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Pharmacotherapy in Temporomandibular Disorders: A Review | jcda |
What are Common TMJ Medications? - Head Pain Institute - What are Common TMJ Medications?
As effective as prednisone can be at treating pain and inflammation symptoms, a number of possible adverse effects are associated with its use 1. Possible side effects vary from person to person.
Short-term effects include headaches, tiredness, insomnia and euphoria. Individuals who take prednisone over long periods are at risk of developing osteoporosis, depression, Cushing's syndrome and type II diabetes 1. Prednisone is usually prescribed as a short-term treatment for TMJ because of its high potential for side effects 1 2.
Non-steroid, anti-inflammatory drugs NSAID like ibuprofen and naproxen may be prescribed along with, or as an alternative to, prednisone to help alleviate pain symptoms 1.
Jacquelyn Jeanty has worked as a freelance writer since Her work appears at various websites. Her specialty areas include health, home and garden, Christianity and personal development. Jeanty holds a Bachelor of Arts in psychology from Purdue University. Monitor the health of your community here. More Articles. Common side effects of opioid administration may include sedation, dizziness, nausea, vomiting, constipation, physical dependence, tolerance and respiratory depression.
All of these are exacerbated in the geriatric patient population. The use of opioids for chronic pain has been discouraged because of their potential for inducing tolerance and physical dependence and the concern over patients who may have a substance use disorder. Thus, prescription of opioids for the management of TMD should be restricted to clinicians with appropriate training in this modality. Moreover, there is little or no evidence that long-term therapy for TMD is any better or worse than other treatments.
Corticosteroids are drugs that closely resemble cortisol, a hormone produced by the adrenal glands. These potent anti-inflammatory drugs have been used to treat moderate to severe TMD.
They have multiple actions, including blockade of phospholipase A2, thus decreasing the production of prostaglandins and leukotrienes. Corticosteroids may be injected directly into the TMJ, taken orally or applied topically in an attempt to reduce the pain and dysfunction associated with TMD. Numerous corticosteroid formulations are available for intra-articular injection, ranging from solutions of soluble agents to suspensions of triamcinolone hexacetonide and other relatively insoluble steroids.
In a controlled study of adults with TMJ arthritis, a single intra-articular injection of methylprednisolone diluted with lidocaine significantly reduced TMJ pain for 4—6 weeks. All groups demonstrated improvement in symptoms, but the corticosteroid and hyaluronic acid groups showed a greater decrease in the number of painful muscles and a remarkable increased interincisal opening. Although injectable corticosteroids have been shown to be very beneficial for pain reduction in TMD, they are associated with various side effects, such as acute adrenal crisis, hypertension and electrolyte anomalies, as well as damage to the fibrous layer and bone resorption.
Centrally acting muscle relaxants have frequently been used in the treatment of TMD. The most common muscle relaxants are carisoprodol, cyclobenzaprine, metaxalone and methocarbamol. Many consider cyclobenzaprine the drug of choice for generalized chronic muscle pain, as it provides significant relief from muscle pain and enhances the quality and quantity of sleep.
Although this drug has not been shown to be beneficial in directly reducing TMJ pain symptoms, several studies report its superiority to placebo in treating muscle spasms in the cervical and lumbar regions, suggesting that it may be useful for patients with TMD.
These drugs must be used with caution as they may cause significant sedation. Therefore, this medication is contraindicated for patients with hyperthyroidism and congestive heart failure.
Furthermore, it should be avoided during the acute phase of recovery from myocardial infarction and by patients with arrhythmias. Also, cyclobenzaprine may have life-threatening interactions with monoamine oxidase inhibitors MAOIs , and it may enhance the risk of seizure in patients taking tramadol.
Evidence suggests that a very low dose of cyclobenzaprine may still provide positive effects in terms of sleep physiology and pain alleviation. In fact, in some cases, patients are encouraged to use fractions of the low dose to reduce the sedating side effects.
Antidepressant drugs have been used for more than 3 decades for the management of pain arising from TMD. Among these medications, TCAs appear to be most effective 37 ; however, selective serotonin reuptake inhibitors SSRIs have also been reported to reduce orofacial pain. Numerous reviews of randomized, controlled trials have concluded that TCAs exhibit clear analgesic efficacy in a number of chronic pain conditions. Another group of antidepressants commonly used are the SSRIs.
Introduced in the late s, these drugs became the first line of treatment for depression because of their favourable side effects profile compared with TCAs. SSRIs block neuronal transport of serotonin leading to increased synaptic serotonin, which in turn stimulates a large number of postsynaptic serotonin receptors. Although the exact mechanism of the analgesic action of these drugs is as yet unknown, the analgesic effect of TCAs may be a result of serotonin and noradrenaline reuptake inhibition at the synaptic level in the CNS.
