|Year : 2022 | Volume
| Issue : 2 | Page : 40-45
Efficacy of customized soft occlusal splints in the management of temporomandibular joint disorders among the population of Parsa District of Nepal: A cross-sectional study
Sartaj Singh Wazir1, Alok Kumar Jaiswal2, Rahul Srivastava3
1 Department of Oral Medicine and Radiology, MB Kedia Dental College and Teaching Hospital, Birgunj, Nepal
2 Department of Orthodontics, MB Kedia Dental College and Teaching Hospital, Birgunj, Nepal
3 Department of Oral Medicine and Radiology, Rama Dental College, Hospital and Research Centre, Kanpur, Uttar Pradesh, India
|Date of Submission||13-Oct-2021|
|Date of Acceptance||19-Dec-2021|
|Date of Web Publication||9-Mar-2022|
Sartaj Singh Wazir
Quarter Premises, MB Kedia Dental College and Teaching Hospital, Birgunj
Source of Support: None, Conflict of Interest: None
Background: In recent years, temporomandibular joint disorders (TMDs) have been a highly debated topic. TMD is the collective term of clinical problems that involves the masticatory apparatus, temporomandibular joint (TMJ), and its associated structures or both. It is really a tough challenge for both the dental and the medical specialists and is often difficult to diagnose and treat such a disorder as the presenting symptoms can be variable. A variety of treatment modalities have been described in the literature for its management and the conservative method is most preferred. The objective of the present study was to evaluate the effectiveness of soft occlusal splint therapy among the population of Parsa district of Nepal in the management of TMDs. Materials and Methods: Thirty subjects with signs and symptoms of TMDs were included in the study, out of which 13 (43.3%) subjects were males and 17 (56.7%) were females, with age ranging from 21 to 40 years. Soft occlusal splints were given to the patients for about 3 months and evaluated for reduced mouth opening, tenderness of TMJ (preauricular), TMJ sounds, and mandibular deviation after 1 week of initiation of therapy and every month for 3 consecutive months. Results: There was a significant improvement of 3.06 mm (9.7%) in mouth opening, 86.7% of subjects showed significant reduction in preauricular tenderness, 80.0% subjects showed reduction in TMJ sounds, and 76.7% of subjects showed improvement in mandibular deviation after 3 months of the splint therapy. Paired t-test and Chi-square tests were done for comparison. Conclusions: Soft occlusal splints can be used effectively as a conservative treatment modality in reducing the signs and symptoms related to TMDs.
Keywords: Occlusal splints, reduced mouth opening, temporomandibular joint disorders
|How to cite this article:|
Wazir SS, Jaiswal AK, Srivastava R. Efficacy of customized soft occlusal splints in the management of temporomandibular joint disorders among the population of Parsa District of Nepal: A cross-sectional study. J Prim Care Dent Oral Health 2022;3:40-5
|How to cite this URL:|
Wazir SS, Jaiswal AK, Srivastava R. Efficacy of customized soft occlusal splints in the management of temporomandibular joint disorders among the population of Parsa District of Nepal: A cross-sectional study. J Prim Care Dent Oral Health [serial online] 2022 [cited 2022 May 27];3:40-5. Available from: http://www.jpcdoh.org/text.asp?2022/3/2/40/339309
| Introduction|| |
TMJ is the joint between the lower jaw and the base of the skull. TMJ is a ginglymosdiarthroidal joint. “Ginglymos” means hinge type movement and “Arthroidal” means gliding movement. The articulation is formed by the mandibular condyle and the glenoid fossa. Separating the two bones from direct articulation is the articular disc. TMJ is a compound joint. By definition, a compound joint requires the presence of at least three bones, but TMJ is made up of two bones only. Functionally, the articular disc serves as a third nonossified bone permitting the complex movements of the joint.
