Functional disturbances of the masticatory apparatus diagnosis and treatment

Functional disturbances of the masticatory apparatus diagnosis and treatment Zaburzenia czynnościowe układu ruchowego narządu żucia diagnostyka i leczenie Grzegorz Kogut (A,B,E,F), Andrzej Kwolek (A,B,E,F) Department of Rehabilitation UR, Rzeszow, Poland Authors' contribution: A project of the study, work; B collection of the data, information; C statistical analysis; D data interpretation; E preparation of the manuscript; F literature query; G obtaining funds Received 02.02.2006; accepted 15.03.2006 Key words temporomandibular joint, masticatory apparatus dysfunction, diagnosis, principles of treatment, prophylaxis Abstract Diagnosis of the masticatory motor system functional disturbances frequently creates significant difficulties. Aside from detailed medical history and examination of a patient, precise analysis of occlusion and lower jaw movements is necessary. Routine radiological examinations of the temporo-mandibular joint reveal pathological changes of joint surfaces shape, as well as malposition of hard tissues. In cases of severe forms of dysfunction, further imaging studies should be performed (computed tomography, magnetic resonance imaging). Treatment of these dysfunctions includes many procedures. The first and important element is combating parafunctions after previously having made the patient aware of the fact of their existence. Stomatologic causal treatment aims at restoring correct intraoral (including patient's own teeth or prosthetic restoration) and extraoral (temporo-mandibular joints) relationships and restoring appropriate activity of the masticatory apparatus muscles. During the initial phase of treatment, various types of oclusion splints, relieving apparatuses and stabilising splints are used, which enable obtaining and maintaining correct position of articular disc and heads of the mandible. In cases complicated by severe pain states, appropriate pharmacological treatment is implemented. Physiotherapeutic methods are used as protective therapy. Simple methods, used even by patients themselves, include warmth-treatment (humid warmth or dry warmth) and cryotherapy. Treatment with physical agents such as electrical current, ultrasound and low-energy laser therapy is also used. Classical massage, connective tissue massage and auto-massage of the masseter muscles act adjunctively. The biofeedback method used simultaneously with passive and active exercises can also be helpful in obtaining a change in patient's behaviour,. Positive results of the therapy of the masticatory apparatus motor system dysfunctions are achieved in 60-80% of the treated patients, while prophylaxis involves mainly counteracting parafunctions of the mandible. Słowa kluczowe staw skroniowo-żuchwowy, dysfunkcje narządu żucia, diagnostyka, zasady leczenia, profilaktyka Streszczenie Diagnostyka zaburzeń czynnościowych układu ruchowego narządu żucia stwarza wielokrotnie duże trudności. Oprócz dokładnego wywiadu i badania klinicznego pacjenta, konieczna jest dokładna analiza zwarcia i czynności ruchów żuchwy pacjenta. Rutynowo wykonywane są badania radiologiczne stawu skroniowo-żuchwowego, które uwidaczniają patologiczne zmiany kształtu powierzchni stawowych, jak również nieprawidłowe położenie względem siebie tkanek twardych. W przypadkach ciężkich postaci zaburzeń należy wykonać dalsze badania obrazujące (tomografię komputerową, rezonans magne- 44

tyczny). Leczenie tych zaburzeń obejmuje wiele etapów postępowania. Pierwszym i ważnym elementem jest zwalczenie parafunkcji, po uprzednim uświadomieniu pacjentowi faktu ich uprawiania. Stomatologiczne leczenie przyczynowe ma na celu przywrócenie prawidłowych stosunków wewnątrzustnych (obejmujących zęby własne pacjenta lub uzupełnienia protetyczne), zewnątrzustnych (stawów skroniowo-żuchwowych) oraz przywrócenie prawidłowej czynności mięśni narządu żucia. We wstępnym okresie leczenia stosuje się różnego rodzaju szyny zgryzowe i aparaty odciążające oraz szyny stabilizujące, które umożliwiają uzyskanie i utrzymanie prawidłowego położenia krążków stawowych i głów żuchwy. W przypadkach powikłanych innymi bólami wdraża się leczenie farmakologiczne. Metody fizykoterapeutyczne są stosowane jako terapia osłonowa. Prostymi metodami, stosowanymi nawet przez samych pacjentów, jest ciepłolecznictwo (ciepło wilgotne i suche) i krioterapia. Zastosowanie znajdują również: elektrolecznictwo, leczenie ultradżwiękami, laserem niekoenergetycznym. Wspomagająco działa masaż klasyczny, masaż tkanki łącznej i automasaż mięśni żucia. W uzyskaniu zmiany zachowania pocjenta pomocna może być metoda biologicznego sprzężenia zwrotnego, stosowana równocześnie z ćwiczeniami aktywnymi i biernymi. Pozytywne wyniki leczenia zaburzeń układu ruchowego narządu żucia uzyskuje się u 60-80% leczonych pacjentów, a profilaktyka obejmuje głównie przeciwdziałanie parafunkcjom żuchwy. DIAGNOSTIC EVALUATION Diagnostic evaluation of functional disturbances of the masticatory apparatus motor system involves taking detailed history, assessment of existing clinical signs, careful analysis of the occlusion, clinical examination of the temporomandibular joints, as well as, frequently, radiological studies of these articulations 1-5. History should include pain complaints and acoustic symptoms of the temporomandibular joints, pain of the masticatory apparatus muscles, headaches, neck and back pain, as well as presence of parafunctions. Detailed general medical history reduces the risk of omitting important systemic factors that can contribute to this specific problem. These include cardiovascular