File Name: temporomandibular disorders an evidence based approach to diagnosis and treatment .zip
Okeson, DMD Perhaps the preeminent text book currently available for the serious student of masticatory function and disorders, Dr. Okeson brings to this field a unique balance of clinical and academic erudition. Wright, DDS This manual is very much focused on the clinical practice of temporomandibular disorders and can provide a quite clear, yet academically rigorous, guide to the clinical dentist.
Int Arch Oral Maxillofac Surg To study the short-term effect of corticosteroid injection on temporomandibular joint structures.
Thirty-six female adult Wistar albino rats divided into three groups according to the number of corticosteroid injection, each group has two subgroups according to the time of scarification either after one week or two weeks after the last injection. The most affected structure of the temporomandibular joint is condylar head and temporal bone, followed by hyaline cartilage and the fibrous layer. The articular disc and retro-discal tissue are the last structure to be affected with intra-articular corticosteroid injection.
Single corticosteroid injection with the recommended dose is safe. Single corticosteroid injection was safe with the return of joint structures to its normal cellular structure after two weeks.
Double injection with six weeks apart resulted in irreversible damage to the components of the joint. Three injections with six weeks apart resulted in massive destruction to most of the temporomandibular joint structures. Experimental study, Intra-articular injection, Repeated corticosteroid injection, Temporomandibular joint.
The most common degenerative joint disease affecting the TMJ is osteoarthritis which reflects the inflammatory changes that may take place in the joint [ 2 ]. The pathological process of TMJ arthritis is characterized by deterioration abrasion and derangement of articular cartilage with local thickening.
These changes are frequently accompanied by the superimposition of secondary inflammatory changes [ 3 ]. Treatment design based mainly to reduce inflammation; however, sometimes more comprehensive treatments are required. Management of TMJ-osteoarthrosis may be divided into noninvasive, minimally invasive, and invasive surgical modalities. Finally, in end-stage disease, salvage modalities must be considered [ 4 ].
Local intra-articular injections of different corticosteroids are tried for treatment of joint arthritis, synovitis, bursitis, epicondylitis, tendonitis.
Intracapsular injection of glucocorticoids in the temporomandibular joint has been reported to decrease pain in patients with both pain and limited mouth opening secondary to inflammatory disorders of the joint, resulted from arthritis and or capsulitis [ 5 ]. The management goals in the treatment of painful TMJ arthritis are; decreasing joint pain, swelling, and masticatory muscle spasm for preventing further joint damage and disability [ 4 ].
Inflammation is reduced, particularly through reductions in the release of interleukin-1, leukotrienes, and prostaglandins. With the reduction of these inflammatory mediators, pain symptoms often are improved. Corticosteroids inhibit cell proliferation and induced cell apoptosis [programmed cell death].
The mechanism by which corticosteroids does this is most likely through blocking the anti-apoptotic effects of Insulin-like growth factor ILGF-1 [ 5 ]. Because they are injected locally, intra-articular steroids avoid most of the systemic effects of oral steroids [ 6 ]. Studies of the efficacy of intra-articular TMJ injections have shown mixed results, with improvement in some patients and disease progression in others [ 7 , 8 ].
Regarding the effect of intra-articular corticosteroid injections, a study showed significant deleterious effects on articular cartilage after only one steroid injection into the knee, furthermore, the authors also found that the higher the dose of steroids injected, the worse the deterioration [ 9 ]. Even one injection into the temporomandibular joint TMJ showed the tremendous destruction of the articular disk and underlying bone, even 16 weeks after a single steroid injection, the joint structure remained biochemically and metabolically impaired [ 10 ].
A study examined the articular cartilage of the TMJ after two injections with triamcinolone revealed higher destruction to all layers of the joints that received when compared to the joints which received no steroid injections [ 11 ].
