Eficácia terapêutica da associação do aconselhamento e do aparelho estabilizador plano sobre a dor crônica presente na dor miofascial

Orientador: Celia Marisa Rizzatti BarbosaDissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Odontologia de PiracicabaResumo: Disfunção temporomandibular (DTM) ou desordem craniomandibular são termos genéricos que abrangem um grupo amplo de problemas clínicos relacionados ao sistema estomatognático (SEG). A etiologia das DTM pode ser considerada multifatorial. Em função da similaridade com outras disfunções musculoesqueléticas, sobre as quais se desconhece o curso natural, terapias conservadoras estão indicadas como tratamento de primeira eleição. Dentre elas, cita-se a conscientização e a educação do paciente, as quais são intervenções rápidas, simples, sem riscos, e que podem obter sucesso sem custo adicional. Da mesma forma, os aparelhos interoclusais planos (AIP) são utilizados com frequência no controle da dor em portadores de DTM. Por tanto, o objetivo no presente trabalho foi avaliar o efeito da associação dessas duas terapias conservadoras (aconselhamento e aparelho interoclusal plano) sobre a dor crônica presente na dor miofascial. Ainda, buscou-se investigar o status psicológico e comprometimento psicossocial presentes nesta disfunção. Foram selecionadas 20 voluntárias com dor miofascial (RDC/TMD Ia e Ib), as quais foram submetidas a uma sessão de aconselhamento para DTM e uma semana após essa sessão AIP foram instalados. O efeito dos tratamentos foi avaliado através das variáveis: Escala Visual Analógica (EVA), para avaliar a dor subjetiva relatada pelas voluntárias, Algometria, para avaliar o limiar de dor à pressão dos músculos masseter superficial e temporal anterior de ambos lados da fase, e Eletromiografia (EMG) para avaliar a atividade elétrica nos mesmos músculos. As avaliações foram feitas no período inicial, e após a aplicação do tratamento (1 semana, 1, 3 e 6 meses). O status psicológico e comprometimento psicossocial (dor crônica, depressão e somatização), foram avaliados no período inicial e após 1 e 6 meses de tratamento. Para a análise estatística foi utilizado ANOVA para medidas repetidas para as variáveis EVA, Algometria e EMG, e o teste de correlação de Pearson para as variáveis EVA e EMG, para a variável RDC/TMD eixo II foram utilizadas, ANOVA para medidas repetidas e o teste post ¿ hoc de Bonferroni. Para todas as análises usou-se nível de significância de 5%. Foram encontradas diferenças significativas após o aconselhamento no EVA (p<0,0001), na Algometria para os músculos temporal e masseter esquerdo (p<0,05) e na EMG para os músculos temporal direito e masseter esquerdo (p<0,05) quando comparadas com o período inicial. Também houve diferença significativa para as avaliações de 1, 3 e 6 meses quando comparadas com o período inicial no EVA (p<0,005), na Algometria nas avaliações de 3 e 6 meses para todos os músculos (p<0,05) exceto para o temporal esquerdo na avaliação de 3 meses, e na EMG nas avaliações de 3 e 6 meses para os músculos temporal direito e masseter esquerdo (p<0,05). Para a variável RDC/TMD eixo II (dor crônica, depressão e somatização) houve diferença significativa nas avaliações de 1 e 6 meses quando comparadas com o período inicial (p<0,05). Assim, considera-se que a associação do aconselhamento e do aparelho estabilizador plano é eficaz no controle da dor crônica presente na dor miofascial, o que fortalece a indicação de terapias conservadoras como tratamento de primeira eleição para essas disfunçõesAbstract: Temporomandibular disorders (TMD) or craniomandibular disorders are collective terms, which described a number group of clinical problems related with the stomatognathic system (SGS). The etiology of TMD can be described by multifactorial models, in which several factors are involved in the development of the disease. Due to its similarity to other musculoskeletal disorders, which natural course are also unknown, conservative therapies are indicated as the treatment of choice, such as auto massages, acupuncture, and pharmacological therapy. In a similar fashion, awareness and patient education (counselling) are considered a treatment for TMD and are used frequently, due to being a fast, simple, and conservative intervention with no risk that can achieved success with no extra cost. Similarly, oral appliances particularly stabilization appliance (SA) have been frequently used to control pain in patients with TMD, especially those of myogenic origin. This study aimed to compare changes in pain intensity (VAS), in the pressure pain threshold (PPT) and in eletromiographic activity (EMG) of masticatory muscles (anterior temporalis and masseter muscles) observed after counselling and association of counselling and stabilization splint in chronic pain patients with Miofascial pain; changes in the psychosocial factors were also investigated. Twenty volunteers with myogenic TMD (RDC/TMD groups Ia e Ib) diagnosis were enrolled in the study. At baseline, counselling patient was performed using a modified TMD manual (translated to Portuguese language) used at the University of Rochester (Rochester, NY, USA). Stabilization appliance were installed one week after since counselling was applied. Pain intensity and pain pressure threshold were evaluated at baseline, weekly for 1 month and at month 3 and 6; Electromyography was performed at baseline, week 1 and month 1, 3 and 6 and psychological measures were evaluated at baseline and month 1 and 6 after treatment. VAS, PPT and EMG values were analyzed by ANOVA for repeated measures, Pearson correlation test was used to analyzed VAS and EMG values; and psychological measures were analyzed by ANOVA for repeated measures, and Bonferroni (post-hoc), with 5% of significance. Significant differences were found after counselling for VAS (p<0,0001), in Algometry for left temporal and masseter muscles (p<0,05) and in EMG for left masseter muscles (p<0,05). Also significant differences were found in the 1st, 3rd and 6th month evaluations when compared with baseline values for VAS variable (p<0,05); in the 3rd and 6th month evaluation for all muscles in Algometry variable (p<0,05), except for left temporal muscle in the evaluation of 3rd month; and in the 3rd and 6th month evaluations for the right temporal and left masseter in the EMG variable (p<0,05). Psychological measurements (chronic pain, depression and somatization) presented significant difference (p<0,05) when compared all evaluations between them. In conclusion, the association of counselling and stabilization appliance showed to be effective in the management of pain in myogenic TMD patients, confirming that conservative therapies such as the ones used in this study should be the first option when treating miofascial pain patientsMestradoPrótese DentalMestre em Clínica OdontológicaCNP