Any event that may interfere with the normal functioning of TMJ like occlusal disharmony, trauma, too wide opening, bruxism, constant deep pain input and increased levels of emotional stress so that it is beyond the physiologic tolerance of the joint, the result is temporomandibular joint disorder (TMD). The American Academy of Orofacial pain classifies TMDs as myogenous and arthrogenous types, both of which can be present at the same time making diagnosis and treatment difficult. Although the etiology of TMD remains unclear, it is believed to be multifactorial in origin, with psychological illness, bruxism, and traumatic injuries from mastication, extreme mouth opening, and dental treatments being considered as the main causes.,
TMDs are characterized by facial pain in the region of TMJ and/or in the muscles of mastication, limitations or deviations in the mandibular range of motion, and TMJ sounds (clicking/grating/popping) during jaw movements and functions. It is also known as craniomandibular disorder and is one of the most frequent causes of facial pain. Treatment options for TMDs include conservative approach, surgical intervention and combined treatment. Conservative approach includes nonpharmacotherapy and pharmacotherapy. Nonpharmacotherapy includes reassurance (patient education, self-care and behavioral and relaxation techniques), manual therapy (soft tissue mobilization, gentle massage, deep massage, joint mobilization, and muscle stretching exercises), physical therapy (thermotherapy, coolant therapy, ultrasound therapy, transcutaneous electrical nerve stimulation therapy, and acupuncture therapy), and occlusal splint therapy (hard acrylic resin or soft and resilient occlusal splints). Pharmacotherapy includes analgesics, nonsteroidal anti-inflammatory drugs, antianxiety drugs, tricyclic antidepressants, and muscle relaxants.,, Surgical interventions include meniscoplasty, meniscectomy, and meniscectomy with disc replacement using the Proplast–Teflon interpositional implant.
TMDs are not cured but are managed instead. The treatment of TMDs starts with conservative therapies which are simple and do not invade the tissues of face, jaw, and joints. Stabilization occlusal splints are commonly used in the treatment of functional disturbances of the masticatory system. When properly adjusted, they provide a good method of eliminating occlusal interferences, reducing neuromuscular activity, and obtaining stable occlusal relationships with uniform tooth contacts throughout the dental arch. The use of occlusal splints is one of the most widely accepted conservative therapy for managing the signs and symptoms of TMDs.,
In this context, the present study was conducted to evaluate the effectiveness of conservative approach using soft occlusal splints in the management of the patients with TMDs belonging to Parsa district of Nepal.
| Materials and Methods|| |
This was a hospital based cross-sectional study conducted in the Department of Oral Medicine and Radiology of M. B. Kedia Dental College Pvt. Ltd. Birgunj, Parsa district of Nepal, from December 2017 to January 2019. Before starting the study, ethical clearance was obtained from the institutional research and ethical board (90/REB/Adm/2017/2074) and written consent to participate in the study was obtained from the patients. The study sample consisted of 30 subjects, with age ranging from 21 to 40 years who were selected from the patients attending the college outpatient department.
As it was an uncontrolled trial, there was no control group. A comparison of pre- and posttreatment parameters was carried out in the same sample. Relevant history and clinical findings were recorded for each subject and filled in the self-structured pro forma.
An alginate impression of maxillary arch was taken using stainless steel perforated tray and the cast prepared using dental stone. Soft occlusal splint was fabricated from 3 mm thick soft polyvinyl sheet using vacuum forming pressure molding machine which is thermally controlled [Figure 1]. Soft, clear sheet was adapted on the maxillary cast, kept in the machine, and taken out. The outline of the appliance was then cut off with the help of surgical blade or scissor at the level of interdental papilla on buccal and labial surfaces of teeth and the posterior palate [Figure 2]. The occlusal splint was then separated from the cast and chair side occlusal adjustments were made by warming the occlusal surfaces of the splint with an alcohol torch. A functional imprint was obtained in centric occlusion by bilateral centric relation manipulation. A soft occlusal splint was then inserted in the patient's mouth.
The subjects were recalled after 1 week of initiation of therapy and evaluated every month for 3 consecutive months for improvement of signs and symptoms.
