| BackgroundsTemporomandibular joint disorder syndrome is the most common syndrome in oral area, its main characteristic is pain in joint and the surrounding muscles, mouth movement disorders associated with or without joint clicking. The etiology and mechanism of the temporomandibular joint disorder is still controversial, the temporomandibular joint dysfunction syndrome in Chinese medicine belongs to the category of "Bi Differentiation".TCM holds that the human body of cold evil invasion leading to Qi and blood performing poorly, evil meridians and Qi blocking pulse, malnutrition of muscles and joints along with local trauma, joint strain, local tissue hyperemia and edema, incongruous movement of muscles and joints, can lead to temporomandibular joint dysfunction manifesting a series of symptoms. Neck pain is common in clinic, research shows that there are at least more than50%of the people in the world experienced a neck pain. Because lack of standardized treatment, chronic neck pain became one of the major social and economic burden. In recent years, some scholars put forward that the temporomandibular joint disorder disease and cervical spondylosis are part of the clinical manifestations of the same. Patients with TMJ disorder often complained of neck pain, and neck pain patients are often accompanied by mouth facial pain. Masticatory muscle often contracts which in turn lead to limited mouth opening. Studies have shown that the head, neck and masticatory muscle may play an important role in temporomandibular disease, these studies suggest a lack of proper exercise or excessive activity is the main cause of the temporomandibular joint disorder, and call it "poor" muscle movement disorders. Muscles relax for a long time not to muscular spasm with and continuous tense, the excessive muscle activities led to the masticatory system and joint dysfunction. Furthermore, yawning, inappropriate jaw movement, muscle fatigue, chronic wrong tooth, acute disease, the body and internal organs, deep pain, etc. can cause head and facial muscle spasms in the temporomandibular joint and masticatory muscle pain, jaw deflection and (or) the limitation of the shed, occlusal disorders are secondary or follow, and called the temporomandibular joint pain dysfunction syndrome. Also we can often see that the temporomandibular joint disorder in clinic patients showed symptoms of cervical vertebra, such as the neck and shoulders, abnormal physiological curvature of cervical vertebrae and (or) the limitation of head and neck movement or hyperthyroidism, etc., similar to the performance of cervical spondylosis. Research shows that most of the patients with temporomandibular disorders cervical dysfunction disease, especially in the temporal area under jaw pain often have neck shoulder pain at the same time, at the same time cervical dysfunction patients also have the temporomandibular joint disorder disease symptoms. Besides high levels of neck nerve centre endings have overlapping distribution phenomenon, some scholars believe that they accept the trigeminal nerve and mixed with facial nerve, glossopharyngeal nerve and vagus nerve somatosensory afferent fibers in the spinal nucleus of trigeminal nerve caudal subnuclear can descend to C1-2segment, reaching the C4segment, some even think of C5levels, connected to high levels of cornu posterius medullae spinalis.called "trigeminal nucleus". The nucleus is the anatomical basis of high neck nerve, trigeminal nerve,mixed facial nerve, glossopharyngeal nerve and vagus nerve somatosensory afferent fibers between convergence. The head, neck and jaw muscles and related neurological interconnected allows us to speculate on whether cervical manipulation treatment could improve the temporomandibular joint disorders. We will explore the cervical spine disorders of the temporomandibular joint disorders, and discusses the correlation of cervical dysfunction and pain, then use the technique of upper cervical manipulation in the treatment of temporomandibular joint disorders in patients with cervical spine, and investigate its clinical efficacy.Objective1.1Temporomandibular joint disorder is defined as a group of syndrome with temporomandibular joint and masticatory muscle pain and tenderness, joint movement clicking, limited mouth opening. A large number of literature shows that the temporomandibular joint disorder syndrome is caused by a complex set of factors, including the structure factors (Temporomandibular anatomy), functional factors(bruxisms, neuromuscular dysfunction), and psychological factors, and the status of each factor in pathogenesis remains unclear. Neck pain is the most common chief complaint of cervical vertebra disease, seen in or after acute injuries (Whiplash Injury) and chronic micro damage(Cervical spondylosis).Neck pain and temporomandibular joint disorder are very common in the general population. Although these symptoms do not cause