INITIAL NON-SURGICAL MANAGEMENT
Non-surgical treatment should be considered for all symptomatic patients with internal derangement or osteoarthritis. For mild or moderate pain and dysfunction, this treatment alone is often sufficient. Patients with severe pain and dysfunction can also be treated non-surgically, but if adequate reduction of symptoms does not occur within a short space of time, surgical consultation is indicated.
In instances of closed lock, regardless of the degree of pain, early surgical consultation is indicated.
LONG TERM CONSERVATIVE MEASURES ARE NOT CONSERVATIVE.
Non-surgical treatment has the following aims:
2. Maximizing joint mobility
3. Reduction of inflammation
4. Control of pain
We are underwhelmed by the success rates of intra-oral appliances in advanced internal derangement. These may help in cases of early dysfunction. Studies have indicated that appliances only acts as a placebo in a large proportion of patients. These work in theory by decreasing the load of the jaw joints and changing proprioceptive feedback. Intra-oral appliance have a role in protecting the joints and teeth in patients who clench or grind their teeth but they do not correct or manage underlying pathology. However, some clinicians still believe they are the panacea for all facial pain. These must be prescribed selectively.
NON-STEROIDALS AND OTHER PHARMACEUTICALS
Joint pain is inflammatory. For pain management, NSAIDS can be added to the regime for a reduction in inflammation. Other pharmaceutical therapy can include Tricyclic Antidepressants which have an analgesic effect and aid disruptive sleep patterns. These should generally be administered by medically qualified personel.
Physiotherapy can also be used to treat functional issues and pain. It plays a major role in post operative rehabilitation. The physiotherapists we work with in Christchurch include:
We also work with other physiotherapists in Auckland and Dunedin when necessary:
Other modalities that can be employed in the non-surgical setting include but not limited to:
- Trans-cutaneous electrical nerve stimulation(TENS)
- Biofeedback with counselling and or psychological evaluation:
- Muscle relaxants
- Behavior modification: Diet load reduction in the TMJ is achieved by modifying the patient’s diet to reduce joint loading from forces of mastication, ie: non-chewing diet such as liquid or pureed food.
- Botox injections into the masseteric muscles has also been used to reduce clenching and bruxism but has variable results and is often not a long-term solution
OUTCOMES OF NON-SURGICAL MANAGEMENT
A summary of results of evidence-based studies on nonsurgical therapy for internal derangement is listed:
- Most patients have improvement in signs and symptoms with time
- Palliative care (NSAIDs, education, diet modification, exercises) seem to be as effective as more costly appliance therapy
- Occlusal appliances do not change disc position
- Occlusal stabilization appliances may reduce myalgia and arthralgia
- Although patients with internal derangement improve with time, the length of time for symptoms to improve is not clearly identified
- Treatments can have a powerful placebo effect
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