2006;137;1108-1114 J Am Dent Assoc

de Araujo
Pereira Castro Ferreira Conti and Carlos dos Reis
de Santos, Evelyn Mikaela Kogawa, Ana Claudia
Paulo Csar Rodrigues Conti, Carlos Neanes dos
clinical trial
joint clicking with oral splints: A randomized
The 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 did
subjects in the nonoccluding splint group.
Key Words. Temporomandibular disorders; occlusion; occlusal splints.
JADA 2006;137(8):1008-14.
T
emporomandibular dis-
orders (TMDs) have
signs and symptoms that
affect the masticatory
muscles, 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, uncoordinated
mandibular 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 systematic
review concluded that stabilization
splints are beneficial for reducing
pain 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-coverage
occlusal splints on the reduction of
TMD signs and symptoms, little is
known about their efficacy, espe-
cially concerning the effects of lat-
eral and protrusive guidance.
Researchers have proposed sev-
eral mechanisms of action to explain
the reported effectiveness of this
therapy, including increasing the
vertical dimension of occlusion,
incorporating the ideal occlusion
pattern, muscle relaxation, cognitive
awareness and use of a placebo.
2
AB STRACT
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
pcconti@fob.usp.br.
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 temporomandibular
joint clicking with oral splints
A randomized clinical trial
Paulo Csar Rodrigues Conti, DDS, PhD; Carlos Neanes dos Santos, DDS, MS, PhD; Evelyn Mikaela
Kogawa, 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 of
canine guidance is crucial for the success of both
natural occlusion and splints.
3-14
DAmico
4
stated
that when the canines are in contact, there is an
immediate interruption on the tension of the tem-
poral and masseter muscles, therefore reducing
the magnitude of force.
On the other hand, some researchers believe
that occlusal contacts on the nonworking side
might provide an advantage for the treatment of
painful TMJs.
15-18
For example, Kahan
16
observed
that symptomatic subjects with and without disk
displacement had significantly smaller amounts
of nonworking side contacts compared with
asymptomatic subjects. In 1990, Minagi and col-
leagues
18
evaluated 430 dental students and
observed a highly significant correlation between
the absence of contacts on the nonworking side
and the increase of joint sounds with age. More-
over, other studies
19,20
indicate that nonworking
side contacts may protect the TMJ at the
same side.
When considering the occlusal design of
splints, Fitins and Sheikholeslam
5
found that
incorporating the canine-protection scheme
seemed to cause a significant decrease in the elec-
tromyographic activity of elevator masticatory
muscles. Other investigators have also used
mutually protected occlusion
21
and extreme
canine-protected occlusion with limited lateral
movement
22
designs in the treatment of patients
with TMD. Gray and colleagues
23
did not find sig-
nificant differences when they compared stabi-
lization splints and splints with a localized
occlusal interference in patients with TMJ pain.
They concluded that the success of the splint
therapy is independent of its occlusal design.
We conducted a double-blind, controlled RCT
to evaluate the efficacy of stabilization splints
with bilateral balanced guidance in the treatment
of 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 patients
attending 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. The
inclusion 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 TMJ
surgery or TMD treatment. We also excluded
people who had a dental prosthesis or who had
more than two posterior missing teeth (except for
third molars and teeth extracted for orthodontic
reasons).
We obtained informed consent from all of the
subjects. The universitys ethics committee
approved the study.
Experimental procedure. An experienced
dentist (C.R.P.A.) examined all of the subjects
according to the Research Diagnostic Criteria for
Temporomandibular 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 randomly
assigned the 55 female and five male subjects to
three groups described below (which we matched
for aging) using a stratification method; that is,
we placed the subjects into different groups
according 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 perform
the randomization.
A second experienced dental practitioner
(C.N.S.) inserted the splints, without mentioning
the type of splint and its expected mechanism to
the 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 incisal
edges 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 stabilization
splint with canine guidance on the maxillary arch
(Figure 2). This design allowed disocclusion of all
posterior teeth by the contact between canines
during lateral movements and between anterior
teeth during protrusive movement.
Subjects in group III (mean age 29.5 years)
received a nonoccluding splint on the mandibular
arch. We built this appliance with acrylic over
buccal and lingual surfaces, with no interferences
Copyright 2006 American Dental Association. All rights reserved.