TCAs are associated with certain adverse events, which include sedation, dizziness, blurred vision, constipation and dry mouth. These drugs also block the reuptake of catecholamines and, as such, may increase catecholaminergic neurotransmission.
SSRIs have been associated with fewer anticholinergic, antihistaminergic and antiadrenergic effects compared with the TCAs, although paroxetine has a relatively high anticholinergic potency among SSRIs. Overall, although antidepressants are quite effective, the dental community should use them only with caution. Patients who would benefit from this mode of therapy should be comanaged with their physician to ensure that they are medically stable enough to engage in long-term treatment.
The physician should also be the primary practitioner managing any side effects or reactions that may arise. Anticonvulsant drugs are widely used to treat neuropathic pain. These medications act at several sites that may be relevant to pain, but the precise mechanism of their analgesic effect remains unclear.
These agents are thought to inhibit neuronal excitation and enhance such inhibition. Gabapentin and pregabalin have been used for the treatment of TMD.
Despite their name and structural similarities, neither agent exerts its mechanism of action through GABA receptors. Gabapentin has been widely used because of its efficacy in several placebo-controlled trials of various chronic pain syndromes.
Pregabalin and gabapentin are generally well tolerated and associated with transient mild to moderate adverse effects, which are dose dependent. Other less-common adverse effects are dry mouth, peripheral edema, blurred vision, weight gain and inability to concentrate.
Benzodiazepines are commonly prescribed for the treatment of acute muscle spasm and sleep disorders. However, this drug class is associated with numerous adverse properties, including tolerance and dependence, which contraindicate their long-term use in the management of TMD or other conditions.
Benzodiazepines enhance the response to GABA by facilitating the opening of chloride channels and, thus, they cause hyperpolarization. These agents have been used primarily as anxiolytics; however, they have been reported to induce both muscle relaxation and sleep. Also, benzodiazepines have been used as anticonvulsant medications, and parenteral benzodiazepines have been used to manage status epilepticus.
Several studies have demonstrated the superiority of these drugs to placebo in double-blind trials for the treatment of TMD. For instance, Singer and Dionne 16 reported that patients taking diazepam displayed a significant reduction in their chronic jaw pain compared with placebo. Furthermore, Harkins et al. However, in another study, where triazolam was compared with placebo, no pain reduction was found, but sleep improved significantly.
Regardless of the positive outcome of some studies, the use of benzodiazepines for TMD has been discouraged because of numerous adverse drug reactions, such as drowsiness, confusion, amnesia and impaired coordination. Also, tolerance to and physical dependence on benzodiazepines can develop if these drugs are given over a prolonged period.
Abrupt discontinuation may result in withdrawal symptoms, including anxiety, agitation, restlessness, insomnia and seizures. Contraindications to their use include allergy, myasthenia gravis and acute narrow-angle glaucoma. A number of benzodiazepines have been shown to interact with numerous drugs, as these medications are CYP A4 substrates. Thus, concomitant foods, such as grapefruit juice, and drugs, such as azole antifungals, erythromycin and the calcium channel blockers that inhibit the 3A4 isoform, can significantly reduce the metabolism of benzodiazepines and, thus, lead to elevated levels in the blood and enhanced CNS depression.
As in the case of opioid use to manage TMD, benzodiazepines have the potential for misuse, abuse and diversion. Many modalities have been proposed for the treatment of TMD, including occlusal splints, physiotherapy and pharmacological interventions, to name just a few.
Despite the wealth of analgesic options, treating TMJ-related pain is still a significant challenge in dental practice. Given the lack of good randomized controlled trials, clinicians are left to use the best evidence available, which shows that NSAIDs are likely effective but may carry significant risks such as gastric bleeding in some populations and that pharmacotherapies such as TCAs may have some effect.
There is an urgent need for high-quality studies to better define the risk—benefit of pharmacotherapy for TMD patients. Finally, given the chronicity of TMD, there must be appropriate training and a full understanding of the risks and benefits of any drug considered for its management. Ouanounou is assistant professor, department of clinical sciences pharmacology , faculty of dentistry, University of Toronto, Toronto, Ontario.
Haas is dean and the Arthur Zwingenberger Decanal Chair, faculty of dentistry, and professor, department of pharmacology, faculty of medicine, University of Toronto. Correspondence to: Dr.
Email: aviv. The authors have no declared financial interests in any company manufacturing the types of products mentioned in this article. Request reprint permission. Search JCDA. Popular Topics: access to care oral conditions children dental profession All Topics.