Efficacy of botulinum toxin on the treatment of persistent myofascial pain

Orientador: Celia Marisa Rizzatti BarbosaTese (doutorado) - Universidade Estadual de Campinas, Faculdade de Odontologia de PiracicabaResumo: A disfunção temporomandibular (DTM) abrange algumas alterações clínicas que comprometem estruturas do sistema estomatognático (SEG). As intervenções terapêuticas conservadoras são as comumente indicadas em seu manejo, onde o aconselhamento e os aparelhos interoclusais planos (AIP) são considerados procedimentos de primeira escolha para este tipo de disfunção, devido ao seu reconhecido índice de sucesso. Atualmente, aplicações de toxina botulínica tipo A (TxBoA) têm sido indicadas para as DTM miogênica com sintomatologia dolorosa aguda. Entretanto, os estudos existentes não confirmam se esta intervenção pode ser eficaz para o controle da dor crônica ligada à DTM; isto devido às características e ação da TxBoA, os quais podem variar substancialmente em função de fatores locais, número e posicionamento das punções realizadas, volume aplicado, concentração da droga, etc. Desta forma, o objetivo deste ensaio clínico, realizado em triplo-cego, randomizado e controlado, foi avaliar a efetividade da TxBoA no controle da dor miofascial persistente relacionada à DTM. Cem voluntárias, classificadas pelo RDC/TMD, foram divididas aleatoriamente em cinco grupos (n=20): um grupo controle, tratado com aconselhamento e aparelho interoclusal plano (SP); um grupo placebo, tratado com aconselhamento e aplicações de solução salina a 0.9% (SS); e três grupos experimentais tratados com aconselhamento e aplicações de TxBoA em três doses distintas: dose baixa (B), dose média (M) e dose alta (A); (30U, 50U e 75U nos músculos masseteres e 10U, 20U e 25U no feixe anterior do músculo temporal, respectivamente). As variáveis dependentes foram: 1) dor, avaliada através do índice subjetivo de dor, mensurado por Escala Visual Analógica (EVA), e através da análise do limiar da dor à pressão (LDP), mensurado por algometria; 2) análise da atividade eletromiográfica (EMG) e da imagem ultrassonográfica (UTS) dos músculos masseter direito e esquerdo (MD, ME) e feixes anteriores dos músculos temporais direito e esquerdo (TD, TE); 3) análise da performance mastigatória das pacientes (PM); 4) análise do volume ósseo do processo coronoide, mediante tomografia computadorizada de feixe cônico (TC); e 5) análise de alguns dados obtidos nos eixos I e II do RDC/TMD. A coleta dos dados foi feita 7 dias antes e até 180 dias após as intervenções terapêuticas. Foram utilizados modelos lineares generalizados para a análise estatística das variáveis EVA, Algometria, EMG e UTS; ANOVA dois fatores para medidas repetidas para PM; correlação de Spearman para PM e UTS; e o teste de Wilconxon para TC. Para todas as análises considerou-se o nível de significância de 5%. Os menores valores encontrados para EVA foram nos grupos SP e TxBoA-B, M e A (p0,05%). Os dados do US mostraram que o TxBoA-L foi o único grupo tratado que não apresentou diferença quando comparado com o grupo SP após 30 e 90 dias pós interveção (p>0,05). Houve correlação negativa entre PM e UTS. Desta forma a TxBoA mostrou-se eficaz no controle da dor miofascial persistente; porém alguns efeitos adversos devem ser considerados na indicação desta intervençãoAbstract: Temporomandibular dysfunction (TMD) involves some clinical changes that compromises the stomatognathic system. Counseling and splint are the procedures usually considered in TMD handling due to their recognized success. Currently, applications of botulinum toxin type A (TxBoA) have been indicated for acute pain myogenic TMD. However, the literature does not confirm whether this intervention may be effective for the control of persistent TMD-related pain. This is due to the characteristics of BoNTA, which may vary substantially depending on the local factors, the number and position of punctures, the drug volume and concentration, etc. Thus, the objective of this double-blind-randomised-controlled clinical trial was to evaluate the effectiveness of BoNTA in the management of persistent TMD-related myofascial pain. One hundred volunteers, classified by RDC/TMD, were randomly divided into five groups (n = 20): control group, that received counseling and splint (SP); placebo group treated with counseling and 0.9% saline (SS); and three experimental groups treated with counseling and three different doses of BoNTA: low dose (L), medium dose (M) and high dose (H); (30U, 50U and 75U in the masseters and 10U, 20U and 25U in the anterior temporal muscles, respectively). The outcome variables were: 1) pain, assessed through the subjective pain index, measured by Visual Analogue Scale (VAS), and through the pressure pain threshold admeasument, reached by algometry; 2) analysis of the superficial electromyographic signals (EMG) and ultrasound (US) of right and left masseter (MD, ME) and anterior temporal muscles (TD, TE); 3) the patients' masticatory performance (PM); 4) bone volume of bilateral coronoid process, acquired by cone bean computed tomography images (CT), and some data obtained from axis I and II of RDC/TMD. The data were collected 7 days before, and until 180 days after the therapeutic interventions. The statistical analysis of the data obtained for VAS, algometry, EMG and US was done with generalized linear models. Two-way ANOVA was used for MP and RDC/TMD data. Spearman's correlation, was used to correlate MP and US. The Wilconxon test was used for the analysis of the bone density data. The level of significance of 5% was considered in all the analyzes. EVA was lowest to SP and TxBoA-B, M, A (p 0.05%). The US data showed that TxBoA-L was the only treated group that did not present difference when compared to SP after 30 and 90 days post-intervention (p> 0.05). There was a negative correlation between PM and UTS. TxBo-A showed effectiveness to control persistent myofascial pain; however, some adverse effects should be considered in the BoNT-A TMD indicationDoutoradoProtese DentalDoutor em Clínica OdontológicaCAPE

