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2006;137;1108-1114J Am Dent Assoc

de AraujoPereiraCastro Ferreira Conti and Carlos dos Reis

deSantos, Evelyn Mikaela Kogawa, Ana ClaudiaPaulo Csar Rodrigues Conti, Carlos Neanes dos

clinical trialjoint clicking with oral splints: A randomizedThe treatment of painful temporomandibular

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1108 JADA, Vol. 137 http://jada.ada.org August 2006

C O V E R S T O R Y

Background. The authors compared the efficacy of bilateral balanced

and canine guidance (occlusal) splints in the treatment of temporo-

mandibular joint (TMJ) pain in subjects who experienced joint clicking

with a nonoccluding splint in a double-blind, controlled randomized

clinical trial.

Methods. The authors randomly assigned 57 people with signs of disk

displacement and TMJ pain into three groups according to the type of

splint: bilateral balanced, canine guidance and nonoccluding. The authors

followed the groups for six months using analysis of a visual analog scale

(VAS), palpation of the TMJ and masticatory muscles, mandibular move-

ments and joint sounds. They used repeated analysis of variance and a 2

test to test the hypothesis.

Results. The type of guidance used did not influence the pain reduc-

tion, yet both occlusal splints were superior to the nonoccluding splint, on

the basis of the VAS. Despite similar outcomes in relation to opening, left

lateral and protrusive movements, TMJ and muscle pain on palpation,

subjects who used the occlusal splints had improved clinical outcomes.

The frequency of joint noises decreased over time, with no significant dif-

ferences among groups. Subjects in the groups using the occlusal splints

reported more comfort.

Conclusion. The type of lateral guidance did not influence the subjects

improvement. All of the subjects had a general improvement on the VAS,

though subjects in the occlusal splint groups had better results that didsubjects in the nonoccluding splint group.

Key Words. Temporomandibular disorders; occlusion; occlusal splints.

JADA 2006;137(8):1008-14.

Temporomandibular dis-

orders (TMDs) havesigns and symptoms that

affect the masticatorymuscles, temporo-

mandibular joint (TMJ) or both.These signs and symptoms include

complaints of facial and TMJ pain,tenderness to palpation on the face

and TMJ, uncoordinatedmandibular movement and the

presence of joint sounds.The full-coverage occlusal splint

is one of the therapies most fre-quently used in the treatment of

these problems. A recent systematicreview concluded that stabilization

splints are beneficial for reducingpain when compared with no treat-

ment.1 The authors, however, sug-gested the need for well-conducted

randomized clinical trial (RCT).Despite reports of high rates of

clinical success of full-coverageocclusal splints on the reduction of

TMD signs and symptoms, little isknown about their efficacy, espe-

cially concerning the effects of lat-eral and protrusive guidance.

Researchers have proposed sev-

eral mechanisms of action to explainthe reported effectiveness of this

therapy, including increasing thevertical dimension of occlusion,

incorporating the ideal occlusionpattern, muscle relaxation, cognitive

awareness and use of a placebo.2

ABSTRACT

Dr. Paulo Csar Rodrigues Conti is an associate professor, Bauru School of Dentistry, University of So

Paulo, Brazil. Address reprint requests to Dr. Paulo Csar Rodgrigues Conti at Al. Dr. Octvio Pinheiro

Brisolla, -9-75, Villa Universitria, BauruSo Paulo, Brasil CEP 17012-901, e-mail

[email protected].

Dr. Santos is a graduate student, Bauru School of Dentistry, University of So Paulo, Brazil.

Dr. Kogawa is a clinical professor, Catholic University of Braslia, Taguatinga-Distrito Federal, Brazil.

Dr. Ana Claudia de Castro Ferreira Conti is a clinical professor, Paulista University, Bauru-So Paulo,

Brazil.

Dr. de Araujo is a clinical professor, Bauru School of Dentistry, University of So Paulo, Brazil.

The treatment of painful temporomandibularjoint clicking with oral splintsA randomized clinical trial

Paulo Csar Rodrigues Conti, DDS, PhD; Carlos Neanes dos Santos, DDS, MS, PhD; Evelyn MikaelaKogawa, DDS, MS; Ana Claudia de Castro Ferreira Conti, DDS, MS, PhD; Carlos dos Reis Pereira de

Araujo, DDS, MS, PhD

Copyright 2006 American Dental Association. All rights reserved.

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JADA, Vol. 137 http://jada.ada.org August 2006 1109

C O V E R S T O R Y

Many studies have shown that the presence ofcanine guidance is crucial for the success of both

natural occlusion and splints.3-14 DAmico4 statedthat when the canines are in contact, there is an

immediate interruption on the tension of the tem-

poral and masseter muscles, therefore reducingthe magnitude of force.

On the other hand, some researchers believethat occlusal contacts on the nonworking side

might provide an advantage for the treatment ofpainful TMJs.15-18 For example, Kahan16 observed

that symptomatic subjects with and without diskdisplacement had significantly smaller amounts

of nonworking side contacts compared withasymptomatic subjects. In 1990, Minagi and col-

leagues18 evaluated 430 dental students andobserved a highly significant correlation between

the absence of contacts on the nonworking sideand the increase of joint sounds with age. More-

over, other studies19,20 indicate that nonworkingside contacts may protect the TMJ at the

same side.When considering the occlusal design of

splints, Fitins and Sheikholeslam5 found thatincorporating the canine-protection scheme

seemed to cause a significant decrease in the elec-tromyographic activity of elevator masticatory

muscles. Other investigators have also usedmutually protected occlusion21 and extreme

canine-protected occlusion with limited lateralmovement22 designs in the treatment of patients

with TMD. Gray and colleagues23 did not find sig-nificant differences when they compared stabi-

lization splints and splints with a localizedocclusal interference in patients with TMJ pain.

They concluded that the success of the splinttherapy is independent of its occlusal design.

We conducted a double-blind, controlled RCTto evaluate the efficacy of stabilization splints

with bilateral balanced guidance in the treatmentof painful TMJ clicking compared with a tradi-

tional splint with canine guidance and a nonoc-cluding splint.

SUBJECTS, MATERIALS AND METHODS

Population sample. We selected 60 subjects

(mean age 29.9 years) from a pool of patientsattending the Orofacial Pain Center, Prosthodon-

tics Department, Bauru Dental School, Univer-sity of So Paulo, Brazil, who met the inclusion

criteria and entered them into the study. Theinclusion criteria were the presence of TMJ recip-

rocal clicking, subjects report of TMJ pain for at

least three months and joint tenderness on palpa-tion on at least one side. We excluded people with

systemic conditions, arthritis, or a history of TMJsurgery or TMD treatment. We also excluded

people who had a dental prosthesis or who had

more than two posterior missing teeth (except forthird molars and teeth extracted for orthodontic

reasons).We obtained informed consent from all of the

subjects. The universitys ethics committeeapproved the study.

Experimental procedure.An experienceddentist (C.R.P.A.) examined all of the subjects

according to the Research Diagnostic Criteria forTemporomandibular Disorders (RDC/TMD).24 We

included in the study subjects who met the diag-nosis criteria for Group II (disk displacement) and

Group IIIa (arthralgia). We then randomlyassigned the 55 female and five male subjects to

three groups described below (which we matchedfor aging) using a stratification method; that is,

we placed the subjects into different groupsaccording to the severity of the initial pain that

was measured using a visual analog scale (VAS)and the tenderness of the TMJ on palpation. We

used a table generated by a computer to performthe randomization.

A second experienced dental practitioner(C.N.S.) inserted the splints, without mentioning

the type of splint and its expected mechanism tothe subject. The dentist instructed the subjects to

wear their splints only at night, while sleeping.We treated the subjects in group I (mean age

28.9 years) with a modified acrylic stabilization(balanced) splint on the maxillary arch. With this

design, the mandibular buccal cusps and incisaledges contacted a flat surface, even contacts on

posterior and anterior regions, allowing for simul-taneous contact of the mandibular teeth in all

segments of the splint during excursive move-ments (right lateral, left lateral and protrusion

excursions) (Figure 1).We treated group II (mean age 31.3 years) with

a conventional acrylic full-covered stabilizationsplint with canine guidance on the maxillary arch

(Figure 2). This design allowed disocclusion of all

posterior teeth by the contact between caninesduring lateral movements and between anterior

teeth during protrusive movement.Subjects in group III (mean age 29.5 years)

received a nonoccluding splint on the mandibulararch. We built this appliance with acrylic over

buccal and lingual surfaces, with no interferences


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C O V E R S T O R Y

on the subjects occlusion (Figure 3).

We did not provide counseling on any sort oftherapy to the subjects during the trial period.

Three subjects left the study: two from group IIIowing to lack of remission of symptoms and one

from group I owing to a change in address.We monitored and evaluated all subjects at 15

days, one month, three months and six monthsafter the insertion of the splints. A third exam-

iner (P.C.R.C.), who was blinded for group distrib-ution, performed these follow-up examinations.

To compare the groups, we used the subjects pain

reports from the VAS, TMJ and muscle palpation(temporal and masseter),25,26 analysis of the active

mandibular range of motion and TMJ manualinspection for joint sounds. We also evaluated the

subjects self-reports as to the progression of jointsounds, changes in occlusion and comfort levels.

Statistical analysis. We conducted statistical

analyses using repeated measurements analysis

of variance, a Friedman test and a 2 test. We con-sidered probability levels of 5 percent (P .05) to

be significant.

RESULTS

Our analysis showed a significant decrease in the

VAS for all of the groups studied (P < .05). Forgroup I, the mean initial value of the VAS was

63.2 millimeters and the final value at six monthswas 10.5 mm (Table 1 and Figure 4). For group II,

the mean initial value of the VAS was 68.0 mm

and the final value was 9.5 mm. For group III, themean initial value of VAS was 62.7 mm and the

final value was of 27.2 mm.As measured by VAS, the mean improvement

was 52.7 mm (83.4 percent) for group I, 58.5 mm(86 percent) for group II and 35.5 mm (56.6 per-

cent) for group III. We found a significant differ-

Figure 1. Frontal view of the bilateral balanced stabilizationsplint. Note the posterior contacts during the protrusive movement.

Figure 2. Canine guidance stabilization splint.

Figure 3. A. Lateral view of the nonoccluding splint. Note the noninterference with the intercuspal position. B. Occlusal view of thenonoccluding splint.

A B


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ence between groups II andIII (P < .05). Despite the

differences between groupsI and III, the significance

level of .05 was not

achieved (P = .064). Indeed,our intragroup analysis

showed a significantimprovement for the whole

sample (P < .05) regardlessof the group studied. This

significant improvementoccurred earlier with the

occlusal splints and wasmore gradual with the nonoccluding splints

(Figure 4).As for mandibular movement, we

observed a significant difference only forthe right lateral movement between groups

I and III (P < .05). The results were similaramong the three groups for the amount of

left lateral and protrusive movement.We observed a reduction in frequency of

joint sounds for the entire sample (P < .05)(Table 2). Although the reduction was more

pronounced for group II, we found no signif-icant differences among the groups.

Indeed, we found no significant differ-ence among groups for TMJ pain on palpa-

tion on both the lateral and posterioraspects of the left and right TMJs. The

intragroup analysis for this variable overtime showed a decrease in joint sounds for

the whole sample. We detected a betteroutcome, however, for groups I and II.

Reduction in muscle tenderness on palpationwas similar for the whole sample. We found sig-

nificant differences in anterior temporalis mus-cles and the body of masseter muscles among

groups (P < .05), with better results from theocclusal splint groups (Table 3).

None of the subjects reported changes in theirbites. Subjects wearing the occlusal splints

reported more comfort and reduction in thefrequency of joint sounds than did those in

group III.