Cite this as: j can dent assoc ; h7. Opioids The possibility of serious GI bleeding associated with chronic NSAID administration combined with the inconsistent efficacy of these drugs for some forms of TMD has led to a look at alternatives.
Corticosteroids Corticosteroids are drugs that closely resemble cortisol, a hormone produced by the adrenal glands. Antidepressants Antidepressant drugs have been used for more than 3 decades for the management of pain arising from TMD. Anticonvulsants Anticonvulsant drugs are widely used to treat neuropathic pain. Conclusions Many modalities have been proposed for the treatment of TMD, including occlusal splints, physiotherapy and pharmacological interventions, to name just a few.
This type of medication relaxes the muscles in your jaw and surrounding areas and also decreases any muscle spasms you might have. Because muscle relaxers operate as a really strong medication, your physician will likely only have you take them for no more than a couple of weeks at a time. Anti-inflammatory medications such as ibuprofen Advil can control inflammation and jaw pain in your TMJ. These medications are also known as non-steroidal anti-inflammatory drugs.
If you have significant jaw pain, your physician may prescribe a corticosteroid for your pain and inflammation. Your doctor will inject the corticosteroid into your joint so that you can get some relief. When you have TMJ, everyday activities such as eating can become an excruciating affair. If you have pain when you chew or experience toothaches, cracking joints, or muscle spasms, seek help right away.
Farrell for a consultation at today.
❿Prednisone for tmj
- Prednisone for tmj
The initial dosage can range from 5 to 60 mg a day depending on the severity of symptoms. It may take up to a week before the full effects of the drug are felt. As effective as prednisone can be at treating pain and inflammation symptoms, a number of possible adverse effects are associated with its use 1.
Possible side effects vary from person to person. Short-term effects include headaches, tiredness, insomnia and euphoria. Individuals who take prednisone over long periods are at risk of developing osteoporosis, depression, Cushing's syndrome and type II diabetes 1. Prednisone is usually prescribed as a short-term treatment for TMJ because of its high potential for side effects 1 2.
Non-steroid, anti-inflammatory drugs NSAID like ibuprofen and naproxen may be prescribed along with, or as an alternative to, prednisone to help alleviate pain symptoms 1. Jacquelyn Jeanty has worked as a freelance writer since Her work appears at various websites. Her specialty areas include health, home and garden, Christianity and personal development. Jeanty holds a Bachelor of Arts in psychology from Purdue University.
Celecoxib showed slightly better pain reduction than the placebo, but was not significantly effective for TMD pain. However, other studies comparing ibuprofen and piroxicam with placebo failed to demonstrate a decrease in symptoms among patients with chronic myogenous pain.
A repeat of the prescription may be considered if the initial regimen is effective, but pain recurs when the drug is discontinued.
From a clinical perspective, the determining factor in the decision to prescribe an NSAID is based on correlating signs that we pick up on examination with the symptoms noted by the patient. In particular, patients will often use a single finger to point to the joint when describing the origin of pain as opposed to a broader tracing of pain when muscle pain is indicated.
Manual palpation of the joint will elicit a painful response. This will also occur when palpation occurs through the external auditory meatus. If pain and crepitus are noted, further radiographic investigation for degenerative joint disease is indicated. The possibility of serious GI bleeding associated with chronic NSAID administration combined with the inconsistent efficacy of these drugs for some forms of TMD has led to a look at alternatives. Opioid analgesics have been used for the management of acute pain in dentistry for many years, and their effectiveness in the treatment of moderate to severe pain is well established.
The most common opioids considered for oral administration are codeine and oxycodone, with hydromorphone reserved for severe intractable pain. If the oral route is not a reasonable option, the fentanyl patch can be considered for those with training in its use. Common side effects of opioid administration may include sedation, dizziness, nausea, vomiting, constipation, physical dependence, tolerance and respiratory depression. All of these are exacerbated in the geriatric patient population.
The use of opioids for chronic pain has been discouraged because of their potential for inducing tolerance and physical dependence and the concern over patients who may have a substance use disorder. Thus, prescription of opioids for the management of TMD should be restricted to clinicians with appropriate training in this modality. Moreover, there is little or no evidence that long-term therapy for TMD is any better or worse than other treatments. Corticosteroids are drugs that closely resemble cortisol, a hormone produced by the adrenal glands.
These potent anti-inflammatory drugs have been used to treat moderate to severe TMD. They have multiple actions, including blockade of phospholipase A2, thus decreasing the production of prostaglandins and leukotrienes.
