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Letters to the Editor Issue 41

by Letters(more info)

listed in letters to the editor, originally published in issue 41 - June 1999

Re: March issue (38): differing treatments for non-malignant musculoskeletal facial pain, Turp and colleagues.

The most common musculoskeletal facial pain is Temporo- mandibular Pain Dysfunction Syndrome (TMPDS) which is essentially a functional disorder of the temporomandibular joint (TMJ) and surrounding structures. Much has been written about TMPDS (or TM dysfunction, facial arthromyalgia, etc.) including a wide variety of different theories of aetiology and treatment. TMPDS is said to affect about 40% of the population at some time (more commonly in females). The aetiology is multifactorial with psychological, traumatic and occlusal factors all being implicated. Of these stress is probably the most important. Its effect is mediated by parafunctional activity (e.g. Bruxism, clenching) which causes pain and spasm of the masticatory muscles and also centrally by decreasing the pain threshold. There is a high association with back pain, headaches and migraine. Clinically the most commonly associated signs and symptoms are: pains during mandibular function, articular noises (crepitus and clicking), jaw locking, trismus and headache.

In view of its multifactorial aetiology and self-limiting nature different interventions may work for different reasons in different patients. The treatment of TMPDS is a challenge for both clinicians and patients. Current treatments for TMPDS include the mechanical approach (occlusal splint therapy, occlusal adjustments and occlusal equilibration), pharmacological therapy, psychological counselling, physical therapy, acupuncture and hypnosis. Any treatment approach must be designed for the specific patient's needs. This relies upon thorough medical and dental examination, which may include psychological testing, and analysis.

Mounting evidence exists to suggest that emotional factors can affect TMPDS, as can acute stressful events. Many have concluded that it is a psychophysiological disorder and propose that patients with TMPDS be treated with psychological techniques. However, this association may not be correct for all patients in the general population who have symptoms of TMPDS.

Despite evidence to the contrary, many dentists still cling to outdated beliefs and practices regarding the aetiology and management of chronic temporomandibular disorders (TMDS). Chronic pain disorders require a strong focus on psychological factors. Treatment failures and relapse are likely if such factors are not considered. Most chronic temporomandibular pain problems are extracapsular and of myofacial origin. Mechanistic or invasive treatments in such cases may be inappropriate and can cause harm. Conservative measures used for other types of chronic muscular pain are generally recommended. All health practitioners who deal with chronic and acute pain should be aware of recent major advances in the understanding of pain mechanisms. Along with psychosocial considerations, these must be emphasised in undergraduate and continuing education programmes.

Dr Robert Dyas BDS FDS RCS MBSMDH MBSECH
Greenways Natural Health Centre
Sheffield Tel: 01629 640830
E-mail: robert.dyas@virgin.net

See below: Rosted, A review of the literature regarding the efficacy of acupuncture in dentistry. From the Research Database in Issue 39.

ROSTED, Sheffield University, UK conducted a review of the literature regarding the efficacy of acupuncture in dentistry.

Methods: A literature search, carried out by the Royal Society of Medicine and the University Library, Copenhagen Denmark identified 74 publications written in 8 European languages between the years 1966-96, under the search headings of acupuncture, electro-acupuncture, randomised controlled trials (RCT), dental pain, postoperative dental pain, painrelieving in dentistry and dental analgesia. From the 74 listed papers, 48 papers were reviewed in English, Danish, Swedish, Norwegian and German; 15 papers were excluded due to being written in French, Italian or Russian, and 11 were excluded due to not being a RCT or not of relevance to acupuncture. All papers were scored on the basis of predefined criteria; 92 points could be achieved. On this scale, papers were rated as Excellent (85-100%; Good (70-84%); Fair (60-69%; and Bad (<60%). 15 of the 48 papers met the inclusion criteria.

Results: There was only one study which met the criteria scoring more than 85%; 5 studies met the criteria with 70-84%; 3 studies scored 60-69% and 6 studies did not meet the criteria. Acupuncture in 11 out of 15 studies proved effective in the treatment of temperomandibular dysfunction (TMD) and as an analgesia. 4 studies showed no effect of acupuncture.

Conclusions: The value of acupuncture as an analgesic needs to be questioned. The effect of acupuncture for the treatment of TMD and facial pain appears to be real, and in these clinical conditions, acupuncture may be a valuable alternative to orthodox treatment.

Rosted P. The use of acupuncture in dentistry: a review of the scientific validity of published papers. Oral Dis 4(2): 100-4 June 1998.

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