diseases, neuromuscular diseases, immune system disorders, gastrointestinal problems 6-9. Focused history referring to the temporomandibular articulations includes questions pertaining to: - disturbances of the mandibular condyle mobility, the so-called "sliding", - clicks and cracks, - subluxations and luxations of the mandible, - restricted lowering of the mandible with or without pain, - radiating pain from the temporomandibular joints 3,10-13. During conversation with the patient, his reported chief complaints should be identified and the associated symptoms evaluated. This frequently allows to determine, whether the occurring symptoms are in concordance with characteristics of a defined disturbance of the temporomandibular joints. The patient should point with his fingertips to the painful sites, although not in everyone can these sites be identified this way. Patients should be helped with in localising deep or imprecisely circumscribed pain. Pain intensity, with the mandible at rest, should be expressed by means of the visual analogue scale (VAS) 2,14-20. Clinical examination of patient's oral cavity should provide the information about: - the status of the teeth and parodontium (damage and lack of teeth), - possible presence of injuries caused by the occlusion, - traces of teeth occlusion and bruxism, - occlusion disturbances 21-23. Clicks in the temporomandibular joints are first localised by the patient. They may occur during abduction and adduction, protrusion and lateral movements of the mandible. Sound characteristics often change. They can be diagnosed using a stethoscope or by palpation examination during mandible movements in various directions. Palpation examination of all parts of the temporomandibular joints is performed to determine possible pain, tenderness to pressure, oedema, clicks and translocations of the mandible condyles. This examination is performed with possibly forceful pressure exerted onto the articulation, during movements in different directions. Palpation examination of the joints via the external acoustic meatus during forceful teeth occlusion should also be conducted. Sometimes, clicks occur only during chewing hard food 1,2,13,24-28. Clinical assessment of temporomandibular joints dysfunction is based on the determination of movement restrictions during the following activities: 45

- chewing of hard food, - yawning, - singing, - job-associated duties, - biting on large pieces of food, - playing a musical (brass) instrument, - performance of other, especially extreme, mandible movements. Muscle tenderness to pressure is a frequent sign of disturbances of the masticatory apparatus motor system. This tenderness is an important clinical sign and is significantly associated with dental occlusion. The temporal muscle should be examined extra-aurally (at rest as well as during its contraction), beginning with its posterior to the anterior part reaching the zygomatic arc. Very often, tenderness to pressure of the part of this muscle's tendon attached to the mandible ramus is observed. Deep and superficial parts of the masseter should be palpated both during dental occlusion and resting conditions. The medial pterygoid muscle is examined extra-orally at the site of its origin at the medial portion of the mandibular angle. Direct palpation of the lateral pterygoid muscle is not possible, although it is considered that the pain in the distal part of the buccal vestibule, posteriorly, behind the third molar tooth, may be a symptom of pressure tenderness of the lateral pterygoid muscle. Examination of the muscles of the neck is commenced by the palpation of the sternocleidomastoid muscle. Patient's head should be slightly bent backwards and stabilised. Subsequently, the trapezius, omohyoid, submandibular, and the scalenus group muscles as well as the muscles of the neck together with suboccipital muscles are subjected to the examination 10,16,17. Analysis of the mandibular occlusion and function According to contemporary views, evaluation of mandible movements is the principal examination enabling the diagnosis of functional disturbances of the masticatory apparatus motor system. In the assessment of mandible mobility, all free movements of the mandible should be considered, i.e.: - lowering and adduction of the mandible; - protrusion and retraction, - lateral movements. The analysis of particular mandible movements assesses: - the range of these motions, - deviation of the mandible during its lowering and protrusion, - presence of pain and acoustic symptoms (clicks). Apart from the direct assessment of mandibular mobility, recording devices can also be used for this purpose. Functiographs are the devises serving to record mandibular function intra-orally. Other devices (articulators) are used to assess the occlusion and mandibular movements outside the oral cavity. Currently, also electronic recording devices are used for this purpose. Normal or enhanced range of a given mandible movement and the accompanying clicks indicate a reposition of the translocated disc during this movement, which is referred to as disc translocation without block. Conversely, restriction of a particular mandible movement and a lack of clicks indicates disc translocation without its reposition, i.e. with a block 1-3, 5,29,30. Imaging studies of the temporomandibular joint In the majority of cases, the diagnosis can be established based on clinical examinations and instrumental functional analysis. From the diagnostic point of view, those imaging studies are useful that not only visualize pathological changes of the shape of the mandibular condyle and articular acetabulum, but also enable the evaluation of intra-articular soft tissues and occlusion-associated incorrect positioning of hard tissues against each other. In routine clinical practice, in most cases, it is sufficient to perform an x-ray of the temporomandibular articulations in the saggital plane at maximal teeth cusping in order to determine the position of the mandibular condyles and the shape of the articular rim. Further imaging studies (computed tomography, magnetic resonance) are indicated in cases, where: 46