Patients complaining of reduced mouth opening (trismus), presence of tenderness in temporomandibular joint (TMJ), joint sounds (clicking/grating/popping), and mandibular deviation were included in this study.
Patients who were completely edentulous wearing full dentures, with more than 3 posterior teeth missing wearing partial dentures, with mal-aligned teeth undergoing orthodontic treatments, elderly patients with clinical or radiographic signs of degenerative diseases and the patients undergoing treatment from a psychiatrist for stress related or other disorders were excluded from the study.
Administered structured pro forma
A self-made structured pro forma was framed to record the relevant history and clinical findings and compared every month to evaluate the efficacy of the soft occlusal splints. The details were collected as a hard copy on the pro forma sheets.
Data collection and analysis
The obtained data was compiled and the statistical analysis was done using Statistical Package for the Social Sciences (SPSS) version 20.00 (IBM Corp., Armonk, N.Y, USA) Statistical Analysis Software, paired t-test and Chi-square tests were done for comparison.
| Results|| |
Out of 30 subjects, 13 (43.3%) were males and 17 (56.7%) were females, with females being more frequently affected with TMD in each age group than males. The mean age of the subjects in the study was 25.36 ± 2.26 years [Table 1].
There was a significant improvement with respect to interincisal distance at baseline and after 3 months of the therapy with a mean difference of 3.06 mm ± 5.07 mm with the P value being 0.003 showing highly significant improvement in the mouth opening [Figure 3].
|Figure 3: Comparison of baseline and 3 months parameters with respect to mouth opening in mm. (P = 0.003)|
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A significant improvement was seen with respect to preauricular tenderness when compared at baseline and after 3 months of the therapy. At baseline, preauricular tenderness was present in 27 (90.0%) subjects and absent in 1 (3.3%) subject, with 2 (6.7%) subjects giving nonspecific response. After 3 months of the therapy, preauricular tenderness was found to be absent in 26 (86.7%) subjects with only 4 (13.3%) subjects complaining of tenderness with χ2 = 39.55 and P value being < 0.01 showing significant improvement [Figure 4].
|Figure 4: Subject comparison of baseline and 3 months parameters with respect to joint tenderness in number. (χ2 = 39.55; P < 0.01)|
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A significant improvement was seen with respect to joint sounds when compared at baseline and after 3 months of the therapy. At the baseline, joint sounds were present in 26 (86.7%) subjects and absent in 3 subjects (10.0%). After 3 months of recall, joint sounds were found to be absent in 24 (80.0%) subjects and present in 5 (16.7%) subjects with χ2 = 30.55 and P value being < 0.01 suggesting significant improvement [Figure 5].
|Figure 5: Subject comparison of baseline and 3 months parameters with respect to joint sounds in number. (χ2 = 30.55; P value < 0.01)|
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Similarly, significant improvement was seen with respect to deviation of the mandible when compared at baseline and after 3 months of the therapy. At baseline, mandibular deviation was present in 25 (83.3%) subjects and absent in 3 (10.0%) subjects with nonspecific finding in 2 (6.7%) subjects. After 3 months of the therapy, mandibular deviation was found to be absent in 23 (76.7%) subjects and present in 5 (16.6%) subjects with χ2 = 28.71 and P value being < 0.01 showing significant improvement [Figure 6].
|Figure 6: Subject comparison of baseline and 3 months parameters with respect to mandibular deviation in number. (χ2 < 28.71; P < 0.01)|
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| Discussion|| |
An occlusal splint is a removable device usually made of hard acrylic or soft resilient material that fits over the occlusal and incisal surface of the teeth in one arch, creating precise occlusal contact with the teeth of opposing arch. It is commonly referred to as occlusal appliance, appliance, bite guard, night guard, intraoral orthotic, orthopedic device, or deprogrammer device.