High doses of corticosteroids are known to increase the risk of aseptic bone necrosis. Repeated, high doses of intra-articular corticosteroid resulting in joint degeneration [ 12 ]. The most common treatment strategy is either a single injection [ 13 ] or a series of two injections spaced 14 days apart [ 14 ]. Although the best method has yet to be determined. Some clinicians have suggested that a single corticosteroid injection is beneficial for patients with severe TMJ pain, while further injections do not provide added pain relief, and may increase the risk of joint degeneration and other complications [ 12 , 15 ].
Animal models are a useful tool for understanding the pathophysiological mechanisms underlying TMJ disorders, and for evaluating the efficacy of intra-articular injections including adverse effects [ 16 ]. Until now the number of intra-articular injections of corticosteroid agent that required controlling the disease with the long-term outcome with patient satisfaction undefined [ 17 , 18 ].
Thirty-six adult Wistar albino not pregnant female rats with weight ranged between gm were selected from the animal house in the faculty of medicine, Cairo University and included in the current study. The rats were fed dried vegetables and the light cycle ratio hours light to dark respectively. The rats were divided into three main groups: A, B, and C.
Every group is subdivided into two sub-groups. Each sub-group had six rats; as follows. Left temporomandibular joints were the target for injection of corticosteroid while the right joint act as a control. The joint felt mm posterior to the lateral canthus of the eye while the mandible was manipulated to provide movement of the condyle for a further positive identification of the joint.
Local hair of all rats were shaved at the areas of injection followed by scrubbing with betadine [Betadine povidone-iodine. The Nile co. The needle was then inserted from a posterosuperior direction until the mandibular condyle was felt.
Once the needle was inside the joint, a 0. At the time of sacrification according to the group the animals were sacrificed by an overdose of anesthesia.
After decalcification, and softening; the specimen washed under running tap water for hours then dried. The left injected joints compared with right one. Figure 1: Photomicrograph showing L. View Figure 1. Figure 2: Photomicrograph showing L. S of the condylar head of subgroup A1: One week after single injection.
View Figure 2. New bone formation documented by the presence of reversal lines in all histological sections. The fibrous layer of the condyle head, temporal bone, and the articular disc appeared normal in thickness except for one animal with a slightly thickened fibrous layer covering the condyle head Figure 3.
Figure 3: Photomicrograph showing L. View Figure 3. The marrow spaces in both condyle head and temporal bone showed widening. The hyaline cartilage of the condyle appeared with apoptosis. The covering fibrous layer of the condyle head showed partial degeneration, however, no changes detected in the articular disc in all animals participating in the current subgroup Figure 4 and Figure 5. Figure 4: Photomicrograph showing L. View Figure 4. Figure 5: Photomicrograph showing L.
View Figure 5. In all animals of the subgroup, the bone marrow spaces still wide both in the condyle and temporal bone, furthermore decrease in thickness of hyaline cartilage covering the condyle show signs of apoptosis and thinning of fibrous tissue layer, while the articular disc is normal Figure 6. Figure 6: Photomicrograph showing L. S of the condylar head spongiosa A , hyaline cartilage B and articular disc C of subgroup B2, two weeks after the second injection.
View Figure 6. In all animals of the subgroup, Widening of the bone marrow spaces in the condylar head and temporal bone. Bone marrow showed inflammatory cell invasion and fatty degeneration. Degeneration of hyaline cartilage and tearing of fibrous layer with thinning of the articular disc Figure 7 and Figure 8. Figure 7: Photomicrograph showing L. S of the condylar head spongiosa A , hyaline cartilage B fibrous layer C and articular disc D of subgroup C1, one week after the last injection.
View Figure 7. Figure 8: Photomicrograph showing L. S of part of condylar head spongiosa A , articular disc B , and hyaline cartilage C of subgroup C1, one week after the last injection. View Figure 8. Bone resorption of the condylar head noticed with surface erosion and microcyst formation.
The wide bone marrow spaces still in both the condyle and temporal bone with inflammatory cell invasion, mixed fibrous and fatty degeneration of marrow spaces detected in all animals Figure Figure 9: Photomicrograph showing L.