- there are difficulties in determining the therapeutic position of the mandible, - clinical status requires more detailed explanation, - satisfactory diagnosis cannot be established, - a clinically severe form of masticatory apparatus dysfunction is present, - beneficial therapeutic effects cannot be reached. In the diagnosis of these disturbsnces, very detailed clinical examination and instrumental analysis are still of crucial importance 2,31-41. THERAPY OF FUNCTIONAL DISTURBANCES OF THE MASTICATORY APPARATUS Principles of the therapy of the masticatory apparatus motor system were formulated e.g. by the German Dentistry Society. It states that: "Principles of general medical and physiotherapeutic treatment of the motor system can also be applied to support the therapy in the mandibular-maxillary domain. They include muscle massages, isotonic physical exercise, as well as use of warmth, especially in a form of microwave diathermy. By making the patient aware not only of the parafunctions, but also of an incorrect body posture, may act as an adjuvant factor, e.g. by self-observation or possibly by use of biofeedback. Admittedly, medical-physical agents act symptomatically and their primary aim is fast alleviation of pain, however, they cannot replace the causative treatment. As the sole form of therapy, these agents are considered only in simple coordination problems due to parafunctions. Besides, also other physiotherapeutic methods (e.g. therapy with cold) are frequently necessary. Removal of harmful occlusion obstacles by polishing and introduction of diagnostically and therapeutically helpful relieving devices is especially important. The purpose of all these methods is to relax the muscles and restore their normal coordination as well as to normalise aberrant movements of the mandible. Therefore, it is important to: precisely determine the indications, properly instruct and carefully conduct patient's therapy. The methods may be used during initial treatment, when restoration of the occlusion with or without denture is inevitable." (quoted from Koeck B. 2 ). Elimination of parafunctions and combating stress The first and very important phase of masticatory system dysfunction therapy is combating parafunctions of this organ. Concomitantly, therapy eliminating stress should be conducted, especially the chronic stress that the principal cause of habitual mandible parafunctions. In depressive states, associated with chronic and frequently severe pain, psychiatric therapy is indicated. In such cases, psychiatrist decides, whether the patient may already be treated by the dentist or else firstly requires psychiatric treatment 3,20,21. An effective method of fighting mandible parafunctions has been elaborated by the Lublin centre (Kleinrok and colleagues), where parafunctions are replaced by other harmless motor habits. Its efficacy was confirmed in a group of pupils biting their nails. In 78.8% of participants, this habit was eliminated without psychologist's assistance 20,42. Elimination of a harmful habit is possible thanks to the strong motivation associated with the will to be freed from pain or to achieve a good aesthetic effect. Application of such therapeutic method requires fulfilment of certain conditions, i.e.: - making the patient aware of parafunctions being performed, - indicating the cause (e.g. stress), - explanation of the destructive influence of parafunctions on the health status, - monitoring therapy results, - teaching the patient stress coping strategies (e.g. practising positive thinking - psychotherapy), - mastering muscle relaxation techniques, including muscles of the masticatory apparatus 1,2,5. 47

Topical treatment The aim of topical treatment is to restore normal extra-oral relations of the temporomandibular joints, normal dental arcs' occlusion (of patient's own teeth as well as of prosthetic fits), and to restore normal function of the masticatory system muscles' function. Restoration of normal relations within the "dento-dental" and the "dentoalveolar" joints eliminates the causes of performance of occlusal parafunctions. For the complete restoration of normal muscular function, it is also necessary to eliminate non-occlusal parafunctions that can sometimes be the only cause of dysfunction 15,20. During the initial phase of therapy of patients with masticatory motor system dysfunction, various occlusal splints and relieving devices are used. The principal goal of such management is the elimination or at least alleviation of pain and an improvement of mandibular function. The applied splints induce: - isolation of teeth contact from muscular and articular dependence, - even distribution of occlusion forces, - prevention of teeth attrition and mobility, - reduction of the intensity of bruxism and other parafunctions, - alleviation of muscle-associated pain, - stabilisation or repositioning of the mandibular condyle 4,42-46. Currently, stabilising splints called relaxation splint devices (of Michigan, Ramfjord and other types) enfolding the whole dental arcs (Pictures 1a and b) are used. Use of occlusion