Corticosteroids may be injected directly into the TMJ, taken orally or applied topically in an attempt to reduce the pain and dysfunction associated with TMD. Numerous corticosteroid formulations are available for intra-articular injection, ranging from solutions of soluble agents to suspensions of triamcinolone hexacetonide and other relatively insoluble steroids. In a controlled study of adults with TMJ arthritis, a single intra-articular injection of methylprednisolone diluted with lidocaine significantly reduced TMJ pain for 4—6 weeks.
All groups demonstrated improvement in symptoms, but the corticosteroid and hyaluronic acid groups showed a greater decrease in the number of painful muscles and a remarkable increased interincisal opening.
Although injectable corticosteroids have been shown to be very beneficial for pain reduction in TMD, they are associated with various side effects, such as acute adrenal crisis, hypertension and electrolyte anomalies, as well as damage to the fibrous layer and bone resorption. Centrally acting muscle relaxants have frequently been used in the treatment of TMD.
The most common muscle relaxants are carisoprodol, cyclobenzaprine, metaxalone and methocarbamol. Many consider cyclobenzaprine the drug of choice for generalized chronic muscle pain, as it provides significant relief from muscle pain and enhances the quality and quantity of sleep.
Although this drug has not been shown to be beneficial in directly reducing TMJ pain symptoms, several studies report its superiority to placebo in treating muscle spasms in the cervical and lumbar regions, suggesting that it may be useful for patients with TMD.
These drugs must be used with caution as they may cause significant sedation. Therefore, this medication is contraindicated for patients with hyperthyroidism and congestive heart failure. Furthermore, it should be avoided during the acute phase of recovery from myocardial infarction and by patients with arrhythmias.
Also, cyclobenzaprine may have life-threatening interactions with monoamine oxidase inhibitors MAOIs , and it may enhance the risk of seizure in patients taking tramadol. Evidence suggests that a very low dose of cyclobenzaprine may still provide positive effects in terms of sleep physiology and pain alleviation. In fact, in some cases, patients are encouraged to use fractions of the low dose to reduce the sedating side effects.
Antidepressant drugs have been used for more than 3 decades for the management of pain arising from TMD. Among these medications, TCAs appear to be most effective 37 ; however, selective serotonin reuptake inhibitors SSRIs have also been reported to reduce orofacial pain. Numerous reviews of randomized, controlled trials have concluded that TCAs exhibit clear analgesic efficacy in a number of chronic pain conditions.
Another group of antidepressants commonly used are the SSRIs. Introduced in the late s, these drugs became the first line of treatment for depression because of their favourable side effects profile compared with TCAs. SSRIs block neuronal transport of serotonin leading to increased synaptic serotonin, which in turn stimulates a large number of postsynaptic serotonin receptors. Although the exact mechanism of the analgesic action of these drugs is as yet unknown, the analgesic effect of TCAs may be a result of serotonin and noradrenaline reuptake inhibition at the synaptic level in the CNS.
TCAs are associated with certain adverse events, which include sedation, dizziness, blurred vision, constipation and dry mouth. These drugs also block the reuptake of catecholamines and, as such, may increase catecholaminergic neurotransmission.
SSRIs have been associated with fewer anticholinergic, antihistaminergic and antiadrenergic effects compared with the TCAs, although paroxetine has a relatively high anticholinergic potency among SSRIs. Overall, although antidepressants are quite effective, the dental community should use them only with caution. Patients who would benefit from this mode of therapy should be comanaged with their physician to ensure that they are medically stable enough to engage in long-term treatment.
The physician should also be the primary practitioner managing any side effects or reactions that may arise. Anticonvulsant drugs are widely used to treat neuropathic pain. These medications act at several sites that may be relevant to pain, but the precise mechanism of their analgesic effect remains unclear.
These agents are thought to inhibit neuronal excitation and enhance such inhibition. Gabapentin and pregabalin have been used for the treatment of TMD. Despite their name and structural similarities, neither agent exerts its mechanism of action through GABA receptors.
Gabapentin has been widely used because of its efficacy in several placebo-controlled trials of various chronic pain syndromes. Pregabalin and gabapentin are generally well tolerated and associated with transient mild to moderate adverse effects, which are dose dependent.
Other less-common adverse effects are dry mouth, peripheral edema, blurred vision, weight gain and inability to concentrate. Benzodiazepines are commonly prescribed for the treatment of acute muscle spasm and sleep disorders. However, this drug class is associated with numerous adverse properties, including tolerance and dependence, which contraindicate their long-term use in the management of TMD or other conditions. Benzodiazepines enhance the response to GABA by facilitating the opening of chloride channels and, thus, they cause hyperpolarization.
These agents have been used primarily as anxiolytics; however, they have been reported to induce both muscle relaxation and sleep.