According to the glossary of prosthodontics, the term “occlusal splint” is defined as any removable artificial occlusal surface used for diagnosis or therapy affecting the relationship of the mandible to the maxilla. It may be used for occlusal stabilization, redistribution of occlusal forces preventing wear and mobility of teeth, reducing bruxism and other parafunctional habits, repositioning of condyle, and treating masticatory muscle pain.
A common goal of occlusal splint treatment is to protect the TMJ discs from dysfunctional forces that may lead to perforations or permanent displacements. Other goals of treatment are to improve jaw-muscle function and to relieve associated pain by creating a stable, balanced occlusion.
The principle on which most occlusal splints function is to alter an occlusion without interfering with complete seating of the condyle in centric relation. Theories on which the splints work include occlusal disengagement theory, vertical dimension theory, maxilla-mandibular realignment theory, TMJ repositioning theory, and cognitive awareness theory.
The treatment of a disease is successful only when its signs and symptoms are recognized and relieved properly. TMDs are multifactorial in origin. Hence, for its successful treatment, various treatment modalities are being tried ranging from most conservative treatment modalities such as soft occlusal splint and physiotherapy to surgical methods. However, still, no single treatment has been proven to be better than any other for TMDs. As most TMD symptoms have a high incidence of remission over time, usually within 2–4 weeks, conservative treatment is considered more appropriate than the surgery for these disorders. As a conservative treatment of TMDs, soft splints have some advantages. The main advantage of occlusal splint therapy is that they cannot cause effects that are in violation of mechanical laws. Thus, an occlusal splint does not unload the condyles as the muscles of mastication act posterior to the splint. These splints could be made to fit either the maxillary or the mandibular arch and are often inserted immediately. Owing to their soft and resilient material features, soft splints easily distribute the heavy loads encountered during parafunctional activities and they have been associated with a high degree of patient tolerance.,,
Thus, this study was conducted to evaluate the effectiveness of soft occlusal splint therapy as a conservative treatment modality in patients with TMDs. Various advantages of the technique used in the study include the splint fabrication was completed within 30 min after diagnostic mounting in the articulator, ease of construction, minimal trimming and finishing required, splint can be fabricated without distortion of the cast, little intraoral adjustment required, and one set of diagnostic casts serves for both occlusal analysis and splint construction.
In this study, patients in the age range of 21–25 years (50.0%) [Table 1] constitute the largest group of patients. This may be attributed to increased stress, as a consequence of malocclusion and other environmental factors which work alone or in combination with each other.
Epidemiological studies have documented a greater frequency and severity of TMDs in females than in males. In recent studies conducted by Nilsson et al., Manfredini et al., and Soni et al., the prevalence of TMD pain was found significantly more in females than males.,, This is in accordance with our study where females were found to have a higher risk of TMD than males with a risk ratio of 2.9:2.1 [Table 1]: 17 females (56.7%) and 13 males (43.3%). The difference in pain perception is attributed to distinct anatomic and hormonal features in females and males. Males have fat-free mass, larger muscle thickness, and maximal voluntary contraction than females contributing to less pain perception. The difference in muscle metabolism among the genders and endogenous reproductive hormones (especially estrogen) is also believed to play a pathophysiological role in the frequency and severity of TMD-related pain among females.,
In the present study, there was a significant increase in the interincisal distance with a mean value of 31.38 ± 5.57 mm at the baseline and 34.44 ± 1.51 mm after 3 months with a mean difference of 3.06 mm (9.7%) ±5.07 mm with P value being 0.003 [Figure 3], suggesting statistically highly significant which is in accordance with Cheema et al. who reported improvement up to 2.86 mm (8.8%) ±6.03 mm and Akbulut et al. who reported improvement up to 1.96 mm (5. 4%) ±5.18 mm after 3 months of therapy., However, Akbulut et al. have reported improvement up to 4.4 mm (12.1%) after continuing the therapy for 12 months. Soni et al. in their study have also reported a significant improvement in interincisal distance after 6 months of therapy, especially in the patients with disc displacement without reduction. The increase in interincisal distance is probably due to the soft occlusal splint therapy that decreases the pain and tenderness in muscle and joints, apparently allowing an increase in their maximal mouth opening.