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1110 JADA, Vol. 137 http://jada.ada.org August 2006
C O V E R S T O R Y
on the subjects occlusion (Figure 3).
We did not provide counseling on any sort of
therapy to the subjects during the trial period.
Three subjects left the study: two from group III
owing 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 months
after 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 manual
inspection for joint sounds. We also evaluated the
subjects self-reports as to the progression of joint
sounds, 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). For
group I, the mean initial value of the VAS was
63.2 millimeters and the final value at six months
was 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, the
mean 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 stabilization
splint. 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 the
nonoccluding splint.
A B
Copyright 2006 American Dental Association. All rights reserved.

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ence between groups II and
III (P < .05). Despite the
differences between groups
I and III, the significance
level of .05 was not
achieved (P = .064). Indeed,
our intragroup analysis
showed a significant
improvement for the whole
sample (P < .05) regardless
of the group studied. This
significant improvement
occurred earlier with the
occlusal splints and was
more gradual with the nonoccluding splints
(Figure 4).
As for mandibular movement, we
observed a significant difference only for
the right lateral movement between groups
I and III (P < .05). The results were similar
among 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 posterior
aspects of the left and right TMJs. The
intragroup analysis for this variable over
time showed a decrease in joint sounds for
the whole sample. We detected a better
outcome, however, for groups I and II.
Reduction in muscle tenderness on palpation
was 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 the
occlusal splint groups (Table 3).
None of the subjects reported changes in their
bites. Subjects wearing the occlusal splints
reported more comfort and reduction in the
frequency of joint sounds than did those in
group III.
DISCUSSION
The use of occlusal splints is one of the most
widely accepted methods of treatment for the
signs and symptoms of TMD.
2,8,27-31
Clinical
reports suggest that stabilization splints are
useful for treatment of pain on TMJs,
32-35
mastica-
JADA, Vol. 137 http://jada.ada.org August 2006 1111
C O V E R S T O R Y
tory muscles
30,36,37
or both. Researchers do not
agree, however, on how the splints work or which
would be a better occlusal design.
25,33,38
In our study, the bilateral balanced splint
design 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 the
change 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 pain
judged as 0 (absence of pain) on the VAS,
whereas just five of the 18 subjects in group III
marked 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: Bilateral
Balanced Splint
II: Canine
Guidance Splint
III: Nonoccluding
Splint
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
G
G
G
G
G
G
G
I
I
I
I
I
I
I
L
L
L
L
L
L
80
70
60
50
40
30
20
10
0
Initial 7 Days 15 Days 1 Month 3
Months
6
Months
EXAMINATION
V
I
S
U
A
L

A
N
A
L
O
G

S
C
A
L
E
(
M
I
L
L
I
M
E
T
E
R
S
)
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.
Copyright 2006 American Dental Association. All rights reserved.