Distribution of depression, somatization and pain-related impairment in patients with chronic temporomandibular disorders

Objective: the aim of this study was to describe the frequency of psychosocial diagnoses in a large sample of patients attending a tertiary clinic for treatment of temporomandibular disorders (TMD). Material and Methods: six hundred and ninety-one patients who sought treatment for painrelated TMD were selected. Chronic pain-related disability (Graded Chronic Pain Scale, GCPS), depression [Symptoms Checklist-90 (SCL-90) scale for depression, DEP] and somatization levels (SCL-90 scale for non-specific physical symptoms, SOM) were evaluated through the Research Diagnostic Criteria for TMD (RDC/TMD) Axis II psychosocial assessment; TMD diagnoses were based on the Axis I criteria. Results: the majority of patients presented a low disability or no disability at all, with only a small portion of individuals showing a severely limiting, high disability pain-related impairment (4.3%). On the other hand, abnormal scores of depression and somatization were high, with almost half of the individuals having moderate-to-severe levels of depression and three-fourths presenting moderate-to-severe levels of somatization. The prevalence of high pain-related disability (GCPS grades III or IV), severe/moderate depression and somatization was 14.3%, 44% and 74.1% respectively. Gender differences in scores of SCL-DEP (p=0.031) and SCL-SOM (p=0.001) scales were signficant, with females presenting the highest percentage of abnormal values. Conclusion: patients with TMD frequently present an emotional profile with low disability, high intensity pain-related impairment, and high to moderate levels of somatization and depression. Therefore, given the importance of psychosocial issues at the prognostic level, it is recommended that clinical trials on TMD treatment include an evaluation of patients’ psychosocial profiles

Temporomandibular joint disc displacement with reduction: a review of mechanisms and clinical presentation

Erratu

Temporomandibular joint disc displacement with reduction: a review of mechanisms and clinical presentation