Also, benzodiazepines have been used as anticonvulsant medications, and parenteral benzodiazepines have been used to manage status epilepticus. Several studies have demonstrated the superiority of these drugs to placebo in double-blind trials for the treatment of TMD.
For instance, Singer and Dionne 16 reported that patients taking diazepam displayed a significant reduction in their chronic jaw pain compared with placebo.
Furthermore, Harkins et al. However, in another study, where triazolam was compared with placebo, no pain reduction was found, but sleep improved significantly. Regardless of the positive outcome of some studies, the use of benzodiazepines for TMD has been discouraged because of numerous adverse drug reactions, such as drowsiness, confusion, amnesia and impaired coordination. Also, tolerance to and physical dependence on benzodiazepines can develop if these drugs are given over a prolonged period.
Abrupt discontinuation may result in withdrawal symptoms, including anxiety, agitation, restlessness, insomnia and seizures.
Contraindications to their use include allergy, myasthenia gravis and acute narrow-angle glaucoma. A number of benzodiazepines have been shown to interact with numerous drugs, as these medications are CYP A4 substrates. Thus, concomitant foods, such as grapefruit juice, and drugs, such as azole antifungals, erythromycin and the calcium channel blockers that inhibit the 3A4 isoform, can significantly reduce the metabolism of benzodiazepines and, thus, lead to elevated levels in the blood and enhanced CNS depression.
As in the case of opioid use to manage TMD, benzodiazepines have the potential for misuse, abuse and diversion. Many modalities have been proposed for the treatment of TMD, including occlusal splints, physiotherapy and pharmacological interventions, to name just a few.
Despite the wealth of analgesic options, treating TMJ-related pain is still a significant challenge in dental practice. Given the lack of good randomized controlled trials, clinicians are left to use the best evidence available, which shows that NSAIDs are likely effective but may carry significant risks such as gastric bleeding in some populations and that pharmacotherapies such as TCAs may have some effect.
There is an urgent need for high-quality studies to better define the risk—benefit of pharmacotherapy for TMD patients. Finally, given the chronicity of TMD, there must be appropriate training and a full understanding of the risks and benefits of any drug considered for its management.
Ouanounou is assistant professor, department of clinical sciences pharmacology , faculty of dentistry, University of Toronto, Toronto, Ontario. Haas is dean and the Arthur Zwingenberger Decanal Chair, faculty of dentistry, and professor, department of pharmacology, faculty of medicine, University of Toronto. Over-the-counter medications such as acetaminophen Tylenol, etc can relieve jaw pain temporarily but often does not deal with inflammation.
Muscle relaxers can relieve the discomfort and pain in your jaw due to TMJ. This type of medication relaxes the muscles in your jaw and surrounding areas and also decreases any muscle spasms you might have.
Because muscle relaxers operate as a really strong medication, your physician will likely only have you take them for no more than a couple of weeks at a time. Anti-inflammatory medications such as ibuprofen Advil can control inflammation and jaw pain in your TMJ. These medications are also known as non-steroidal anti-inflammatory drugs. If you have significant jaw pain, your physician may prescribe a corticosteroid for your pain and inflammation.
Your doctor will inject the corticosteroid into your joint so that you can get some relief. When you have TMJ, everyday activities such as eating can become an excruciating affair.
TMJ disorders encompass a group of conditions that involve joint and muscle pain in the jaw 2. According to the National Institute of Dental and Craniofacial Research, as many as 10 million people in the United States suffer from some form of jaw-related disorder.
The exact cause of the condition remains unknown, though certain medications like prednisone and other analgesics may be effective treatment options 1. TMJ stands for the temporomandibular joints that connect the jawbone to the skull on either side of the head 2. These joints make tasks like talking, eating, and facial expressions possible. TMJ junctions are among the most highly used joints in the body 2. TMJ disorders result when one or both of these joints begin to malfunction 2.
Individuals who suffer from this condition may experience stiffness in the jaw, ongoing ear pain, headaches and a popping or clicking sound when opening and closing the jaw.
Both muscle and joint pain are possible, either as sharp pains or a dull, continuous ache. Prednisone is a synthetic cortiscosteroid medication used to treat conditions where inflammation is present 1. Its formula is based on cortisol, a natural hormone secreted by the adrenal glands. The anti-inflammatory effect works to decrease the pain symptoms associated with TMJ 2. For the body to use prednisone, it must be processed through the liver and converted into prednisolone 1.