View Figure 9. Figure Photomicrograph showing L. S of the temporal bone of a case of subgroup C2, two weeks after the last injection. View Figure S of part of the condylar head showing marrow spaces with inflammatory cells and fatty degeneration a case of subgroup C2, two weeks after the last injection. Although, there is a controversy about the effect of intra-articular injection of corticosteroids on both bone and soft tissues of the joint histopathological studies of this topic is limited.
This study was conducted on the temporomandibular joint in its normal healthy state to study the effect of corticosteroids on the joint structure in relation to the number of corticosteroid injections used. The animal model is necessary for a histopathologic examination of TMJ changes.
Rats are selected because they have condylar translation movements similar to the human condyle. The dosage used in the study [4 mg of the active drug] determined according to the manufacturer directions for injection of small joints. In the current study three injections selected according to Arroll and Goodyear [ 19 ] protocol, who found that the number of injections required to get the improvement of joint symptoms between one to three injections. Thinning of the articular cartilage explained that intra-articular hydrocortisone has a direct inhibitory effect which concomitant with the results of a study by Hauser [ 20 ] who mentioned that the rate of the cartilage protein synthesis affected by corticosteroids given by intra-articular route.
In contrary to previous studies that reported, even one injection into the temporomandibular joint TMJ showed the tremendous destruction of the articular cartilage and underlying bone, furthermore, the cartilage remained biochemically and metabolically impaired. Our findings detected that any deviations corrected by body regenerative mechanism and no harm from single injection on articular structures. Our findings reveal that the order of changes in animal joints due to intra-articular steroids injection as follows; the bone of the condylar head and the temporal bone was the first structures affected, followed by the fibrous layer covering the condyle.
In spite of long-term treatment of TMJ with repeated steroid injections appears to be clinically effective for the relief of symptoms of the disease [as pain and range of motion] but this is not enough for acceptance of the treatment when weighing benefits against harm.
The clinical improvement after the intra-articular corticosteroid injection documented in the short term assessment, however, these effects declined gradually two weeks after injection leaving irreversible damage to the joint structure. Based on the results of the current study the bone structures are the most sensitive to intra-articular injection, however, the deleterious effect of corticosteroids on the TMJ healthy bony structures could be avoided with the use of single intra-articular injection.
It is a common experience for most dental practitioners to meet patients seeking treatment for temporo-mandibular disorders TMDs. Due to the complexity of the temporomandibular system and uncertain aetiology, these disorders are often treated with radically different approaches, depending upon the clinicians' education and beliefs. Theoretically, the best way to provide basic guidelines for the management of these difficult patients would be to collect exhaustively and to examine systematically, the large body of evidence arising from the most up to date scientific research available in the literature. This excellent textbook can be considered the successful result of such a challenge, which was fulfilled by an expert team that included 42 of the most eminent researchers and clinicians in the field. Apart from a few exceptions, each chapter has been written according to an evidence-based approach rather than an opinion-based approach. The textbook is divided into two main parts: 1 biological basis and 2 clinical management.
Not a MyNAP member yet? Register for a free account to start saving and receiving special member only perks. Many patients here and around the world are lost, forgotten, and suffering. Historically, the care of some individuals with temporomandibular disorders TMDs , especially those with chronic and painful TMDs, has been fraught with challenges and complications. This chapter discusses these challenges and describes the current state of prevention, detection, assessment, diagnosis, and treatment of TMDs.
Despite continuing research, which is providing an increasing evidence base, the dental profession still does not have a standard of care for diagnosing or managing temporomandibular disorders TMDs. Although guidelines have been published by organizations including the American Academy of Orofacial Pain 1 and the American Academy of Oral Medicine, which has published a handbook 2 for managing various orofacial conditions causing pain, these are not officially recognized as authoritative documents by national associations. The Canadian Dental Association and American Dental Association have not established clinical guidelines for this segment of dental practice. In , the statement was revised in light of continuing research and the strengthened evidence base. The AADR recognizes that temporomandibular disorders TMDs encompass a group of musculoskeletal and neuromuscular conditions that involve the temporomandibular joints TMJs , the masticatory muscles, and all associated tissues.