life-threatening, but impair work and quality of life, bringing pain to patients.It has been reported in recent years that patients with TMJ disorder and neck pain often show the symptoms and signs associated with each other. In order to further confirm the neck pain and temporomandibular joint disorder in patients with signs and symptoms of their mutual relevance, we did a small-scale epidemiological investigation at a nearby hospital, school and community.The present study was performed to investigate whether patients with cervical pain and subgroups of patients with temporomandibular disorders differ regarding specific and accompanying signs and symptoms of temporomandibular disorders and cervical spine disorders.1.2There is data supporting the notion that referred pain from masticatory muscles may be involved in myofascial temporomandibular disorders. Experimental studies had reproduced sensory(hyperalgesia, local, and referred pain) and motor disturbances similar to those reported for temporomandibular disorders patients by injection of glutamate,hypertonic saline,bradykinin,or nerve growth facto into the masseter muscle. In fact, intramuscular injection of hypertonic saline into the masseter muscle of healthy subjects causes a localized and referred pain similar to pain distribution seen in the temporomandibular disorders patients.In addition, these studies have also shown that the referred pain from other muscles, eg, upper trapezius, spreads to the head, simulating symptoms perceived by temporomandibular disorders patients and also by patients with tension-type headaches. It has been suggested that different muscles may be involved in the pathophysiology of temporomandibular disorders and tension-type headache, since temporomandibular disorders pain is clinically more similar to the pain patterns produced by stimulation of the masseter muscle and tension-type headache pain is more similar to the pain patterns evoked by stimulation of neck muscles, eg, upper trapezius.From a clinical viewpoint, referred muscle pain is linked to trigger points (TrPs). TrPs are defined as painful spots in a taut band of a skeletal muscle that are painful on stimulation and give rise to a referred pain.Some scholars found in different studies that the referred pain elicited by TrPs in the suboccipital, upper trapezius sternocleidomastoid, and temporalis muscles reproduced the pain pattern of tension-type headaches. Although it is suggested that TrPs may be involved in the pathophysiology of temporomandibular disorders, the description of the local and referred pain elicited by TrPs in myofascial temporomandibular disorders is still insufficient and further studies are needed. A study showed that the referred pain patterns following manual stimulation of TrPs in temporomandibular disorders patients were similar to the classical maps described by the classic model. Nevertheless, this study did not include a control group and patients were not examined blinded.To our knowledge, there are no controlled studies that investigate the characteristics of myofascial TrPs in temporomandibular disorders. Our aims were to examine the presence of TrPs in the masticatory and neck-shoulder muscles in patients with myofascial temporomandibular disorders and healthy controls,and to compare the differences of trigger points in masticatory muscle and neck-shoulder muscles between temporomandibular disorder patients and healthy controls and describe the referred pain area distribution models of masticatory muscle and neck-shoulder muscles in temporomandibular disorders patients.1.3Temporomandibular joint disorder syndrome is the most common syndrome in oral area, its main characteristic is pain in joint and the surrounding muscles, mouth movement disorders associated with or without joint clicking. The etiology and mechanism of the temporomandibular joint disorder is still controversial, but a common phenomenon is that masticatory muscle tension and limited mouth opening existed in temporomandibular joint disorder patients. Epidemiological survey data have shown that the temporomandibular joint disorder’s prominent performance is masticatory muscle disorder rather than the joint itself. Most of the patients have trigger points and obvious tenderness in masticatory muscles. Studies found that chewing muscles tense phenomenon exists not only in patients with temporomandibular disorders, but also common in the general population. In recent years, some scholars put forward that the temporomandibular joint disorders and is part of the same clinical manifestations of cervical spondylosis.Patients with TMJ disorders often complained of neck pain, and neck pain patients are often accompanied by oral and facial pain. Masticatory muscles spasms often in turn lead to limited mouth opening.We can often see that the temporomandibular joint disorder patients showed symptoms of cervical vertebra, such as in neck and