Prednisone may be prescribed along with other medications like analgesics and muscle relaxants depending on the severity of the disorder 1. TMJ disorders can develop into actual joint damage in the jaw, making essential everyday tasks like eating an excruciating experience 2. Joint damage occurs when the bone structures that form the joint begin to deteriorate. Inflammation that persists over long periods can work to quicken this deterioration process. Prednisone mimics the effects of cortisol by reducing the amount of inflammation in the TMJ joints 1 2.
As a result, joint pressure decreases and pain symptoms subside. The initial dosage can range from 5 to 60 mg a day depending on the severity of symptoms. It may take up to a week before the full effects of the drug are felt.
As effective as prednisone can be at treating pain and inflammation symptoms, a number of possible adverse effects are associated with its use 1. Possible side effects vary from person to person. Short-term effects include headaches, tiredness, insomnia and euphoria. Individuals who take prednisone over long periods are at risk of developing osteoporosis, depression, Cushing's syndrome and type II diabetes 1. Prednisone is usually prescribed as a short-term treatment for TMJ because of its high potential for side effects 1 2.
Non-steroid, anti-inflammatory drugs NSAID like ibuprofen and naproxen may be prescribed along with, or as an alternative to, prednisone to help alleviate pain symptoms 1. Jacquelyn Jeanty has worked as a freelance writer since Her work appears at various websites. Her specialty areas include health, home and garden, Christianity and personal development. Jeanty holds a Bachelor of Arts in psychology from Purdue University. Monitor the health of your community here. More Articles.
Diseases and Injuries. Written by Jacquelyn Jeanty. If you are experiencing serious medical symptoms, seek emergency treatment immediately. Related Articles. References Prednisone.
Prednisone is usually prescribed as a short-term treatment for TMJ because of its high potential for side effects Non-steroid, anti-. In certain cases of intractable pain in the temporomandibular joint after conservative treatments have been unsuccessful, a single intra-articular injection. Corticosteroids may be necessary if your jaw pain and inflammation are significant. However, they're rarely used to treat TMJ disorders. At first onset of TMJ symptoms or when first reported first line treatment should be conservative reversible modalities. Anti-. Examples: prednisone, dexamethasone. Evidence: There is good evidence that corticosteroids can help with TMJ pain over a period of 4–6 weeks, but. Epidemiol Psychiatr Sci.Temporomandibular disorder TMD is a collective term that includes disorders of the temporomandibular joint TMJ and of the masticatory muscles and their associated structures. TMDs are characterized by pain, joint sounds and restricted mandibular movement, and drugs are widely used in the management of that pain. Pharmacological agents commonly used for the treatment of TMDs include non-steroidal anti-inflammatory drugs NSAIDs , opioids, corticosteroids, muscle relaxants, antidepressants, anticonvulsants and benzodiazepines.
In this paper, we discuss these agents and the potential adverse drug reactions and interactions associated with their use.
Temporomandibular disorder TMD is a collective term used for a number of clinical problems that involve the masticatory muscle complex, the temporomandibular joint TMJ and associated structures.
TMD is one of the most common disorders in the maxillofacial region. Signs and symptoms of TMD may include pain, impaired jaw function, malocclusion, deviation from the midline on opening or closing the jaw, limited range of motion, joint noises and locking.
Most TMD symptoms resolve over time, but, for a significant number of patients, this may take a year or more. Many non-invasive therapies, such as self-care, physical therapy and appliance therapy, are commonly used for the treatment of TMD. However, we found only 1 relevant Cochrane study, which included 11 randomized controlled trials of pharmacotherapy for TMD. The NSAIDs are a large group of drugs that inhibit cyclo-oxygenases, thereby preventing the formation of prostaglandins. Traditionally, they have been the drugs most commonly prescribed for pain in the orofacial region.
To achieve an anti-inflammatory effect in TMD, these medications should be taken for a minimum of 2 weeks. A number of NSAIDs, including ibuprofen, naproxen, diflunisal and ketorolac, have been shown to be effective for dental pain. NSAIDs cause gastric erosion that can lead to ulcers and then gastric bleeding; this tends to be more severe in the elderly than in younger people. Naproxen and ibuprofen appear to be the safest NSAIDs with respect to the cardiovascular system, and ibuprofen has been shown to be relatively safe with respect to GI risk.
In addition to severe adverse reactions, NSAIDs can interact with multiple medications and result in an unwanted effect. This action is generally not relevant clinically with the low doses of methotrexate commonly taken by patients with rheumatoid arthritis, who have normal renal function, but it is significant when methotrexate is used in high doses for cancer therapy.