This book continues the tradition established by 4 editions of the classic monograph, The Temporomandibular Joint: A Biological Basis for Clinical Practice , which was coedited by Daniel Laskin, the senior editor of this book. Temporomandibular Disorders is written primarily for oral and maxillofacial surgeons and other clinicians and researchers interested in the etiology, pathogenesis, and treatment of temporomandibular joint TMJ disorders. It integrates the contributions of basic scientists and clinicians in an evidence-based approach to temporomandibular disorders TMDs.
Patients with temporomandibular disorders TMD can become very complex. This article aims to highlight the importance of the multimodal and multidisciplinary approach in this type of patients to improve clinical outcomes. At present we have innumerable techniques and tools to approach this type of patients from a biopsychosocial model where active and adaptive type treatments are fundamental.
This article traces the history of the development of the current diagnostic and therapeutic approaches to the management of temporomandibular disorders, with emphasis on the mistakes or misconceptions that occurred during their development and the lessons that can be learned from these errors. It also makes recommendations for future areas of investigation, and methods for facilitating such studies, in order to improve the future treatment of these patients. This is a preview of subscription content, access via your institution.
Examination of temporomandibular disorders in the orthodontic patient: a clinical guide. The possible association between orthodontic treatment and temporomandibular disorders TMD is a topic of great interest in the current literature. The true role of orthodontic therapy on the etiology of TMD, however, is still uncertain. From the clinical prospective, a thorough examination of the stomatognathic system is always necessary in order to detect possible TMD signs and symptoms prior to the beginning of the orthodontic therapy. Caution should be exercised when planning, performing and finalizing orthodontics, especially in patients who with history of signs and symptoms of TMD. The clinician must always eliminate patient's pain and dysfunction before initiating any type of orthodontic mechanics.
Temporomandibular disorder TMD is one of the most common disorders in the maxillofacial region which usually presents with pain, unusual sounds, discomfort in chewing and locking of the jaw. TMD patients comprise a considerable proportion of patients seeking treatment; early diagnosis is important because it is proven that acute TMD responds well to treatment in contrast to chronic TMD. True diagnosis and treatment of TMD can be difficult, as these patients often suffer from some other disorder at the same time. In these cases, a successful treatment is due to true diagnosis of all initiating factors, predisposing and perpetuating factors and treatment of other established disorders. An important point is the close relation of intrajoint disorders to disorders of masticatory muscles. Today, it has been proven that disorder of masticatory muscles can lead to TMD.
Int Arch Oral Maxillofac Surg To study the short-term effect of corticosteroid injection on temporomandibular joint structures. Thirty-six female adult Wistar albino rats divided into three groups according to the number of corticosteroid injection, each group has two subgroups according to the time of scarification either after one week or two weeks after the last injection. The most affected structure of the temporomandibular joint is condylar head and temporal bone, followed by hyaline cartilage and the fibrous layer. The articular disc and retro-discal tissue are the last structure to be affected with intra-articular corticosteroid injection. Single corticosteroid injection with the recommended dose is safe. Single corticosteroid injection was safe with the return of joint structures to its normal cellular structure after two weeks.
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View My Stats. Background: Temporomandibular disorder TMD is a common term used to describe the problems related to masticatory muscles, joints, and supporting tissues. TMD commonly causes orofacial pain and has been the subject of considerable research in the field of dentistry. The treatment chosen for patients who have TMD is largely determined by the knowledge of general dental practitioners.
Request PDF | On Jan 1, , Daniel Laskin and others published Temporomandibular Disorders: An Evidence-Based Approach to Diagnosis and Treatment.Reavininsmond 15.05.2021 at 03:41
Temporomandibular Disorders: An Evidence-Based Approach to Diagnosis and Treatment Author(s)/Editor(s): Laskin, Daniel M.; Greene, Charles S.; Hylander.Berangaria G. 15.05.2021 at 16:44
Patient information : See related handout on temporomandibular disorders , written by the authors of this article.Max H. 16.05.2021 at 20:22
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