Disfunção temporomandibular: aspectos relacionados à ansiedade e depressão e tratamento por terapia manual

Abstract

The prevalence of temporomandibular disorders (TMD) signs and symptoms on general population is around 40% and physical therapist actuation has been more and more important to the treatment of the dysfunction. In this context, three different studies on this area were developed, which are explained on this dissertation. The first one is an observational longitudinal study with the following objectives: (1) to verify clinical symptoms and jaw functionality in college students with TMD according to the level of anxiety and depression (A/D) evaluated in two different moments, and (2) to evaluate the correlation between A/D, clinical variables and muscle activity. The results showed that although college students A/D levels changed over the academic semester, no difference in TMD signs and symptoms was observed in subjects with either high or low levels of A/D. Furthermore, the significant correlation between A/D and functional impairment, as well as between A/D and maximum mouth opening without pain in low A/D condition suggests an association between these factors, being important a better investigation. In order to better explore the physiotherapy techniques and overcome the lack of a review study, which addressed the effectiveness of MT in these patients, the second survey was conducted. This study was a systematic review to evaluate the isolated effects of MT in reducing painful symptoms and reduced mouth opening. The review included 12 randomized controlled trials, most of them of high methodological quality that addressed myofascial release, cervical spine manipulation techniques and mixed protocols. They have shown from low to high clinical evidence that MTTM reduces symptoms of pain, increase pressure pain threshold and maximum mouth opening of subjects with TMJ impairment, depending on the applied technique. A third study was conducted in parallel with the other two, which was based on biomechanical and neuroanatomical relationships between the cervical spine, head and the temporomandibular joint. It is a pilot clinical trial that aimed to verify the effects of a rehabilitate program of MT and exercises, designed to cervical function on subjects with TMD. It was evaluated clinical signs, functionality and pressure pain threshold of masseters and temporalis, taking into account the sample´s baseline. The results showed that treatment focused on the cervical spine was effective in increasing maximum mouth opening, as well as to reduce hypersensitivity of the masticatory muscles and functionality of the stomatognathic system in individuals with myofascial and mixed TMD. However, further studies are needed for more accurate conclusions. In general, the studies described on the present dissertation indicate the importance of standardizing TMD patient s assessment, and classifying them according to the type of the disorder. