Pain Symptoms inPatients with Orofacial Pain andTemporomandibular DisordersDavis CE, Carlson CR, et al.J Orofac Pain. 2010 Winter;24(1):89-100

T he purpose of this study was to develop and test abiopsychosocial model using structural equationmodeling for predicting orofacial pain symptoms

in a sample of patients with masticatory muscle pain(MMP). Data were collected from clinic records of251 adult patients who presented for initial evaluationto the Orofacial Pain Center at the University ofKentucky College of Dentistry and were subsequentlydiagnosed with MMP. Data were used to fit a modelrelating stressors, psychological distress, arousal, sleepproblems, oral parafunction, and pain symptoms. Itemsfrom the Multidimensional Pain Inventory (MPI) andthe IMPATH:TMJ, a comprehensive biopsychosocialassessment of patients with temporomandibulardisorders (TMD), were used to construct a measurementmodel of five latent variables.

Estimation of the model indicated a good fit to thedata and significant associations between stressors,psychological distress, arousal, sleep problems, andpain symptoms. Sleep problems partially mediated therelation between arousal and pain symptoms. Contraryto hypotheses, no association occurred between oralparafunction and pain symptoms, possibly indicatingthat any relationship between oral parafunction and painsymptoms may not exist. Results from the model testedin this study are an additional step toward developing amore comprehensive biopsychosocial model explainingthe nature and etiology of MMP in orofacial pain andTMD. With additional development and testing, it mayalso serve as an aid to planning interventions, especiallypsychosocialinterventions targeting stress management,psychophysiological regulation, psychological distress,and sleep problems.

This newsletter is a publication of this office. Its information is intended solely for dentists and other healthcare providers. It is not intended for use as a replacement for medicaladvice. For individual situations or conditions, appropriate dental/medical consultation should be obtained.