splint devices as one of the treatment methods should be preceded by detailed examination of the patient apart from the history and the clinical examination, including detailed analysis of mandibular movements, the most modern visualisation techniques are used. The aim of the therapy is the achievement of correct position of the articular discs and the mandibular condyles by application of a repositioning occlusion splint in the therapeutic position of the mandible. It is, therefore, necessary to construct a 24-hour occlusion splint device, made of acrylate. Such splint requires even a severalmonth use and regular follow-up visits in order to correct the occlusion surfaces, with the changing position of the articular discs and the mandibular condyles. However, in a too small percentage of cases, it is possible to successfully withdraw splint application and achieve a permanent and correct positioning of the mandibular disc-condyle complex. Thus, the second, irreversible phase of the therapy is necessary that aims to achieve a balanced occlusion, namely persistent remodelling of the occlusion by means of preventive dental, prosthetic or orthodontic methods 47-51. In cases complicated by severe pain, pharmacotherapy is indicated starting with the first visits. The purposes of this therapy are as follows: - alleviation and elimination of pain, - inhibition of inflammatory processes, - decreasing muscle tone, - attenuating states of psychological stress. Agents with isolated analgesic and anti-inflammatory properties are poorly effective in patients with syndromes of painful dysfunction. In these patients, it is also necessary to relax the skeletal muscles and reduce mental stress. Tetrazepam, administered for 3 weeks at doses of 25-50 mg in the evening, before sleep seems to be the agent that fulfils these criteria 20,52. Picture 1 a and b The Michigan stabilising splint 48

Therapy with physical agents Therapeutic methods based on the effects of physical agents have usually symptomatic effects, hence it is purposeful to apply them as a protective treatment concomitantly with other methods 1,2,20. Warm therapy It is recommended to reduce the increased muscle tone in subacute arthropathies and inflammatory rheumatic diseases. This form of the therapy with physical agents, however, cannot affect the tissues located deeper, including the lateral and medial pterygoid muscles 1. Dry warmth may be supplied by means of Solux lamp (distance 20 cm, duration approx. 15 minutes). Tensed and aching tissues may be warmed using a thermophor filled with water at temperature of 70-80ºC and additionally wrapped in a towel. Supply of dry warmth may be also performed using an electric pillow or hair-dryer. Humid warmth, however, has better effects than dry warmth. A simple method of using humid warmth is, apart from a hot shower, also a hot bath. Sulphur and iodide baths or baths with addition of carbonic acid show good effects. Other confirmed sources of humid warmth include peat poultices (pelotherapy) and peat packs. Although warmth immediately alleviates strong pains, its effects are most frequently short-term. Its major advantage is harmfulness and the fact that it can be used by the patients at home, even at night at any time, when pain occurs. Cryotherapy It is used in a form of cold packs, ice compresses, cold spray or air. It is among the most effective analgesic agents and is applied immediately prior to kinesitherapy in acute muscle tensions and tendopathies as well as in acute arthritic and inflammatory rheumatic diseases. Use of cold aerosols proved to be effective; however, because of possible skin damage (frostbites), they are not commonly used. Cooling skin surface with ice cubes or containers with ice wrapped in a towel is safe and effective. In acute disease states, compresses are applied for 10-15 minutes. During subsequent physical exercises of the mandible, the patient should experience attenuation of pain symptoms, reduced stiffness, as well as demonstrate a better mandibular mobility 1,2,20. Electrical therapy short-wave diathermy The effectiveness of penetration of energy of high frequency deep into the tissues depends on the wave length, frequency and shape of the used source of radiation. Use of the cask method was proposed for microwave therapy of the masseter and medial pterygoid muscles (Shulte) 2. At power of 25 W, exposition duration is 8-10 minutes. The patient leads the electrode, at constant contact wit the skin, using slow, round movements over the painful areas. Dependently on pain intensity, irradiation may be used 1-2 times a day. Currently, better focusing of the wave field and partial removal of their disadvantages in comparison to microwaves has been made possible. The depth of penetration of short waves has markedly increased thanks to a reduction in their absorption. In acute pathological states, a pulsating mode of application should be selected, at which warmth is not produced. If, during the treatment with high frequency current, intensification of pain occurs, the procedure should be terminated. In patients with implants, cardiostimulators, etc., such therapy is contraindicated. Furthermore, the area subjected to microwaves effects must not comprise the brain and the orbit and hence the temporal muscle must not be treated by means of this method 2,20. Ultrasound therapy In ultrasound therapy, in general, three types of signals are used: - constant waves, - sound impulses, - ultrasounds combined with stimulation current (a type of the current with effects involving alleviation of pain symptoms and muscle tone reduction should be selected for the therapy). Duration of a single procedure, at dynamic form of head leading, is 6-8 minutes, once every 1-2 days, with a total number of procedures ranging 6-12; in case of devices emitting constant waves: 0.5 or 0.7 W/cm, and sound impulses (50 or 100 Hz) 0.6 0.9 W/cm. Ultrasound therapy, especially in combination with stimulation current, is one of efficacious methods of reducing pain symptoms, decreasing muscle tone and improving muscular fucntion 1,2. 49

