When the underlying mechanisms and etiology of TMD pain are only known in part (see under Differential diagnosis) it is difficult to perform causal therapy and cure the pain and dysfunction. Instead, a more realistic goal will be to alleviate TMD pain and restore function.
It is a common clinical experience that various physical strategies (e.g. stretching, relaxation, etc.) can be effective for the management of different types of TMD pain. Unfortunately, it has been much more difficult to support this with proper research data adhering to randomized controlled trial (RCT) principles. Critical reviews and meta-analysis have, however, started to appear to evaluate the claimed efficacy of the procedures.48,49 [III] There have been attempts to calculate the number needed to treat (NNT) values for oral splints. The available NNT estimates range between three and four for management of myofascial TMD patients and around five and six for TMJ arthralgia patients,50 suggesting a moderate efficacy of oral splints.51,52[I] Very recently, another controlled study compared the conventional hard splint with a soft splint and a usual self-care-based treatment approach.53 This study failed to show any significant differences between the three different treatment groups and all patients improved over time which suggests that oral splints are not essential in the management of most TMD patients and that low-cost nonsplint self-care therapy should be considered as an initial step in the management.
Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen in combination with diazepam have been shown to provide significantly better pain relief compared to ibuprofen alone and placebo in myofascial TMD pain patients.54[II] However, naproxen (500 mg twice a day) is significantly better than celecoxib (100 mg twice a day)
and placebo for the management of TMJ arthralgia.55[II] A short-acting benzodiazepine (triazolam) has also been shown to improve sleep but failed to provide significant pain relief in myofascial TMD patients.56[II] Cyclo-benzaprine (a muscle relaxant) has been shown to have a minor but significant effect on jaw-muscle pain upon awakening57[II] and it has been suggested that flupirtine (another muscle relaxant), with its additional effects on potassium channels and membrane-stabilizing actions, may be useful in management of myofascial TMD pain.58 [V] A combination of paracetamol, codeine, and dox-ylamine succinate (antihistamine) provided significantly greater pain relief than placebo in another study on mixed TMD patients.59[III] Also, low doses of tricyclic antidepressants (TCA) have been shown to provide significantly better pain relief than placebo.60[III] Open studies later supported the usefulness of TCAs in the management of persistent TMD pain.61[IV] Intraarticular morphine (0.1-1.0 mg) administered as a single dose has been shown to increase the pressure pain thresholds and mouth opening capacity and to reduce the visual analog scale (VAS) pain intensity. However, the clinical relevance of these findings was not impressive.62 [II] The use of botulinum toxin for myofascial TMD pain cannot be recommended at present due to inconclusive evidence.63'64[II] Recently, evidence was presented in favor of gabapentin in the management of myofascial TMD pain and tenderness.65[II] There is clearly a need for more research before firm recommendations of specific pharmacological procedures in the management of TMD pain conditions can be given since there is only scattered, reliable information on the efficacy of most of the suggested drugs.66
There is nevertheless good evidence that self-care instructions and monitoring can provide at least as good pain relief as usual dental approaches to TMD pain and that in more severely affected patients the inclusion of comprehensive care provided by a clinical psychologist will provide a significant advantage compared to the usual dental treatment.67,68[II] It appears to be important to tailor the treatment to each individual patient and not consider psychological interventions of TMD pain as a treatment of last resort, but rather use it concurrently with biomedical/dental treatments.69 Recently, it was shown that a brief cognitive-behavioral treatment program was, indeed, able to significantly reduce catastro-phizing and increase perceived control over pain and improve activity interferences and jaw use limitations.70 [II] The current guidelines recommend reversible and noninvasive management of TMD pain.
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