DISCUSSION

The use of occlusal splints is one of the mostwidely accepted methods of treatment for the

signs and symptoms of TMD.2,8,27-31 Clinicalreports suggest that stabilization splints are

useful for treatment of pain on TMJs,32-35 mastica-


C O V E R S T O R Y

tory muscles30,36,37 or both. Researchers do not

agree, however, on how the splints work or whichwould be a better occlusal design.25,33,38

In our study, the bilateral balanced splintdesign used in group I did not seem to influence

the improvement in subjects pain reports as mea-sured by the VAS when compared with the canine

guidance splint design used in group II. Indeed,despite the absence of a difference between

groups I and III (P = .064), we found that thechange in the group I subjects pain reports to be

much more significant, since 14 of the 19 subjects

in group I reported some discomfort and painjudged as 0 (absence of pain) on the VAS,

whereas just five of the 18 subjects in group IIImarked 0. The rate of improvement was 83.4

percent for group I and 56.6 percent for group III.Regarding the presence of joint sounds, we

found no significant difference among the groups

TABLE 1

Pain reports at different examinations.

GROUP

Six

Months

Three

Months

One

Month

15

Days

Seven

Days

Initial

VISUAL ANALOG SCALE (MILLIMETERS)

I: BilateralBalanced Splint

II: CanineGuidance Splint

III: NonoccludingSplint

Whole Sample

63.2

68.0

62.7

64.6

43.2

45.0

56.6

48.2

36.8

32.0

50.0

39.6

16.3

25.0

40.6

81.9

15.3

18.0

35.0

33.8

10.5

9.5

27.2

15.7

80

70

60

50

40

30

20

10

0Initial 7 Days 15 Days 1 Month 3

Months

6

Months

EXAMINATION

VISUALANALOGSCALE

(MILLIMETERS)

Group I Bilateral

Balanced Splint

Group II Canine

Guidance Splint

Group III

Nonoccluding Splint

Figure 4. Pain reports at different times. VAS: Visual analog scale.


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C O V E R S T O R Y

treatment had a significant recovery after the six-month follow-up in a one-year controlled study

when compared with people who received stabi-lization and repositioning splints.54 There is a

regression to the mean for most people, which

characterizes the benign aspect of theseconditions.

The acceptable outcome in patients usingnonoccluding splints in our study also can be

explained by the fact that the patients belief thatthe treatment will be effective plays a vital role

in placebo response.2,51 The patients personalrelationship with the professional and his or her

feeling of being under treatment are importantinfluences on the final outcomes of most pain

management therapies. The presence of thesplint as a foreign object in the mouth would

change the oral tactile stimuli and make thepatient aware of the potentially harmful use of

the jaw.2

When considering the presence of joint

clicking, we found a general improvement.Although it is considered to be one of the goals of

TMD treatment, the resolution of TMJ clickingno longer is the primary objective of using oral

splints. In a one-year controlled study with asample comparable to that used in our study,

Conti and colleagues54 found similar outcomes forimprovement of joint noises between subjects

wearing oral splints and subjects in a no-treatment group.

As the goal of the splints used in our study wasnot to re-establish a normal disk-condyle rela-

tionship, the improvement observed for the pres-ence of clicking probably is due to morphological

alterations and remodeling in the joint structuresover time (disk, ligaments and retrodiskal tis-

sues), diminishing the physical obstruction forthe condyle translation and, consequently,

decreasing the sound. To substantiate this state-ment, however, the use of more sophisticated

diagnostic tools, set as the gold standard, wouldbe necessary (for example, magnetic resonance

imaging, which we did not use in our study). Thisoverall reduction on joint clicking did not influ-

ence the overall result (that is, decrease in pain

and dysfunction).

CONCLUSIONS

As our results suggest, TMJ pain and clicking

seems to subside over time, regardless of the typeof oral splint used. We found that the occlusal

splints provided earlier improvement compared

with the nonoccluding splint, when we consideredsubjects pain reports and TMJ tenderness on

palpation.

This study was supported by Conselho Nacional de DesenvolvimentoCientfico e Tecnolgico (CNPq BRAZIL) grant 14164312000-5.

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