TMJ Diseases & Disorders - Treatments - Splints
Splints
The following article, "A Help For Many But Not Everyone" has been written by Christian Stohler, D.D.S., Dr. Med Dent., specifically for The TMJ Association Web site. Dr. Stohler is the Dean at the University of Maryland Dental School in Baltimore, Maryland. Our appreciation goes to Dr. Stohler for his contribution to this Web site.
Occlusal Bite Splints: A Help For Many But Not Everyone
Bite splints or occlusal appliances have been used in the management of temporomandibular joint (TMJ) patients for more than one century. Despite their long and common use, few high quality scientific data exist about (1) their efficacy in relieving symptoms of patients with painful TMJ, (2) their incremental benefit over other forms of treatment, or (3) the mode of action by which symptom relief occurs with the use of such appliances. Many TMJ patients experience relief with such devices but in as much as 30 per cent of cases, a favorable outcome is not obtained from the patient's point of view. The decision of whether a bite splint is a sensible treatment in your particular case is a clinical judgment call rather than a decision that is based on sound, scientifically validated criteria.
If you opt for a bite splint, you should be aware of the fact that not all bite splints are equal. Two major types are distinguished, namely (1) those that maintain the existing jaw relationship, and (2) those whose purpose is to intentionally alter the existing bite for a particular therapeutic intent, such as "capturing the articular disk" or "the realignment of the condyle in the articular fossa". Occlusal appliances of the first group are also referred to as "stabilization" splints and members of the second group are often called "repositioning" appliances. Neither design has been proven to be incrementally superior over the other with any consistency as far as benefit for the patient is concerned. In terms of negative consequences, however, splints of the second group pose a substantially greater risk of inducing bite changes. When worn for months to years, the resulting bite changes often call for costly bite repair by means of new dental work, orthodontic treatment or even jaw surgery. Bite splints are typically constructed in hard acrylic resin. The resilient or soft type is less durable, more difficult to adjust and harder to keep clean. However, current data suggest that the material properties have minimal or no bearing on patient-reported success rates. On the other hand, this does not mean that one patient may strongly favor one over the other material.
The stabilization splints are typically worn during the night and intermittently during the day, if beneficial from the patient's perspective. Versions of this class of splints exist for both the upper and lower jaw. Splints that are fitted to the upper jaw tend to be bulkier than those that fit the lower jaw. This design attribute makes the upper splints less maintenance-sensitive than the appliances that are constructed for the lower jaw. Although the smaller splints that are fitted to the lower jaw have an esthetic and speech advantage, these features are often regarded as a secondary matter in a case of mostly nighttime use. Patients' reports suggest that the stabilization splints have their place in the management of pain arising from the TMJ, the jaw musculature or both with patient reported improvement rates of more than 70 percent among first time users. From this perspective, it is clear that stabilization splints represent a viable alternative to pain medications for many, although not all TMJ patients.
Patients that are fitted with repositioning splints are often told that their jaws are malaligned or that the articular disk is out of place and needs to be repositioned. The repositioning appliance is supposed to hold the jaw in a more favorable position than the patient's present jaw alignment. Consequently, patients are advised to wear these types of splints on a 24-hour basis. In recent years, however, it became increasingly clear that the scientific basis underlying the theories surrounding the repositioning appliances are in question and that the incremental benefit of the repositioning appliances over the stabilization splints is doubtful. For these reasons, many experts view the negative long-term bite effects of the repositioning splints as an unwarranted outcome.
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Recommended Reading:
Occlusal splints for treating sleep bruxism (tooth grinding). This 2007 study found insufficient evidence to either support or refute the use of occlusal splints for treating patients with tooth grinding or clenching during sleep (sleep bruxism) Sleep bruxism is characterised by several signs and symptoms. Among them abnormal tooth wear, fractured teeth, joint pain or tenderness, jaw muscle discomfort, and headaches. Treatments include odontological devices such as occlusal splints, pharmacotherapy, and psychotherapy. An occlusal splint is a removable appliance worn in the upper jaw (maxilla) or the lower jaw (mandible), with coverage of the dental surfaces. They are usually used to prevent tooth wear. There is not enough evidence in the literature to show that occlusal splints can reduce sleep bruxism.
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Stabilization Splint Therapy for Temporomandibular Pain Dysfunction Syndrome. Al-Ani MZ, Davies SJ, Gray RJM, Sloan P, Glenny AM (2005).Click here to view abstract.
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National Institutes of Health (1996). National Institutes of Health Technology Assessment Conference Statement: Management of Temporomandibular Disorders. J Am Dent Assoc 127:1595-1603.
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Controlled Clinical Splint Trials: Abstract cited in the Journal Dental Research 78:292 (IADR Abstracts) 1999Abstract 1490 - Randomized Clinical Trial of Splints for TMD: Clinical Findings at 12 Months. K.H. Huggins*, E.L. Truelove, S.F. Dworkin, L. Mancl, E. Sommers, L. LeResche (Department of Oral Medicine, University of Washington, Seattle, WA).
Few longitudinal studies have compared hard splints with soft splints for management of TMD pain and dysfunction. We previously reported results from a randomized clinical trial (RCT; n=200) of usual treatment with a conventional flat plane hard acrylic splint (HS) vs. a soft vinyl athletic mouthguard (SS) vs. no splint usual treatment (UT) indicating no differences between groups at 3 month follow up in self reported rates of pain, symptoms or parafunctional habits, or in clinical findings.