shoulders, abnormal physiological curvature of cervical vertebrae and (or) the limitation of head and neck movement or hyperthyroidism, etc. similar to the performance of the cervical spondylosis. Research shows that most of the patients with temporomandibular disorders dysfunction disease of cervical vertebra, especially under the jaw area pain often at the same time have a neck shoulder pain, and dysfunction of the cervical vertebra disease also have temporomandibular disorder disease symptoms. The scope of this study was to investigate the immediate effects on elevating the tenderness thresholds and maximizing mouth opening degree by utilizing atlanto-occipital joint manipulation vs. suboccipital muscle tuina in temporomandibular joint disturbance patients.1.4In the previous study we found that atlanto-occipital joint manipulation or suboccipital muscle tuina could rapidly improve the tenderness thresholds and maximizing mouth opening degree in temporomandibular joint disorder, but the therapy effect remains to be seen.Therefore in this study we will explore the clinical effects of upper cervical manipulation combined with local acupuncture interventions on myofascial temporomandibular disorders in a time-dependent manner.Method2.1124patients (56males and68females)diagnosed with temporomandibular disorders from the outpatient in our hospital and139ordinary individuals were recruited in this survey Each patient or healthy individual’s information was accessed to immediately through the questionnaire made by us, everyone was told the intention of the patients in this study and to complete the questionnaire on the spot.The content included the temporomandibular joint disorder,neck pain and pain related content.The authors assessed the results of an anamnestic self-administered questionnaire given to these individuals.Record the temporomandibular joint disorder symptoms in corresponding with the number of patients with neck pain. Count data chi-square test was used for count data, using IBM SPSS21.0analysis of statistical data and a=0.05as inspection level.2.233temporomandibular disorder patients and31healthy controls were enrolled into this study.Trigger points in bilateral upper trapezius, sternocleidomastoid, suboccipital, temporalis, superficial masseter, and deep maseter muscles were explored and then documented by experienced physicians in detail. The diagnosis criteria of trigger points was identified according to the international general criteria.IBM SPSS21.0application software to establish database, mean, standard deviation is obtained by using the descriptive analysis of measurement data and normality test, compute the than count data, and USES the chi square test, the treatment group after comparison between the analysis of covariance method, inspection standard for alpha=0.05.2.365patients(28males and37females), from outpatients of our hospital with tenderness at the masseter muscle and restriction of mouth opening, with or without clicking of joint, all of them had atlanto-occipital subluxation and cervical pain. Patients were randomly divided into3groups: manipulative group who received atlanto-occipital reduction, soft tissue group who received tuina over the suboccipital muscles and control group who did not receive any intervention. Changes in tenderness thresholds over masseter and maximizing mouth opening degree were measured respectively. IBM SPSS21.0was applicated to establish database software, the descriptive analysis of measurement data calculated the mean, standard deviation and normality test, Analysis of covariance was used to analyze the differences between these groups,a=0.05was regarded as examine levels.2.465Patients diagnosed as myofascial temporomandibular disorders with C1or C2subluxations in the X-ray during2011.2to2013.6were randomly classified into observation group(n=31)and control group(n=30).Both parameters of sex,age,BMI,duration has no significant differences.Patients in observation group received upper cervical manipulation combined with local acupuncture where as the control group received only local acupuncture treatment.Both group were treated once every day and the process lasted10days.Visual Analog Scale(VAS) assessment and Maximal Mouth Opening were documented before or after interventions to evaluate the effects in both groups.Basic data were examined by chi-square test; measurement data set is compared between group adopts two independent samples t test, the data with mean±standard deviation. All the statistical data were analyzed by IBM SPSS21.0software.Analysis of covariance were utilized for intra and inner groups, a=0.05was regarded as the examine levels.Results3.1263candidates finished our survey in time limited,83of124TMD patients reported cervical pain,and only50of139ordinary people had cervical pain.Those with temporomandibular symptomatology had significant cervical pain symptoms than ordinary