When used with other drugs that also increase bleeding e. Compared with placebo, naproxen significantly reduced the symptoms of painful TMJ disc displacement. Celecoxib showed slightly better pain reduction than the placebo, but was not significantly effective for TMD pain. However, other studies comparing ibuprofen and piroxicam with placebo failed to demonstrate a decrease in symptoms among patients with chronic myogenous pain. A repeat of the prescription may be considered if the initial regimen is effective, but pain recurs when the drug is discontinued.
From a clinical perspective, the determining factor in the decision to prescribe an NSAID is based on correlating signs that we pick up on examination with the symptoms noted by the patient.
In particular, patients will often use a single finger to point to the joint when describing the origin of pain as opposed to a broader tracing of pain when muscle pain is indicated. Manual palpation of the joint will elicit a painful response. This will also occur when palpation occurs through the external auditory meatus.
If pain and crepitus are noted, further radiographic investigation for degenerative joint disease is indicated. The possibility of serious GI bleeding associated with chronic NSAID administration combined with the inconsistent efficacy of these drugs for some forms of TMD has led to a look at alternatives.
Opioid analgesics have been used for the management of acute pain in dentistry for many years, and their effectiveness in the treatment of moderate to severe pain is well established.
The most common opioids considered for oral administration are codeine and oxycodone, with hydromorphone reserved for severe intractable pain. If the oral route is not a reasonable option, the fentanyl patch can be considered for those with training in its use. Common side effects of opioid administration may include sedation, dizziness, nausea, vomiting, constipation, physical dependence, tolerance and respiratory depression. All of these are exacerbated in the geriatric patient population.
The use of opioids for chronic pain has been discouraged because of their potential for inducing tolerance and physical dependence and the concern over patients who may have a substance use disorder. Thus, prescription of opioids for the management of TMD should be restricted to clinicians with appropriate training in this modality.
Moreover, there is little or no evidence that long-term therapy for TMD is any better or worse than other treatments. Corticosteroids are drugs that closely resemble cortisol, a hormone produced by the adrenal glands. These potent anti-inflammatory drugs have been used to treat moderate to severe TMD. They have multiple actions, including blockade of phospholipase A2, thus decreasing the production of prostaglandins and leukotrienes.
Corticosteroids may be injected directly into the TMJ, taken orally or applied topically in an attempt to reduce the pain and dysfunction associated with TMD. Numerous corticosteroid formulations are available for intra-articular injection, ranging from solutions of soluble agents to suspensions of triamcinolone hexacetonide and other relatively insoluble steroids. In a controlled study of adults with TMJ arthritis, a single intra-articular injection of methylprednisolone diluted with lidocaine significantly reduced TMJ pain for 4—6 weeks.
All groups demonstrated improvement in symptoms, but the corticosteroid and hyaluronic acid groups showed a greater decrease in the number of painful muscles and a remarkable increased interincisal opening. Although injectable corticosteroids have been shown to be very beneficial for pain reduction in TMD, they are associated with various side effects, such as acute adrenal crisis, hypertension and electrolyte anomalies, as well as damage to the fibrous layer and bone resorption.
Centrally acting muscle relaxants have frequently been used in the treatment of TMD. The most common muscle relaxants are carisoprodol, cyclobenzaprine, metaxalone and methocarbamol. Many consider cyclobenzaprine the drug of choice for generalized chronic muscle pain, as it provides significant relief from muscle pain and enhances the quality and quantity of sleep.
Although this drug has not been shown to be beneficial in directly reducing TMJ pain symptoms, several studies report its superiority to placebo in treating muscle spasms in the cervical and lumbar regions, suggesting that it may be useful for patients with TMD. These drugs must be used with caution as they may cause significant sedation.
Therefore, this medication is contraindicated for patients with hyperthyroidism and congestive heart failure. Furthermore, it should be avoided during the acute phase of recovery from myocardial infarction and by patients with arrhythmias. Also, cyclobenzaprine may have life-threatening interactions with monoamine oxidase inhibitors MAOIs , and it may enhance the risk of seizure in patients taking tramadol. Evidence suggests that a very low dose of cyclobenzaprine may still provide positive effects in terms of sleep physiology and pain alleviation.
In fact, in some cases, patients are encouraged to use fractions of the low dose to reduce the sedating side effects. Antidepressant drugs have been used for more than 3 decades for the management of pain arising from TMD. Among these medications, TCAs appear to be most effective 37 ; however, selective serotonin reuptake inhibitors SSRIs have also been reported to reduce orofacial pain.
Numerous reviews of randomized, controlled trials have concluded that TCAs exhibit clear analgesic efficacy in a number of chronic pain conditions. Another group of antidepressants commonly used are the SSRIs. Introduced in the late s, these drugs became the first line of treatment for depression because of their favourable side effects profile compared with TCAs.