Laser therapy For the treatment of inflammatory states of the muscles and articulations, irradiation with lasers emitting infrared waves has been recommended increasingly often. The laser light (wavelength 904 nm, frequency 700 Hz) penetrates through the skin 30 mm deep. However, due to a too small number of clinical studies, this method is not yet widely used 1,2,20,53. Therapy using constant current As a result of current effects, ion flow occurs within the tissues. Data from the literature indicate that transdermal iontophoresis of the temporomandibular joints using non-steroidal anti-inflammatory agents, is an efficacious method of pain alleviation in case of rheumatoid arthritis, sequels of traumatic injury of these articulations, as well as in patients with masticatory apparatus dysfunction. An important factor favouring the use of this method is a possibility to avoid gastrointestinal system or renal complications following oral administration of these preparations. In the Lublin centre (Kleinrok), Profenid-gel 2.5% was used by means of this method of delivery. Transdermal iontophoresis of this preparation was conducted in a group of patients with painful masticatory apparatus dysfunction. A gel amount of approx. 1.5 cm was given onto a humid, warm gauze pad that was subsequently placed in the region of painful temporomandibular joints. Cathode was the supplying electrode, current intensity was up to 3 ma, and the duration of a single procedure was 10 minutes. In each patient, 10 procedures of iontophoresis were applied. After data analysis (assessment of pain intensity before and after iontophoresis), the authors demonstrated that transcutaneous iontophoresis of the temporomandibular joints using 2.5% of Profenid (ketoprofen), with concomitant therapy with occlusal splint, results in a significant attenuation of pain intensity in patients with a syndrome of painful dysfunction, which encourages further studies on this method 52,54. Transcutaneous nerve stimulation It belongs to one of the more frequently used forms of therapy with physical agents. Apart from the analgesic effects, the electrical current also reduces the increased muscle tone, augments the vasomotor activity thus ameliorating nutritional and metabolic processes. The aim of electrostimulation is also a replacement of the lacking bioelectrical activity or removal of its excess, as well as prevention of sequels of these states. Advantages of electrostimulation include non-invasiveness, as well as the absence of undesirable effects. It is, therefore, becoming a competitive method in the therapy of chronic pain to pharmacological agents because of their undesirable effects. An additional benefit of some of electrostimulation devices is associated with their construction, being user-friendly, allowing self-application by the patients. Mieszkowski and Kleinrok 55 applied this method in 63 patients with the masticatory dysfunction syndrome. In all participants, 10 procedures of electrostimulation were conducted. The M-M Analgator device was used. Superficial electrodes placed on the defatted skin of the face were used dependently on the intensity and symptoms of dysfuntion, the electrodes were placed around the lower origins of the masseter muscles, orifices of the mental, infraorbital and the supraorbital nerves, or at sites pointed to by the patient as particularly painful. One of the electrodes constituted the active electrode, while the other was passive, current flow duration was 5 minutes. Stimulation was applied at two pairs of points, located symmetrically on both sides of the face. It was demonstrated that electrostimulation is worth being recommended as a method of adjuvant therapy, especially in patients with signs of anterior translocation of the articular disc with blockade, although the effects of this method application may sometimes occur as late as after several weeks. Massage In cranio-mandibular and cervical-shoulder syndromes, massage should be used only after a careful initial examination. This is limited, first of all, to the muscles participating in chewing, nuchal muscles, muscles of the back and shoulder girdle. It is used in cases, where as a result of careful palpation local changes in soft tissue density are found. Use of massage is especially effective, when it is preceded by the therapy with physical agents, for example with warm therapy. It is recommended to initiate the treatment of cranio-mandibula and cervical-shoulder dysfunctions with every-day massage (of duration no longer than half an hour), for a period of 2-3 weeks. If correction of occlusion is performed in paralel as a form of initial treatment, concomitantly with physiotherapy then the effect reducing muscle tone will be fully taken advantage of. Classical massage In the classical massage, influencing primarily on muscular dysfunctions, the following techniques are used: - rubbing out, 50