A significant improvement was seen with respect to preauricular tenderness when compared at baseline and after 3 months of the therapy. At baseline, preauricular tenderness was present in 27 (90.0%) out of 30 subjects. After 3 months of the therapy, preauricular tenderness was found to be absent in 26 (86.7%) subjects with only 4 (13.3%) subjects complaining of tenderness with P value being < 0.01 [Figure 4], suggesting statistically highly significant which is in accordance with the study conducted by Cheema et al. in which 92.0% of the subjects showed improvement with respect to preauricular tenderness. Similarly, Akbulut et al. reported improvement in 60.0% and 69.0% of the subjects after 3 months and 12 months of the therapy, respectively. Soni et al. have also reported a progressive reduction in the mean pain score noted with maximum improvement as far as myofascial pain was considered after 6 months of therapy. In a study conducted by Naikmasur et al., 55.0% of patients showed a complete reduction in muscle tenderness and the remaining 45.0% had a significant reduction.
The joint sounds as compared to the baseline and after 3 months of soft occlusal splint therapy showed a significant reduction. At the baseline, joint sounds were present in 26 (86.7%) out of 30 subjects. After 3 months of recall, joint sounds were found to be absent in 24 (80.0%) subjects and present in 5 (16.7%) subjects with P value being < 0.01 [Figure 5], suggesting statistically highly significant which is in accordance with the study conducted by Cheema et al., who showed marked improvement in 84.0% of subjects. Soni et al., Naikmasur et al., and Mona et al. have also reported a significant reduction in joint sounds after 3 and 6 months of therapy.,, The occlusal splint allows a muscle to function more efficiently during contact and be less active during postural functions. Hence, the vertical dimension increases from the occlusal contact on insertion of a splint, muscular effort decreases resulting in the relaxing of the muscles and hence relaxing the TMJ.
In the current study, significant improvement was seen with respect to deviation of the mandible when compared at baseline and after 3 months of the therapy. At baseline, mandibular deviation was present in 25 (83.3%) out of 30 subjects. After 3 months of the therapy, mandibular deviation was found to be absent in 23 (76.7%) subjects and present in 5 (16.6%) subjects with P value being < 0.01 [Figure 6], suggesting statistically highly significant which is in accordance with the study conducted by Cheema et al. who showed marked improvement in 88.0% of subjects.
In the current study, 9.7% improvement was noticed in mouth opening, 86.7% of subjects showed significant reduction in preauricular tenderness, 80.0% subjects showed reduction in TMJ sounds, and 76.7% of subjects showed improvement in mandibular deviation after 3 months of the splint therapy, thus suggesting that there is improvement in signs and symptoms of TMDs. The result of the present study is encouraging; the soft occlusal splints are effective in the treatment of TMDs. Therefore, soft occlusal splints can be recommended for the management of TMDs. The present study has certain limitations such as visual analog scale has not been used to assess the tenderness in TMJ, the number of samples was less, and there was no control group with blinding during the evaluation of patients; therefore, it is necessary to conduct blind trials with larger samples and appropriate control groups to evaluate the effectiveness of occlusal splint therapy.
| Conclusions|| |
The use of soft occlusal splint has significantly reduced the signs and symptoms in patients suffering from TMDs. The occlusal splints have a positive effect as a treatment option for patients with TMDs. Soft Occlusal splint therapy is a much safer and effective mode of conservative line of treatment when compared to other treatment modalities. Occlusal splint therapy is advantageous as it has better patient compliance, better results with fewer side effects. These are also less expensive and easier to fabricate than heat-cured splints. The results of this short-term evaluation suggest that the soft occlusal splint therapy may be beneficial in managing the patients with TMDs and can be recommended as a noninvasive therapy for the management of TMDs.
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Conflicts of interest
There are no conflicts of interest.
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