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1112 JADA, Vol. 137 http://jada.ada.org August 2006
C O V E R S T O R Y
over time. The percentages, however, suggest a
mild reduction in the number of subjects with
joint sounds in all groups; the reduction was
slightly higher in subjects in group II (Table 1).
We also observed a reduction in muscle tender-
ness for most of the muscle spots we evaluated,
which could reflect a decreased co-contraction
after the improvement of the TMJ pain, which
was the chief complaint,
38
and one of the inclusion
criteria for the study.
Joint loading depends on the splint design.
25,39-43
Several studies have concluded that part of the
occlusal force applied on the teeth is transmitted
to the TMJ
14,35,44-50
; yet the more anterior the tooth
contact on the splint is, the higher the load that is
transferred to joint.
14,35,44-50
It also has been
reported that the TMJ is submitted to tension
forces (compression and distraction) during uni-
lateral clenching,
19,20,42
and that the force applied
to the contralateral joint side is reduced highly
when simultaneous con-
tacts are established at
both working and non-
working sides.
17,19,20
On the basis of the
assumption that people
with disk displacement may
have a reduced capacity to
absorb occlusal loading,
51
we believe that the use of
balanced splints could help
them protect the joint.
Studies have found that
the load transmitted to the TMJ at the contralat-
eral side is higher owing to the leverage action
caused by the canine guidance on the working
side.
17,20
Therefore, a contact on the nonworking
side would provide more stability to the joints,
especially during tooth clenching on the canine
edge-to-edge position, which would decrease joint
loading. This decreased joint loading could
improve and enhance the healing process and,
consequently, result in faster healing in people
with signs and symptoms of TMJ pain.
The role of the canine guidance in splints to
decrease muscle activity and pain has to be con-
sidered. Other studies have found that
mechanoreceptors in the periodontal ligaments of
canine teeth could produce a measurable reduc-
tion in the contraction of elevator muscles.
7,9,25
This observed reduction in muscle contraction, if
caused by these receptors, could be responsible for
the decreased intra-articular pressure in patients
using bilateral balanced splints to levels similar
to what the mechanical configuration of the
canine guidance splints could produce.
Our discussion is about the role of canine guid-
ance in splints to treat TMJ pain. The function of
this feature in the natural dentition to protect
posterior teeth from lateral forces is important
and should be considered when establishing
occlusal patterns for orthodontic treatment or full-
mouth rehabilitation.
Clinicians should consider mechanisms other
than splints. A natural and progressive adapta-
tion of TMJ structures to loading may explain the
general improvement for most of the subjects in
our study, regardless if they used the occlusal
splints. It is suggested that the formation of a
retrodiskal fibrosis and the establishment of a
pseudodisk seem to be the natural progression of
TMJ with displaced disks and pain.
52,53
People with joint pain and clicking with no
TABLE 2
Joint sounds detected at different examinations.
GROUP
Six
Months
Three
Months
30
Days
15
Days
Seven
Days
Initial
PRESENCE OF JOINT SOUNDS (%)
I: Bilateral
Balanced Splint
II: Canine
Guidance Splint
III: Nonoccluding
Splint
100
100
100
73.7
80.0
94.4
84.21
95.0
94.4
84.2
95.0
88.9
79.0
70.0
77.8
84.21
70.0
83.3
TABLE 3
Intragroup analysis of muscle
tenderness on palpation after
six months.
MUSCLE
.068
.146
.849
.007*
.588
.492
.108
.164
.076
.307
.096
.092
.003*
.377
Anterior
Medium
Posterior
Anterior
Medium
Posterior
Deep masseter
Origin
Body
Insertion
Deep masseter
Origin
Body
Insertion
Right
Left
Right
Left
SIDE AREA P VALUE
Temporal
Masseter
* Statistically significant.
Copyright 2006 American Dental Association. All rights reserved.

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JADA, Vol. 137 http://jada.ada.org August 2006 1113
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 these
conditions.
The acceptable outcome in patients using
nonoccluding splints in our study also can be
explained by the fact that the patients belief that
the treatment will be effective plays a vital role
in placebo response.
2,51
The patients personal
relationship with the professional and his or her
feeling of being under treatment are important
influences on the final outcomes of most pain
management therapies. The presence of the
splint as a foreign object in the mouth would
change the oral tactile stimuli and make the
patient 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 clicking
no longer is the primary objective of using oral
splints. In a one-year controlled study with a
sample comparable to that used in our study,
Conti and colleagues
54
found similar outcomes for
improvement 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 was
not 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 structures
over time (disk, ligaments and retrodiskal tis-
sues), diminishing the physical obstruction for
the 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, would
be necessary (for example, magnetic resonance
imaging, which we did not use in our study). This
overall 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 type
of oral splint used. We found that the occlusal
splints provided earlier improvement compared
with the nonoccluding splint, when we considered
subjects pain reports and TMJ tenderness on
palpation. I
This study was supported by Conselho Nacional de Desenvolvimento
Cientfico e Tecnolgico (CNPq BRAZIL) grant 14164312000-5.
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