people(x2=25.137, OR=3.603,95%CI:2.163-6.000, P<0.001),and female had significance compared with male(x2=22.930,OR=0.139,95%CI:0.059-0.326, P<0.001).In the general population in49cases of male patients with neck pain in15cases, and90female patients with neck pain has35cases, no significant differences between (χ2=0.944, P=0.331),no significant difference were found between them.3.2The entire trigger points in temporomandibular disorders patients differ significantly from the healthy people:total (χ2=235.366,P＜0.001) trigger points in all the muscles examined were larger than that the control group:upper trapezius (χ2=37.276, P＜0.001), sternocleidomastoid (χ2=22.199,P＜0.001),suboccipital (χ2=22.199,P<0.001), temporalis (χ2=53.72,P＜0.001), superficial masseter (χ2=57.405,P<0.001), and deep maseter muscles(x2=52.515, P＜0.001),temporomandibular disorders patients have large referred pain areas(all P＜0.001) except superficial masseter (left P=0.315;right P=0.077.)3.3Before treatment the maximal mouth opening were (46.4±7.6) mm in the manual reduction group,(46.2±6.2) mm in the suboccipital muscles alleviation group and (46.0±6.0) mm in the blank control group. Results from covariance analysis showed that covariate has significance in maximal mouth opening before the treatment between the three groups (Fpre=517.408, P＜0.001).After covariate was controlled,covariate has significance in maximal mouth opening after the treatment between the three groups (Fpost=28.267, P＜0.001),49.792mm in manual reduction group、49.749mm in the suboccipital muscles alleviation group、and45.768mm in the blank control group.Manual reduction group and suboccipital muscles alleviation group has significance compared to the blank control group, but there were no significance between manual reduction group and suboccipital muscles alleviation group. Before treatment the tenderness threshold were (2.6±0.6) Kg/cm2in the manual reduction group,(2.7±0.6) Kg/cm2in the suboccipital muscles alleviation group and (2.8±0.7) Kg/cm2in the blank control group.Results from covariance analysis showed that covariate has significance in tenderness threshold before the treatment between the three groups(Fpre=388.056, P＜0.001). After covariate was controlled,covariate has significance in tenderness threshold after the treatment between the three groups (Fpost=50.021, P＜0.001),3.249Kg/cm2in manual reduction group,3.194Kg/cm2in the suboccipital muscles alleviation group,and2.562Kg/cm2in the blank control group.Manual reduction group and suboccipital muscles alleviation group has significance compared to the blank control group, but there were no significance between manual reduction group and suboccipital muscles alleviation group.3.4Before treatment the maximal mouth opening were (45.4±6.6) mm in the observation group and (45.3±6.0) mm in the control group. Results from covariance analysis showed that covariate has significance in maximal mouth opening before the treatment between the two groups (Fpre=146.489, P＜0.001).After covariate was controlled,covariate has significance in maximal mouth opening after the treatment between the two groups (Fpost=13.008, P＜0.001),49.798mm in observation group and49.923mm in the control group.Before treatment the VAS scores were4.6±1.3in the observation group and4.7±1.4in the control group.Results from covariance analysis showed that covariate has significance in maximal mouth opening before the treatment between the two groups (Fpre=303.692, P＜0.001),After covariate was controlled,covariate has significance in VAS scores after the treatment between the two groups (Fpost=22.328, P＜0.001),3.851in the observation group and3.246in the control group.These data indicate observation group is superior to the the control group in improving the maximal mouth opening and pain.Conclusions4.1These findings confirm that there is a possible association between neck pain and the temporomandibular symptomatology.Females have a high incidence of neck pain and neck pain is significantly increased with age. 4.2The current study described the referred pain area distribution models of masticatory muscle and neck-shoulder muscles in temporomandibular disorders patients.The referred pain area in temporomandibular disorders patients were larger than that in healthy people which indicates peripheral and central pain sensitization take place in temporomandibular disorders patients.4.3The application of atlanto-occipital manipulation or suboccipital muscles tuina might led to elevate the trigger point tenderness thresholds and maximum mouth opening degree which indicated the temporomandibular joint disorders could be improved by the application of upper cervical manipulation.4.4Upper cervical manipulation combined with local acupuncture interventions on myofascial temporomandibular disorders is superior to the local acupuncture only and is more valuable for clinical applications. |
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