STUDY OBJECTIVES: To examine long term outcomes for clinical findings across these three treatment groups participating in a 12 month longitudinal study.
METHODS: Clinical findings were gathered by calibrated examiners using Research Diagnostic Criteria for TMD (RDC/TMD) examination methods. All subjects met criteria for myofacial pain at baseline. Baseline (BL) and 12 month follow up data were compared for HS, SS, and UT groups. Data are present for the 118 SS (HS=47, SS=38, UT=33) for whom 12 month clinical examination data are available.
RESULTS: ANOVA indicate no significant differences (p.25) between the 3 treatment groups at BL or at 12 months for extraoral, intraoral or joint palpation pain, range of motion, joint sounds or for RDC/TMD diagnoses. For example, maximum unassisted opening (mean mm ± s.e.): BL (HS=48.8±1.3, SS=51.4±1.4, UT=50.1±1.4); 12 month (HS=51.5+1.0, SS=51.1.±1.5, UT=53.0±1.2); extraoral muscles palpation summary score (0-48 points): BL (HS=10.6±1.3, SS=10.2±1.4, UT=9.3±1.1); 12 months (HS=4.6±0.9, SS=5.9±1.3, UT=6.2±1.4). Chi-square analyses indicate no significant differences between groups at BL or 12 months for presence of clicking on opening or closing: BL % (HS=46.8, SS=42.1, UT=43.8); 12 month% (HS=57.5, SS=46.0, UT=63.6).
CONCLUSION: In a randomized clinical trial (RCT) testing intraoral splints vs. no splint usual treatment, 12 month follow up found no differences in clinical findings for range of motion, muscle or joint palpation pain or clicking among hard, soft, or non-splint subjects. These data indicate that for the long term clinical outcomes examined, neither the more costly hard acrylic splint (HS) or the less expensive soft vinyl athletic mouthguard (SS )is superior to non-splint therapy(UT).
Research support by National Institute of Dental Research (NIDR) Grant DE08773
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Abstract cited in the Journal Dental Research 78:292 (IADR Abstracts) 1999Abstract 1491 - Randomized Clinical Trials of Splint Treatment in TMD: 12-month Self Report Outcomes. E.L. Truelove*, K.H. Huggins, S.F. Dworkin, L. Mancl, E. Sommers, L. LeResche (Department of Oral Medicine University of Washington, Seattle, WA).
Randomized clinical trials (RCTs) of conservative TMD treatments are uncommon. Subjects were 200 clinic patients meeting RDC criteria for myofascial pain (MFP) enrolled in a 12 month RCT of a conventional flat plane hard acrylic splint (HS) vs. a low cost soft vinyl athletic mouthguard (SS) vs. conservative TMD treatment without a splint (UT). Three month data were previously reported and demonstrated no significant differences in clinical findings or self report measures.
STUDY OBJECTIVES/METHODS: To compare self report findings after a 12 month treatment period. Data are presented for 168 (HS=65, SS=55, UT=48) subjects (84% response rate) for whom 12 month questionnaire data are available.
RESULTS: No significant differences between groups were observed in mean pain levels (0-10 scale) at 12 months or in mean change in pain from baseline to 12 months. (ANOVE, p>.05). However, a significant decrease in pain was observed for all groups (mean change ±s.e.) HS=2.4±0.3, SS=2.6 ±0.3, UT=2.4 ±0.4 (paired t test, Bonferroni p<.0001). No significant differences were found between groups for change in other TMD symptoms (TMJ sounds, eating difficulty, tinnitus, clenching/bruxism, or jaw locking/catching; X2, p>.05).
CONCLUSION: Of randomized clinical trial subjects followed up at 12 months, all three treatments yielded similar levels of reported pain reduction and of non-painful jaw symptoms in all major outcome categories. These data suggest that treatments using lower cost alternatives conservative TMD treatment without a splint (UT) or a low cost soft vinyl athletic mouthguard (SS) to hard splints, provide levels of pain control and symptom reduction equivalent to more costly splint therapy even over an extended period of time. Further research may confirm that these alternatives should be considered as the primary treatment in myofascial pain and may be the only treatment needed by most patients.
Research support by National Institute of Dental Research (NIDR) Grant DE08773
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Cited in Pain, 56 (1994) pg. 85-94The efficacy of oral splints in the treatment of myofascial pain of the jaw muscles: a controlled clinical trial
Thuan T.T. Dao, Gilles J. Lavigne, Anne Charbonneau, Jocelyne S. Feine and James P. Lund
Oral splints are widely used in the treatment of myofascial pain of masticatory muscles, even though their mechanism of action is unknown. The present study evaluated the therapeutic efficacy of splints using a parallel, randomized, controlled and blind design. Following a sample size estimation, 63 subjects were recruited and assigned to 3 groups: (1) passive control: full occlusal splint worn only 30 minutes at each appointment; (2) active control: palatal splint worn 24h/day; and (3) treatment: full occlusal splint worn 24h/ day. On each of 7 visits over 10 weeks, subjects rated on 100 mm visual analogue scales their pain intensity and unpleasantness at rest and after experimental mastication. The effect of pain on the quality improved for all 3 groups. However, there were no significant differences between groups in any of the variables. These data suggest that the gradual reduction in the intensity and unpleasantness of myofascial pain, as well as the improvement of quality of life during the trial, was non-specific and not related to the type of treatment.