TMJ Pain, Trauma and the Effectiveness of Different Treatments

Two recent studies on temporomandibular joint (TMJ) pain and trauma provide some important information on what kind of treatments work best—and the factors that complicate treatment.

The first study was another in a series of reports from Kolbinson et al¹ that studied a group of 50 trauma and 50 non-trauma TMJ patients. In this study, the "treatments provided were generally currently accepted TMD treatments." Most of the time this consisted of occlusional splint therapy and physiotherapy.

In the second study—conducted by Greco et al²—59 trauma patients and 174 non-trauma patients were examined. The treatment in this study, however, was a multidisciplinary approach consisting of splint therapy, biofeedback, and stress management training. Treatment in this study was not ongoing, as in the other study, but was limited to a series of six sessions.

Although these two studies were conducted separately, they both worked with patients with long-term symptoms—most patients had experienced onset between five and six years previous to treatment. The Kolbinson¹ study was also significantly different in that many of the trauma patients were undergoing litigation, while none of the trauma patients in the Greco² study were litigating at the time of treatment.

Significant differences were found between the outcome measures of both studies, as the following charts show:

Traditional Treatment¹

Multi-Disciplenary Treatment²

As we can see, the multi-disciplinary approach had a higher level of success treating traumatic patients. In the Kolbinson¹ study, 40% of the trauma patients had the same number of symptoms at the end of treatment as they had at the beginning. In the Greco² study, only 3.5% had no change in symptoms.

At least two factors may account for the difference:

1. Long-term TMJ pain may not be purely physical. "...when symptoms have persisted for several months or more, the effects of initial trauma may be reduced relative to other effects of coping with ongoing pain, such as increased depressive symptoms, postural changes that increase pain, and the tendency to clench facial muscles in response to discomfort. Patients who have been living with a chronic pain condition such as TMD for many months or years may require a multi-disciplinary treatment that focuses on pain management as well as on pain reduction, whether or not they have had traumatic onset of symptoms."² In comparing these two studies, it may be the biofeedback and stress management sessions that resulted in the different outcomes.
2. Litigation can extend the treatment time. "Obviously, comparison of symptom presentation and treatment outcome among TMD patients with and without traumatic onset is complicated by the potential effects of compensation and litigation. Kolbinson and associates³ reviewed the literature on postinjury temporomandibular disorders and concluded that these patients respond less well to treatment than did TMD patients whose symptoms were not attributed to specific traumatic events. These conclusions also held for litigating versus nonlitigating patients...In efforts to elucidate the effects of litigation status on post-traumatic TMD, Burgess and Dworkin⁴ compared litigating and nonlitigating post-traumatic TMD patients. They found that the litigating group reported a greater number of pain sites initially, remained in treatment longer, and acknowledged a smaller percentage of improvement in symptoms following nonsurgical treatment modalities..."²

1. Kolbinson DA, Epstein JB, Senthilselvan A, Burgess JA. A comparison of TMD patients with or without prior motor vehicle accident involvement: treatment and outcomes. Journal of Orofacial Pain 1997;11:337-345.
2. Greco CM, Rudy TE, Turk DC, Herlich A, Zaki HH. Traumatic onset of temporomandibular disorders: positive effects of a standardized conservative treatment program. The Clinical Journal of Pain 1997;13:337-347.
3. Kolbinson DA, Epstein JB, Burgess JA. Temporomandibular disorders, headaches, and neck pain following motor vehicle accidents and the effect of litigation: review of the literature. Journal of Orofacial Pain 1996;10:101-125.
4. Burgess JA, Dworkin SF. Litigation and post-traumatic TMD: how patients report treatment outcome. Journal of the American Dental Association 1993;124:105-110.