Pain and Pharmacotherapy in Temporo Mandibular Disorders

Abstract

TemporoMandibular Disorders (TMDs) are comprised of varied conditions that result in Temporo Mandibular Joint (TMJ) pain, masticatory muscle pain or both.

Editorial

TemporoMandibular Disorders (TMDs) are comprised of varied conditions that result in Temporo Mandibular Joint (TMJ) pain, masticatory muscle pain or both. Chronic TMD-related pain may radiate or be referred to adjacent oral, cranial, facial and cervical regions [1].The Research Diagnostic Criteria (RDC/TMD) provides differentiation of the physical manifestations of TMD for the analysis of underlying pathophysiology of pain in these disorders. The RDC/TMD divides TMDs into three diagnostic categories: (i) masticatory muscle pain, (ii) TMJ disc displacement and (iii) other joint conditions (arthralgia, arthritis, and arthrosis) [2].

The underlying pain mechanisms in TMDs remain poorly understood [3]. The correlation between the severity of pain complaints and evidence of definitive pathophysiology is often poor. This has led to the concept that pain in some proportion of patients may result from altered central nervous system pain processing, and that this altered pain processing may be attributable to specific heritable genes [3].

Analgesic drugs are an integral part of the primary treatment for TMD-related pain and dysfunction with more that 90% of treatment recommendations involving use of medications [4]. The most commonly used agents include Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), corticosteroids, muscle relaxants, anxiolytics, opiates and Tricyclic Antidepressants (TCAs) [1].

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), which are both analgesic and antiinflammatory, are considered the first choice of drug to relieve TMD pain [5]. Studies demonstrating the efficacy of this class of drug have been limited mainly to a few agents. The NSAID diclofenac, given at the maximum suggested therapeutic dose of 50 mg orally three times per day, has been reported to reduce pain in TMJ arthritis patients by more than 50% over 3 months [6]. In a different, double-blinded, randomized study, the NSAID naproxen sodium (500 mg twice daily) was found to reduce TMJ pain by more than 50% compared to placebo [7]. A high efficiency of TMD pain relief is shown with ibuprofen (average daily dose of 400-800 mg) and meloxicam (average daily dose of 7.5-15 mg) [8]. Pain relief may result more from the anti-inflammatory effect of NSAIDs than their analgesic action.

The question whether pain relief demonstrated in these short duration clinical trials is maintained over months to years is yet to be answered. Muscle relaxants (baclofen, tizanidin, and cyclobenzaprine), opiates (morphine), anticonvulsants (gabapentin) and TCAs (amitriptyline) have been used clinically for TMJ management, but there is no sufficient evidence for their efficacy [8]. Invasive treatment options include intra-articular injections of sodium hyaluronate and corticosteroids.

References

1. Cairns BE. Pathophysiology of TMD Pain--Basic Mechanisms and their Implications for Pharmacotherapy.J Oral Rehabil. 2010; 37: 391-410.

2. Dworkin SF, LeResche L. Research Diagnostic Criteria for TemporoMandibular Disorders: Review, Criteria, Examinations and Specifications, Critique. J CraniomandibDisord. 1992; 6: 301-355.

3. Sessle BJ. Role of peripheral mechanisms in craniofacial pain conditions. In: CairnsBE, ed. Peripheral receptor targets for analgesia: novel approaches to pain management. Hoboken: John Wiley & Sons Inc. 2009: 3-20.

4. Israel HA, Ward JD, Horrell B, Scrivani SJ. Oral and Maxillofacial Surgery in Patients with Chronic Orofacial Pain. J Oral Maxillofac Surg. 2003; 61: 662-667.

5. Xu W, Wu Y, Bi Y, Tan L, Gan Y, Wang K. Activation of Voltage-Gated KCNQ/Kv7 Channels by Anticonvulsant Retigabine Attenuates Mechanical Allodynia of Inflammatory Temporomandibular Joint in Rats. Mol Pain. 2010: 6: 49.

6. Mejersjö C, Wenneberg B. Diclofenac Sodium and Occlusal Splint Therapy in TMJ Osteoarthritis: A Randomized Controlled Trial. J Oral Rehabil. 2008; 35: 729-738.

7. Ta LE, Dionne RA. Treatment of Painful Temporomandibular Joints with A Cyclooxygenase-2 Inhibitor: A Randomized Placebo-Controlled Comparison of Celecoxib to Naproxen. Pain. 2004; 111: 13-21.

8. Wieckiewicz M, Boening K, Wiland P, Shiau YY, Paradowska-Stolarz A. Reported Concepts for the Treatment Modalities and Pain Management of Temporomandibular Disorders. J Headache Pain. 2015;16;106.

Citation

Becker T. Pain and Pharmacotherapy in TemporoMandibular Disorders. SM Musculoskelet Disord. 2018; 3(1): 1026.