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Dr. Aviv Ouanounou returns to Oasis Discussions to highlight valuable information he and his fellow authors, Dr. Goldberg and Dr. Haas, recently published related to the pharmacological management of patients suffering from temporomandibular disorders. He spke with Dr. Suham Alexander, CDA Oasis Clinical Editor. Submit a question or share your feedback with us through oasisdiscussions@cda-adc.ca |
Highlights
Temporomandibular disorders (TMD) are prevalent in patients aged 20 – 40 years of age. It is estimated that approximately 30% of population exhibits at least 1 TMD symptom, while approximately 3 – 7% of population have TMD with more severe symptoms. Anxiety, stress and other emotional disturbance exacerbate TMD. Studies have shown that ~75% of TMD patients also have psychological abnormalities. The majority of studies to date have been carried out in the Caucasian population.
Pharmacological agents
NSAIDs
- This is a major group used in the treatment of TMD.
- Relieve inflammation in TMJ.
- Good to relieve pain from acute trauma, TMD inflammation due to acute disc displacement.
- Patients would need to take medication for 2-3 weeks.
- Several side-effects are associated with long-term use of NSAIDs including GI issues, bleeding, renal impairment and the potential for allergies.
- These patients should be co-managed by their physician as they often have co-morbidities or sleep disorders that must also be managed appropriately.
Opioids
- Can be beneficial for those patients unable to take NSAIDs.
- Must consider using carefully given the high risk of dependence.
- Should not be prescribed by those dentists who do not have significant experience or knowledge with this group of drugs.
- Can be given orally and there is an option for a fentanyl patch or parenteral use.
- These patients should be co-managed by their physician as they often have co-morbidities or sleep disorders that must also be managed appropriately.
Benzodiazepines
- Prescribed for acute muscle spasms, sleep disturbances.
- Many side effects such as tolerance and dependence.
- These patients should be co-managed by their physician as they often have co-morbidities or sleep disorders that must also be managed appropriately.
Muscle Relaxants
- Prescribed for chronic orofacial pain.
- Acts to reduce skeletal muscle tone.
- These patients should be co-managed by their physician as they often have co-morbidities or sleep disorders that must also be managed appropriately.
Anti-depressants
- Should not be prescribed by those dentists who do not have significant experience or knowledge with this group of drugs.
- Used to relieve chronic facial pain, TMJ pain.
- Also used in patients with sleeping disturbances.
Anti-convulsants
- Should not be prescribed by dentists who do not have significant experience or knowledge with this group of drugs.
- Produces analgesic effect through enhancement of neuronal inhibition and reduction of neuronal excitement.
Cortisol
- Prescribed for those patients with moderate to severe TMD.
- Reduces action of phospholipase A2, reduces production of leukotrienes, prostaglandins.
- Can be injected into TMJ area.
Full Interview (12.03″)
I’m not a fan at all with regards to pharmacological management of TMD. After almost 40 years of treating this problems on a regular basis I’d have to say I haven’t prescribed anything more than short-term NSAIDs and moist heat for palliative care about never. I’ve found zero value with muscle relaxants, and anti-depressant medications, especially the Holy Trinity of Paxil, Zoloft and Effexor, can trigger or worsen TMD problems. Elavil as a low-dose anti-bruxism agent we prescribe post-orthognathic surgery, but not as a form of treatment. TMD is an occlusal disease, and really all about muscles trying to protect teeth from trauma. Occlusal treatment must be the ultimate form of resolution for this condition and if you’re going to help a patient on a more permanent basis, this must be part of your treatment plan. Administering drugs as anything more than an emergency stop gap should not be considered IMHO. The concept of injection of cortisol into a joint is one that frankly scares me. Garden-variety TMD is not a joint problem – the joint SYMPTOMS are only symptoms, and a result of the malocclusion. Cortisol can cause cell death, and can make ligaments brittle and friable. To me, this is the last thing I’d ever inject into a joint, least of all one whose clicking and popping and pain are only the result of it being displaced by a malocclusion. We made the mistake 30 years ago of operating on joints in TMD cases, which ended up creating a generation of chronic pain patients. I don’t see injecting cortisol into joints as being any better.