- beating, - rubbing of the affected site, - pulling the subcutaneous integuments. These techniques differ with respect to the site and direction of movement. Initially during the treatment, applying of greater forces should be avoided. In most of the grips, the course of fibres situated under the massaged body parts determines the direction of the movement. The massage is performed from the more distal to more proximal regions. Connective tissue massage Using this technique, only skin and the subcutaneous connective should be massaged, which should have a form of pulling. Muscle tissue should be excluded from the massage. Application of this technique increases the mobility between the subcutaneous layer and the body integument, as well as it induces vegetative re-adjustment by eliciting cutaneous-visceral reflexes 1,2,20. Self-massage of the muscles involved in mastication To achieve a successful effect of the self-massage, detailed instructions given to the patient and motivation of a mutual cooperation are inevitable. Independently of the positive, therapeutic action of the soft tissues, the patient, via an active cooperation, does affect the course of the therapy. It is important that he is able to evaluate the density of the muscles and their tone. The following techniques (that must be presented to the patient in detail) are used: rubbing, pressing and muscle friction. Firstly, such muscles as: the masseter, temporal, sternocleidomastoid, medial pterygoid (at the region of its origin), biventer (the posterior belly), as well as possibly muscles of the fundus of the oral cavity and the nuchal muscles are subjected to the massage. In cases of excessive muscle tone, massage is resigned on initially, while attempts are made to remove indurations by means of relieving devices, warm therapy or pre-medication for a period of several days. Self-massage of the muscles involved in mastication is indicated during the whole period of initial therapy as an adjuvant treatment. In certain patients, it may be used for a longer period of time, however, only when needed and not on a daily basis 2,5. Kinesitherapy In the physiotherapy of the masticatory motor system dysfunction, the following techniques are used: - active movements performed by the patient at isotonic muscle contractions, - active exercises, conducted by the patient at isometric muscle contractions, with overcoming the resistance, - general physical exercise, The principal rule of relaxing exercises is reflex relaxation of the muscles by their alternating stimulation and inhibition. The patient should try to open his mouth widely, while counteracting this movement with a pressure exerted on the chin. During this procedure, contraction of the muscles lowering the mandible inhibits muscle tone of the adducting muscles. These exercises may be combined with active or passive stretching, until the maximum mouth opening. The patient should observe himself in the mirror to ensure that during abduction of the mandible, its deviation does not occur. The exercises are usually recommended to be performed concomitantly with other therapeutic methods and it is thus difficult to assess its specific value 1,2. 51

Picture 2 An exercise, in which the patient is opening the mouth while counteracting the pressure exerted by his own fist. Picture 3 An exercise of mouth opening; the fingers help in counteracting resistance of the fist. Picture 4 Patient's clenched fist is opposing the protrusion movement of the mandible. 52

The biofeedback method The method can help the patient in changing his behaviour. By providing acoustic or visual signals, using appropriate devices, this method can convey to the patient the information on muscular activity, skin temperature, generation of cerebral potentials, pulse rate, blood pressure, skin resistance or other physiological measures. Only by means of these parameters can the patient learn to directly control his physiological activities. There are biofeedback devices for use at home that can control night time bruxism. However, both bruxism and the pain may recur after termination of use of the device, hence application of biofeedback is currently being evaluated in research studies, despite some success in the therapy of stress-induced myoarthropathies 1,2. Other methods Both hypnosis and transcendental meditations are being recommended for patients with dysfunctions-associated pain. However, control studies of these methods are lacking; moreover, the dentists do not have qualifications for conducting such procedures. Patients with the masticatory motor system dysfunctions frequently suffer from depression that often have a complicated nature. Psychiatric consultation and possibly treatment is necessary in such cases. It should, however, be kept in mind that the majority of patients, although stressed, do not wish to undergo psychotherapy. Nonetheless, these patients need an objective advise and compassion. Frequently, they had searched for help in other dentist and physicians of other specialties, who informed them that there was no evidence for the presence of any disease in these patients and that they did not require any treatment. They may also have cancerphobia and it is thus important to explain in detail that the observed symptoms are not indicative of a severe disease. Advising is an active therapy and not only a placebo-like method. Muscle tone can be reduced by the patients themselves if they are aware of their status. An advise is usually insufficient as the only therapy, but it improves the relationship between the patient and his physician, which is important for the success of any therapy 2,21. Surgical treatment Surgery, as the initial therapy of myoarthropathy, is never indicated. Performance of a surgical procedure seems to be necessary only in cases, where there are certain morphological prerequisites or