ORAL HEALTH EVIDENCE-BASED PRACTICE PROGRAM
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Title Protrusive Splint Therapy (PST) Reduces Pain For Patients With Temporalmandibular Disorder (TMD)
Clinical Question Is Protrusive Splint Therapy (PST) more effective at reducing pain for patients suffering from Temporalmandibular Disorder compared to no treatment or compared to flat (Michigan) occlusal splints?
Clinical Bottom Line Two PST studies (one for 6 months & one for 3 years) show that PST is effective at reducing TMD pain. However, another study was done with non-PST, flat occlusal Michigan splints and it was also effective at reducing TMD pain. More studies comparing PST to flat occlusal splints are needed to justify PST's more aggressive mandibular positioning compared to the flat Michigan occlusal splint. These studies suggest that occlusal splint therapy can be an effective treatment for TMD pain.
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 21959663Madami/ 2011Patients with acute TMD pain <6 months on at least one side, and the presence of joint clicking during jaw opening that was eliminated on protrusive openingRandomized Clinical Trial
Key resultsThe study evaluated the effect of 3 different treatments: PST treatment alone, physical therapy (PT) alone, and PST + PT on reducing TMD pain compared to baseline VAS pain scores. Pain was assessed using the Visual Analog Scale (VAS), with ratings between 0 for pain free and 100 for maximum pain. Each group consisted of 20 randomly assigned patients for a duration of 6 months. PST yielded the best results of the three treatments, indicating that PT may not be necessary with PST treatment.
#2) 2308094Tallents/1990Patients with TMD pain due to meniscus displacement with reductionCase control design
Key results86 patients with TMD related pain due to meniscus displacement with reduction were evaluated to determine the effectiveness of PST treatment for 6 months on pain reduction. Follow-up examinations were conducted at 1 year (15 patients), 2 years (39 patients), & 3 years (14 patients). Of these 86 patients, 68 were treated via PST for 6 months and 18 were monitored without treatment (control group). Pain was rated by the patient on a scale of 0 to 10, with 0 indicating no pain and 10 representing intense pain. Results indicated that PST statistically improved the VAS pain compared to the control. PST reduced VAS pain 2.55 from a baseline of 3.30 while the control group resulted in a reduced VAS pain of 0.43 from a baseline of 2.71. It should be noted that 17% of the PST patients subsequently required TMJ surgery during the 6 month trial, suggesting careful patient selection is critical prior to PST treatment.
#3) 17919246Ismail/2007Patients with arthrogenic painRandomized Controlled Trial
Key results26 patients suffering from TMD pain were randomized into two groups: 13 in Group I, treated solely with Michigan flat occlusal splint (not a PST design) & 13 in Group II were treated with splint therapy + physical therapy. The trials were conducted over 12 weeks. Pain was assessed using the Visual Analog Scale (VAS), with ratings between 0 for pain free and 100 for maximum pain. The baseline VAS pain for Group I & II were 42 & 45 respectively. The improvement of VAS for Group I & II were 23 & 28 respectively. These improvements were statistically significant, but the difference between the groups were not. Therefore, the results indicate that the Michigan splints are effective at reducing TMD pain and that the supplemental physical therapy did not provide any meaningful pain relief.
Evidence Search (temporomandibular pain protrusive splint therapy) OR (TMD Michigan arthorgenous) OR (comparison temporomandibular painful clicking options)
Comments on
The Evidence
The Madami study has the highest level of evidence since it is a RCT with 60 total patients grouped in to 3 groups of 20. The Ismail study is also RCT, but only has two groups of 13 patients each. The Tallents study is a case series with a small sample size of patients at the recall years to compare the treatment vs control groups.
Applicability The patient group included in these studies are representative of the patients that are suffering from TMD related pain that are commonly encountered in dentistry. Some TMD cases require surgical intervention supplemental or beyond splint therapy.
Specialty/Discipline (General Dentistry) (Prosthodontics)
Keywords temporomandibular pain, TMD, protrusive splint
ID# 2308
Date of submission: 08/10/2012spacer
E-mail levh@livemail.uthscsa.edu
Author Vu Le
Co-author(s)
Co-author(s) e-mail
Faculty mentor/Co-author James Piper, DDS
Faculty mentor/Co-author e-mail jmpiidmd@gmail.com
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?)
post a rationale
by Vu Le (San Antonio, TX) on 09/18/2012
The etiology of some temporomandibular pain disorders is the abnormal anterior displacement of the articular disc relative to the condyle during jaw motion (opening/closing and lateral excursions), causing the condyle to transmit painful compressive forces on the highly innervated tissue called the bilaminar zone, posterior to the articular disc. The biological basis for this treatment modality is the use of a protrusive mandibular splint that will anteriorly position the mandible to improve the orientation of the condyle to the articular disc (publication PMID: 3857335). The protrusive splint may eliminate pain by alleviating the compressive forces on the bilaminar zone by repositioning the the alignment of the condyle to the normal, non-innervated region of central intermediate zone of the articular disc. This same treatment modality may also eliminate TMJ click reciprocal click of internal joint derangement with reduction.
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