SSRIs block neuronal transport of serotonin leading to increased synaptic serotonin, which in turn stimulates a large number of postsynaptic serotonin receptors.
Although the exact mechanism of the analgesic action of these drugs is as yet unknown, the analgesic effect of TCAs may be a result of serotonin and noradrenaline reuptake inhibition at the synaptic level in the CNS. TCAs are associated with certain adverse events, which include sedation, dizziness, blurred vision, constipation and dry mouth.
These drugs also block the reuptake of catecholamines and, as such, may increase catecholaminergic neurotransmission. SSRIs have been associated with fewer anticholinergic, antihistaminergic and antiadrenergic effects compared with the TCAs, although paroxetine has a relatively high anticholinergic potency among SSRIs. Overall, although antidepressants are quite effective, the dental community should use them only with caution.
Patients who would benefit from this mode of therapy should be comanaged with their physician to ensure that they are medically stable enough to engage in long-term treatment. The physician should also be the primary practitioner managing any side effects or reactions that may arise. Anticonvulsant drugs are widely used to treat neuropathic pain.
These medications act at several sites that may be relevant to pain, but the precise mechanism of their analgesic effect remains unclear. These agents are thought to inhibit neuronal excitation and enhance such inhibition.
Gabapentin and pregabalin have been used for the treatment of TMD. Despite their name and structural similarities, neither agent exerts its mechanism of action through GABA receptors.
Gabapentin has been widely used because of its efficacy in several placebo-controlled trials of various chronic pain syndromes. Pregabalin and gabapentin are generally well tolerated and associated with transient mild to moderate adverse effects, which are dose dependent. Other less-common adverse effects are dry mouth, peripheral edema, blurred vision, weight gain and inability to concentrate. Benzodiazepines are commonly prescribed for the treatment of acute muscle spasm and sleep disorders.
However, this drug class is associated with numerous adverse properties, including tolerance and dependence, which contraindicate their long-term use in the management of TMD or other conditions. Benzodiazepines enhance the response to GABA by facilitating the opening of chloride channels and, thus, they cause hyperpolarization.
These agents have been used primarily as anxiolytics; however, they have been reported to induce both muscle relaxation and sleep. Also, benzodiazepines have been used as anticonvulsant medications, and parenteral benzodiazepines have been used to manage status epilepticus. Several studies have demonstrated the superiority of these drugs to placebo in double-blind trials for the treatment of TMD. For instance, Singer and Dionne 16 reported that patients taking diazepam displayed a significant reduction in their chronic jaw pain compared with placebo.
Furthermore, Harkins et al. However, in another study, where triazolam was compared with placebo, no pain reduction was found, but sleep improved significantly. Regardless of the positive outcome of some studies, the use of benzodiazepines for TMD has been discouraged because of numerous adverse drug reactions, such as drowsiness, confusion, amnesia and impaired coordination.
Also, tolerance to and physical dependence on benzodiazepines can develop if these drugs are given over a prolonged period. Abrupt discontinuation may result in withdrawal symptoms, including anxiety, agitation, restlessness, insomnia and seizures. Contraindications to their use include allergy, myasthenia gravis and acute narrow-angle glaucoma. A number of benzodiazepines have been shown to interact with numerous drugs, as these medications are CYP A4 substrates. Thus, concomitant foods, such as grapefruit juice, and drugs, such as azole antifungals, erythromycin and the calcium channel blockers that inhibit the 3A4 isoform, can significantly reduce the metabolism of benzodiazepines and, thus, lead to elevated levels in the blood and enhanced CNS depression.
As in the case of opioid use to manage TMD, benzodiazepines have the potential for misuse, abuse and diversion. Many modalities have been proposed for the treatment of TMD, including occlusal splints, physiotherapy and pharmacological interventions, to name just a few.
Despite the wealth of analgesic options, treating TMJ-related pain is still a significant challenge in dental practice. Given the lack of good randomized controlled trials, clinicians are left to use the best evidence available, which shows that NSAIDs are likely effective but may carry significant risks such as gastric bleeding in some populations and that pharmacotherapies such as TCAs may have some effect.
There is an urgent need for high-quality studies to better define the risk—benefit of pharmacotherapy for TMD patients. Finally, given the chronicity of TMD, there must be appropriate training and a full understanding of the risks and benefits of any drug considered for its management.
Ouanounou is assistant professor, department of clinical sciences pharmacology , faculty of dentistry, University of Toronto, Toronto, Ontario. Haas is dean and the Arthur Zwingenberger Decanal Chair, faculty of dentistry, and professor, department of pharmacology, faculty of medicine, University of Toronto.
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