Disc displacement with reduction (DDWR) is one of the most common intra-articular disorders of the temporomandibular joint (TMJ). Factors related to the etiology, progression and treatment of such condition is still a subject of discussion. This literature review aimed to address etiology, development, related factors, diagnosis, natural course, and treatment of DDWR. A non-systematic search was conducted within PubMed, Scopus, SciELO, Medline, LILACS and Science Direct using the Medical Subjective Headings (MeSH) terms "temporomandibular disorders", "temporomandibular joint", "disc displacement" and "disc displacement with reduction". No time restriction was applied. Literature reviews, systematic reviews, meta-analysis and clinical trials were included. DDWR is usually asymptomatic and requires no treatment, since the TMJ structures adapt very well and painlessly to different disc positions. Yet, long-term studies have shown the favorable progression of this condition, with no pain and/or jaw locking occurring in most of the patients27sem informaçãosem informaçã

Temporomandibular joint disc displacement with reduction: a review of mechanisms and clinical presentation

Erratum Disc displacement with reduction (DDWR) is one of the most common intra-articular disorders of the temporomandibular joint (TMJ). Factors related to the etiology, progression and treatment of such condition is still a subject of discussion. This literature review aimed to address etiology, development, related factors, diagnosis, natural course, and treatment of DDWR. A nonsystematic search was conducted within PubMed, Scopus, SciELO, Medline, LILACS and Science Direct using the Medical Subjective Headings (MeSH) terms “temporomandibular disorders”, “temporomandibular joint”, “disc displacement” and “disc displacement with reduction”. No time restriction was applied. Literature reviews, systematic reviews, meta-analysis and clinical trials were included. DDWR is usually asymptomatic and requires no treatment, since the TMJ structures adapt very well and painlessly to different disc positions. Yet, long-term studies have shown the favorable progression of this condition, with no pain and/or jaw locking occurring in most of the patients

Botulinum toxin type A and acupuncture for masticatory myofascial pain: a randomized clinical trial

BoNT-A has been widely used for TMD therapy. However, the potential benefits compared to dry needling techniques are not clear.&nbsp;Objective: this study aimed to compare the immediate effects of botulinum toxin type A (BoNT-A) injections and Acupuncture in myofascial temporomandibular disorders (TMD) patients.&nbsp;Methodology: 54 women were divided into three groups (n=18). AC patients received four sessions of traditional acupuncture, being one session/week during 20-min. BoNT-A patients were bilaterally injected with 30U and 10U in masseter and anterior temporal muscles, respectively. Moreover, a control group received saline solution (SS) in the same muscles. Self-perceived pain was assessed by visual analog scale, while pressure pain threshold (PPT) was verified by a digital algometer. Electromyographic evaluations (EMG) of anterior temporal and masseter muscles were also measured. All variables were assessed before and 1-month after therapies. The mixed-design two-way repeated measures ANOVA and Tukey’s post-hoc tests were used for analysis, considering a=0.05.&nbsp;Results: Self-perceived pain decreased in all groups after one month of therapy (P&lt;.001). BoNT-A was not better than AC in pain reduction (P=0.05), but both therapies were more effective in reducing pain than SS (P&lt;0.05). BoNT-A was the only treatment able to improve PPT values (P&lt;0.05); however, a severe decrease of EMG activity was also found in this group, which is considered an adverse effect.&nbsp;Conclusion: after one month of follow-up, all therapies reduced the self-perceived pain in myofascial TMD patients, but only BoNT-A enhanced PPT yet decreased EMG

Is There Enough Evidence To Use Botulinum Toxin Injections For Bruxism Management? A Systematic Literature Review

The objective of the study was to conduct a systematic review of the literature assessing the effects of botulinum toxin (BoNT-A) injections in the management of bruxism. Search for articles involved the PubMed, Scopus, Web of Science, Embase, Cochrane, Scielo and Lilacs databases. Specific terms were used and the search carried out from 1980 to March 2016 by three independent researchers. Randomized controlled studies (RCTs), prospective and before-after studies that applied BoNT-A at the masseter and/or temporalis muscles were included. Three RCTs and two uncontrolled before-after studies out of 904 identified citations were included in this review. All five articles dealt with sleep bruxism and featured a small sample size. None of them was about awake bruxism. Two randomized clinical trials were double-blinded, with a control group using saline solution. Two studies used polysomnography/electromyography for sleep bruxism diagnosis, whilst others were based on history taking and clinical examination. All studies using subjective evaluations for pain and jaw stiffness showed positive results for the BoNT-A treatment. In contrast, the two studies using objective evaluations did not demonstrate any reduction in bruxism episodes, but a decrease in the intensity of muscles contractions. Despite the paucity of works on the topic, BoNT-A seems to be a possible management option for sleep bruxism, minimizing symptoms and reducing the intensity of muscle contractions, although further studies are necessary especially as far as the treatment indications for bruxism itself is concerned. BoNT-A has been increasingly diffused in dentistry over recent years, being also used for pain management in patients with bruxism. Nonetheless, there is no consensus about its effects in this disorder.213727734Piracicaba Dental School, University of Campinas, Sao Paulo, Brazi