when marked disturbances of the joint function are observed that cannot be cured by appropriate preventive treatment. In general, effects of surgery can be expected to be the better, the more disturbances can be identified within the articulation itself, the more these disturbances are perceived during the activity (of eating and speaking) and the less are these disturbances masked by muscles-related ailments. Indications for surgery pertain to as little as 4% of patients with temporomandibular joints diseases 1,2. Effects of therapy Because of the occurrence of marked differences in the views referring to the aetiology, diagnosis and treatment methods of the temporomandibular joints dysfunction, there are no unequivocal and comparable studies assessing the results of the therapy. Headaches associated with the masticatory apparatus dysfunction are treated effectively in 60%, while in the remaining 30%, marked improvement is achieved. Clicks in the temporomandibular joints are treatable, in general, in 60%, in the remaining cases, a reduction in their frequency is reached and they are markedly attenuated. Nuchal pain may be efficaciously cured in 80% of these patients. Poorer effects are achieved in the therapy of patients with advanced intra-articular disturbances. They constitute particularly difficult cases, requiring long-term treatment, especially, when the articular discs are markedly enlarged. Bad patient's mental condition is also a pronounced obstacle in achieving good effects of treatment 8,20. 53

PREVENTION The principal rule in the prevention of disturbances of the masticatory motor system is combating mandibular parafunctions and their causes. Because systemic diseases also play a role in the aetiology of these disturbances, an interdisciplinary cooperation of the dentists with physicians of other specialties (neurologists, endocrinologists, laryngologists, ophthalmologists, orthopaedists, oncologists and rehabilitation specialists) is also necessary 20,56. References 1. Ash M.M., Ramfjord S.P.,Schmidseder J.: Terapia przy użyciu szyn okluzyjnych. Wydanie I polskie. Urban & Partner. Wrocław 1999 2. Koeck B. : Zaburzenia czynnościowe narządu żucia. Wydanie I polskie pod redakcją Teresy Maślanka. Urban & Partner. Wrocław 1997 3. Kleinrok M.: Rozpoznawanie i leczenie zaburzeń czynnościowych układu ruchowego narządu żucia. Wyd. IV, Wydawnictwo Sanmedica. Warszawa 1992 4. Katzberg R.W.: Anatomic disorders of the temporomandibular joint disc in symptomatic subjects. J. Oral. Maxillofac. Surg. 1996; 2: 147-153 5. Wigodowicz-Makowerowa N.: Zaburzenia czynnościowe narządu żucia. PZWL. Warszawa 1984 6. Worz R.: Pain in depresion depresion in pain. Pain Clinical Updates, 2003; 3: 1-4 7. Kleinrok M., Drop A., Mielnik-Hus J., Kister A.: Bólowy zespół dysfunkcji narządu żucia u chorych z osteoporozą. Prot. Stom.1999; 49(6): 328-333 8. Litko M.: Analiza, potrzeby i skuteczność leczenia dysfunkcji narządu żucia u młodocianych. Praca doktorska, AM Lublin 2003 9. Jensen R., Rasmussen B. K., Pedersen B., Lous I., Olesen J.: Prevalence of oromandibular dysfunction in general population. Orohac. Pain., 1993; 2: 175-182 10. Travell J.: Temporomandibular joint pain referr from muscles of the head and neck. J. Prosthet. Dent., 1960; 10: 745 11. Karasiński A.: Badania nad zależnością pomiędzy bólami twarzy a zaburzeniami w układzie ruchowym narządu żucia. Praca hab. ŚLAM Katowice 1986 12. Baron S., Karasiński A., Namysłowski P.: Narząd słuchu a dysfunkcje stawów skroniowo-żuchwowych. Czas. Stom., 2002; 55, 5: 319-323 13. Kleinrok M.: Objawy kliniczne towarzyszące przemieszczeniom krążków stawowych ssż i głów żuchwy. Mag. Stom., 2004; 14 (10): 44-49 14. Krakowiak K., Kleinrok M., Mielnik-Hus J., Doraczyńska-Banach E.: Nawykowe żucie gumy a dysfunkcje układu ruchowego narządu żucia. Prot. Stom., 1996; 46 (6): 360-368 15. Kleinrok J.: Badania nad częstością występowania bólów głowy związanych z dysfunkcją układu ruchowego narządu żucia. Neur. Neurochir. Pol., 2000; 3: 475-486 16. Domżał T.M.: Samoistne bóle mięśniowe. Ból. 2001; 2, 2: 22-26 17. Risatti-Barbosa C.M.: Eagles syndrom associted with temporo-mandibular disorder. A clinical report. J. Prost. Dent. 1999; 81, 6: 549-650 18. Krajewska M.: Bóle głowy typu napięciowego (T-TH) a zaburzenia czynnościowe narządu żucia. Prot. Stom. 2000; 50, 5: 252-258 19. Karasiński A., Szczerbankiewicz B.: Zespoły bólowe w obrębie jamy ustnej twarzoczaszki. Część III. Łódź CEDE 2003; Materiały zjazdowe: 4-8 20. Kleinrok M.: Bólowe i bezbólowe objawy związane z zaburzeniami czynności układu ruchowego narządu żucia. Terapia, 2004; 10: 19-26 21. Kłosek-Porszke B., Baron S., Dróżdż T., Hottowy A.: Leczenie psychologiczne w terapii bruksizmu. Twój Przegląd stomatologiczny. 2005; 9: 46-51 22. Baron S., Tarnawska B., Tarnawski M.: Wpływ zaburzeń zwarcia ekscentrycznego na wybrane elementy układu stomatognatycznego. Mag. Stom., 2004; 14 (5): 62-67 23. Homa A., Split W.: Rozległe braki w uzębieniu a występowanie dysfunkcji narządu żucia. Mag. Stom., 2004; 14 (4): 78-81 24. Chladek W., Karasiński A., Kasperski J.: Krążek stawowy jako element redukujący naprężenia stykowe. Prot. Stom., 2002; 52 (6): 319-323 25. Kleinrok M., Kleinrok J.: Podział i rozpoznawanie kliniczne przemieszczeń krążka stawowego stawu skroniowożuchwowego w maksymalnym zaguzkowaniu zębów. Prot. Stom., 2000; 50 (4): 185-194 26. Dorobek W.: Manualna analiza czynnościowa układu ruchowego narządu żucia. Mag. Stom., 1999; 9 (1): 44-48 54

