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(I) Introduction
Among the treatments provided for temporomandibular disorders (TMD), intra-oral dental appliances,
whether with full or partial occlusal coverage, and
referred to in this paper as oral splints, have been repeatedly reported as being the most widely adopted choice.
Introduced by Karolyi in 1901 (see Ramfjord and Ash,
1994) for the treatment of bruxism, it is striking to see
the versatility of their current applications. Other than
their use in the prevention of dental injuries and oral
soft-tissue trauma potentially induced by bruxism,
sports, cheek biting (Walker and Rogers, 1992), and electroconvulsive therapy (Minneman, 1995), oral splints of
various designs have been prescribed in the management of diverse disorders including: (a) motor disorders
such as Parkinson's disease (Durham et al., 1993) and oral
tardive dyskinesia (Kai et al., 1994); (b) sleep disorders
such as snoring (George, 1993) and sleep apnea (George,
1993; Athanasiou et al., 1994; Lowe, 1994; Yoshida, 1994;
Osseiran, 1995); (c) sensitive teeth related to chronic
sinusitis (Dawson, 1974); (d) various headaches, from the
tension-type to migraine (Ouayle et al., 1990; Lamey and
Steele, 1996); and (e) all subgroups of TMD, e.g., myofascial pain, disc displacement disorders, and the arthritides (Table 1).
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TABLE 2
Synonyms for Oral Splints Used in the
Treatment of Temporomandibular Disorders
and Bruxism
Anterior deprogramming splint
Anterior positioning splint
TABLE 1
Applications of Oral Splints
Temporomandibular disorders
Myofascial pain
Disc displacement disorders
Arthritides of the temporomandibular joints
Other pain disorders
Headaches/migraine
Motor and sleep disorders
Sleep bruxism
Sleep apnea
Parkinson's disease
Oral tardive dyskinesia
Occlusal rehabilitation
Orthodontics
Periodontics
Prosthodontics
Phantom bite
Others (Prevention of tissue trauma, habits)
Diurnal bruxism
Sports
Cheek or fingernail biting
Electroconvulsive therapy
Lip commissure burn
Esophageal reflux
Sinusitis
Disclusion splint
Distal push splint
Flat occlusal splint
Hawley splint
Herbst splint
Hydrostatic splint
Levandoski splint
Mandibular advancing repositioning splint
Mandibular orthopedic repositioning appliance
Mandibular repositioning splint
Michigan occlusal splint
Muscle deprogramming splint
Night guard
Occlusal correcting splint
Occlusal disengagement splint
Orthopedic interocclusal appliance
Pain release splint
Pivoting appliance
Protrusive positioners
Stabilization splint
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TABLE 3
Mechanisms Proposed for Oral Splint
Efficacy/Effectiveness
Myofascial pain
Change in the vertical dimension of occlusion
Repositioning of the temporomandibular joints
Decrease in the level of muscle activity
Reducing bruxism
Removal of occlusal interferences
Enhancing the patient's cognitive awareness
Disc displacement disorders
"Recapturing" the disc
'Unloading" the joints
Arthritis/arthralgia
"Unloading" the joints
Sleep bruxism
Removal of occlusal interferences
Change in muscle activity
Modification of patient's habits
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19)Ci
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cant decrease of
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ciated with DD do not always occur as a result of a displaced disc. In light of these results, the "Phase II" concept of therapy-where irreversible alterations of the
dentition with occlusal equilibration, prosthodontics,
orthodontics, or orthognathic surgery are performed to
stabilize the recaptured disc-becomes totally unjustified. This is even more true considering the frequent
return of signs and symptoms of DD after/during postsplint extensive oral reconstruction: For example, the
disc was displaced again in 33% of the patients after 6
months' treatment with mandibular repositioning onlays
(Westesson and Lundh, 1988), while joint noises
recurred in 43% during or soon after the completion of
major prosthodontic treatment (Moloney and Howard,
1986). In patients who received orthodontic intervention,
500o experienced a return in joint sounds, and in 35%,
pain recurred during the treatment (Moloney and
Howard, 1986). These high relapse rates inspire caution
against the use of invasive therapies.
The literature on the use of a soft oral splint in the
treatment of DD is more limited. Favorable results such
as a decrease in pain and joint noises have been reported following 20 days of continuous use of a soft splint (24
hrs/day; Harkins et al., 1988). However, the validity of
these data is questionable, since they were not collected
under blind conditions, and patients were not randomized into treatment groups. Furthermore, there are concerns that the use of soft splints may be associated with
occlusal changes (Singh and Berry, 1985; Harkins et al.,
1988).
Taken together, the available data indicate that,
although oral splints have been repeatedly reported to
be effective in improving the range of mandibular motion
and in decreasing pain and joint noises associated with
DD, these results need to be confirmed with welldesigned clinical trials. Furthermore, the belief that the
disc can be either consistently recaptured or predictably
stabilized by oral splints is not supported by any of the
imaging studies reviewed so far. If the clinical improvements observed in DD patients are not associated with
apparent changes in the disc position, it becomes evident that disc repositioning should not constitute the
ultimate objective of the splint. Moreover, in view of the
questionable benefits and the potential harmful effects
associated with ARSplints (i.e., uncontrolled tooth movements; Brown et al., 1994), and the expense and invasiveness of so-called "Phase II" therapy, we conclude that
these approaches appear unacceptable in either the
short- or long-term treatment of DD.
Our conclusion is further supported by the body of
evidence suggesting that DD is unlikely to be a progressive disorder in the majority of patients. For instance, it
has been reported that 40% of the patients who had only
counseling for DD were symptom-free after 8-15 years
(Pedersen and Hansen, 1987); the condition was consid1998)
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(VI) Conclusion
Despite the nearly universal prescription of oral splints
in the treatment of TMDs or bruxism, the quality of the
evidence supporting the mechanisms of action suggested for their presumed efficacy is still questionable. This
is not surprising, since their efficacy itself remains
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Acknowledgments
The authors thank Drs. A Charbonneau, J.S Feine, and I.P. Lund for
their contributions in earlier clinical trials. G.I. Lavigne is presently
supported by the Medical Research Council of Canada and the Fonds
de la Recherche en Sante du Quebec.
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