Estimation of Jaw Muscles Exercises Effectiveness in Comparison to Medication in Treating Patients with Temporomandibular Joint Disorders

Aims : This clinical study is aimed at evaluating the effectiveness of exercise therapy in patients with temporomandibular joint disorder and comparing them with patients who take medications . Materials and Methods : 44 patients with temporomandibular joint disorder were divided into 2 groups, 22 patients were instructed to perform jaw exercises and the other 22 patients were given a non-steroidal anti-inflammatory drug and muscle relaxant. Clinical examination of joints and muscles, including pain, spasm, interincisal distance


MATERIALS AND METHODS
A Inclusion criteria were as follows: (1) Male and female were included.

RESULTS
Out of the 44 patients eligible for inclusion in the study.The patients were randomized into two groups, there were 22 in exercise treatment group (5 males, 17 females), their age range was 14-50 years with the mean age± SD was 29.5 ±8.9.In second group, patients treated by medications, were 22 (8 males, 14 females) age ranges 15-50 years, mean age± SD was 26.8±7.9.Not all patients committed their three visits, and they were break off their treatment.No adverse effects occurred during the treatment.The number of patients' visits for each group is shown in table 2. In the comparison of the two groups, the exercise group and medication group showed that no significant differences in variance after two visits.Only in the lateral incisal distance, there was statistically significant difference between two groups in base line visit and visit 1, (table 3).

DISCUSSION
This study, like several others (7, 10, 11, 17) did not include a placebo or a control group, hence the observations may simply have been the results of time in both groups.
Self-exercises like resistant mouth opening can be used in a more idiosyncratic manner to manage the TMJDs pain, and any unique therapeutic effects beyond the basic muscle stretch have not been established (2,18).In this study, the clinical results showed that patients with locked jaw experienced such benefit from exercises more than patients with medication group.This agrees with Yoshida et al who suggested that exercises of the mandibular condyle are efficient initial treatment for patients with closed lock TMJDs (18).
In the medication group, patients administrated meloxicam -which is a nonsteroidal anti-inflammatory drug that exhibits anti-inflammatory and analgesic effects-combined with skeletal muscle relaxant (2,3,6,16).Drug therapies of chronic pain of TMJDs are complex and require knowledge and experience (2,15).
A short trial was used in this study to avoid the incidence of gastrointestinal tract side effect and kidneys toxicity after long-term administration of non-steroidal antiinflammatory drug (15,16).In review of pharmacological interventional studies, most of pharmacological agents used to manage TMJDs have not completed any standardized assessment of efficacy (15).
The main finding of this study when comparing the effectiveness of exercises in TMJDs patients with those who took medication was that no statistically significant difference in any of the outcome variables seen between the two groups within 14 days follow-up of treatment.
Moreover, like this study, many researches showed that exercises did not have clear superiority over other conservative treatments for TMJDs (5,14,17).
A short term follow up perhaps obliterate differences.Furthermore, less than 50% of the patients rated the expectations as totally or partly fulfilled.In addition to that, various interventions and events occurring during the follow-up period may have an impact that is beyond the control of the researchers and can therefore interfere with the follow up results.The overall level of other studies evidences in TMJ exercises is low, and because of the shortcomings their effectiveness has not been proven (7,14,18).It is hard to make comparisons between the outcomes and difficult to draw any conclusions about the impact of a guide line treatment on TMJDs in particular (4, 5, 14, 19).However, other randomized trials have shown that exercises have a positive effect on TMJDs (10, 12,13,18).So that, the existence of multiple clinical trials for TMJDs is commendable.
In conclusion, in spite of lacking a definite evidence of treatment efficacy in patients with TMJDs between two groups, exercises of the masticatory muscles are as effective treatment for locked jaw in short time trial more than medical agents did.
In the near future it will be necessary to make a more detailed study of the long term benefits of jaw exercise.High randomized clinical study was tried and the samples were recruited from Oral Diagnosis and Oral Medicine Department at Al-Noor Specialized Dental Center in Mosul city-Iraq.Period from September 2018 to end of March 2019.A comparative study was conducted after having an approval of the research protocol by the Research Scientific Committee in Nineveh Health Directorate, Ministry of Health.All patients presenting with TMJDs complaints were recorded -except those refused study participation-.The sample size was 44 patients.After testing the inclusions and exclusions criteria, the included patients were randomized into two groups consecutively.The exercise group (n=22), patients were given instructions a standard program of active and passive jaw exercises according to Carlsson and Magnusson instructions (6), three times a day over a period of 10-14 days, each exercise was done 20 times for each session.The second group was the medication group (n=22), patients were given nonsteroidal anti-inflammatory drug (7.5 mg of meloxicam) and skeletal muscle relaxant; orphenadrine 35 mg plus acetaminophen 450 mg (myogesic) every 12 hours.Patients of both groups were requested to refrain from the use of any medicaments throughout the trial.Informed consent was obtained from all participants.the acceptance for the participation patients younger than 18 was taken from and consent signed by one of the parents.Wherever all patients were informed about the nature of the clinical trial and they had the right to participate or refuse without affecting their treatment, each patient had the information about the procedure and the method of treatment and he could not continue the drug or physical therapy at any stage of the procedures.The patient instructed to stop the exercises if the exercise is accentuating the pain.

Table 1 :
Recorded data of the patients in each visit (V).

Table 2 :
Patients' number in each visit for each group