27. De Laat A.: Temporomandibular disorders as a source of orofacial pain. Acta Neurolog. Belg., 2001; 101: 26-31 28. Leader J.: The influence of mandibular movements on joint sounds in patient with temporomandibular disorders. J. Prost. Dent., 1999; 6: 81-87 29. Czubak K., Kaska-Czubak O., Krajewska M., Wojtaszek-Słomińska A., Sadlak-Nowicka J.: Badania nad diagnostyką i leczeniem chorych z dysfunkcją narządu żucia z wykorzystaniem artykulatora nastawnego Condylatora. Prot. Stom., 2002; 52 (6): 324-329 30. Kleinrok M., Krakowiak K., Dąbrowska M., Janczarek M.: Dotylne przemieszczenie krążka stawowego stawu skroniowo-żuchwowego. Prot. Stom., 2002; 52 (2): 17-25 31. Kostrzewa-Janicka J.: Przebudowa powierzchni stawowych stawu skroniowo-żuchwowego związanych z przemieszczeniem krążka. Prot. Stom., 2001; 51 (2): 85-89 32. Kleinrok M., Węgłowska A., Janczarek M.: Obustronne przyśrodkowe przemieszczenie krążków stawowych stawów skroniowo-żuchwowych. Prot. Stom., 2002; 52 (2): 76-84 33. Kleinrok M., Piórkowska B., Kuzioła a., Janczarek M., Kostrawa M., Szybiński W.: Przemieszczenie krążków stawów skroniowo-żuchwowych i głów żuchwy w płaszczyźnie czołowej w maksymalnym zaguzkowaniu zębów. Badania metodą rezonansu magnetycznego i tomografii komputerowej. Czas. Stomat., 2003; 56 (8): 543-553 34. Baron S., Karasiński A.: Metoda określania położenia głów żuchwy i krążków stawowych za pomocą MR w leczeniu chorych z dysfunkcją narządu żucia doniesienie wstępne. Czas. Stomat., 2003; 56 (12): 875-879 35. Kleinrok M., Hawryluk E., Nowicka-Dudek K., Doraczyńska E., Żyśko D., Kister A., Mazurek B., Pytlewski A.: Analiza przyczyn niepowodzenia w leczeniu chorych z bólową postacią dysfunkcji narządu żucia w oparciu o badanie stawów skroniowo-żuchwowych metodą rezonansu magnetycznego doniesienia wstępne. Prot. Stom., 1997; 47 (5): 276-283 36. Kleinrok M., Nowicka-Dudek K., Kleinrok J., Hawryluk E., Kobyłecka E.: Badania nad zależnością pomiędzy przemieszczeniem krążka stawowego a ułożeniem głów żuchwy w stawie skroniowo-żuchwowym. Prot. Stom., 2000; 50 (2): 71-78 37. Kleinrok M., Sarna-Boś K., Litko M., Piórkowska-Skrabucha B., Mieszkowski P., Janczarek M.: Analiza stawów skroniowo-żuchwowych ze znacznie powiększonymi krążkami stawowymi. Prot. Stom., 2004; 54 (4): 219-223 38. Kleinrok M., Markiewicz M., Dąbrowska M., Krakowiak K., Zwolak A., Szkutnik J., Janczarek M.: Badania nad przemieszczeniem krążka stawowego stawu skroniowo-żuchwowego w płaszczyźnie czołowej doniesienie wstępne. Prot. Stom., 2001; 51 (2): 76-82 39. Kostrzewa-Janicka J., Pytlewski A.: Przebudowa powierzchni stawowych stawu skroniowo-żuchwowego związanych z przemieszczeniem krążka. Prot. Stom. 2001; 51,2: 85-92 40. Kleinrok M., Krakowiak K., Dąbrowska M., Janczarek M.: Dotylne przemieszczenie krążka stawowego stawu skroniowo-żuchwowego. Prot. Stom., 2002; 52 (1): 17-25 41. Okifuji A., Turk D.C.: Fibromyalgia syndrome: prevalent and perplexing. Pain Clinical Updates, 2003; 3: 1-4 42. Kleinrok M.: Leczenie wstępne bólowego zespołu dysfunkcji narządu żucia. Mag. Stom., 2002; 12 (5): 12-16 43. Dubojska A.M., Split W., Gajewicz W., Góraj B.: Zwalczanie objawów dysfunkcji narządu żucia za pomocą zniesienia kontaktów przedwczesnych. Opis przypadku. Quintessence 1998; 4 (3): 159-162 44. Kleinrok J., Kleinrok M.: Jatrogenny bólowy zespół dysfunkcji narządu żucia po leczeniu protezami stałymi. Prot. Stom., 2001; 51 (5): 265-273 45. Fabjański P., Ślusarska A.: Wybrane aspekty leczenia protetycznego zaburzeń narządu żucia. Prot. Stom., 2000; 50 (4): 195-197 46. Kubecka-Brzezinka A., Karasiński A.: Próba określenia czasu leczenia doprzedniego przemieszczenia krążka bez zablokowania w stawach skroniowo-żuchwowych. Prot. Stom., 2000; 50 (5): 272-276 47. Suwalska J., Gawor E.: Zastosowanie szyn zgryzowych w leczeniu dysfunkcji układu ruchowego narządu żucia na podstawie piśmiennictwa z ostatnich lat (część I). Prot. Stom., 2001; 51 (3): 141-145 48. Suwalska J., Gawor E.: Zastosowanie szyn zgryzowych w leczeniu dysfunkcji układu ruchowego narządu żucia (część II). Prot. Stom., 2001; 51 (4): 202-205 49. Baron S., Karasiński A., Tarnawska B., Kokot T.: Obraz sił zgryzowych przed i po zastosowaniu szyny relaksacyjnej u pacjentów z rozpoznanym bruksizmem. Prot. Stom., 2000; 50 (5): 266-270 50. Karasiński A., Baron S., Kubecka-Brzezinka A.: Choroby stawów skroniowo-żuchwowych. Mag. Stom., 1999; 9 (1): 13-18 51. Kleinrok M.: Leczenie przemieszczeń krążków stawowych stawów skroniowo-żuchwowych i głów żuchwy repozycyjną szyną zgryzową. Mag. Stom., 2005; 15 (5): 56-63 52. Pilak M., Krzysztoń E.: Profenid-żel:Ketoprofen 2,5% w leczeniu bólu jako objawu klinicznego zaburzeń czynnościowych narządu żucia. Mag. Stom., 1999; 9 (12): 10-14 53. Baron S., Karasiński A.: Zastosowanie lasera terapeutycznego w leczeniu bólowych postaci zaburzeń czynności stawów skroniowo-żuchwowych. Mag. Stom., 1996; 6 (12): 36-38 54. Kleinrok M., Litko M.: Jonoforeza przezskórna stawów skroniowo-żuchwowych z zastosowaniem 2,5% ketoprofenu u chorych z bólowym zespołem dysfunkcji narządu żucia. Prot. Stom., 2001; 51 (6): 342-346 55

55. Mieszkowski P., Kleinrok J.: Porównanie skuteczności leczenia elektrostymulacją chorych z objawami doprzedniego przemieszczenia krążka stawu skroniowo-żuchwowego bez i z ograniczeniem zakresu opuszczania żuchwy. Prot. Stom., 2003; 53 (1): 3-7 56. Lennros H.: Leczenie schorzeń czynnościowych stawu skroniowo-żuchwowego. Polskie Wiadomości Stomatologiczne. Medi-Media Pacific Ltd. Wydanie III.: 5-7 Adress for correspondence Grzegorz Kogut MD, PhD Instytut Fizjoterapii Uniwersytetu Rzeszowskiego ul. Warszawska 26A, 35-205 Rzeszów, Poland tel. 0-606 170 787; fax: (017) 872-19-20 e-mail: askogut@neostrada.pl Translated from Polish into English language: Marcin Tutaj, MD, PhD 56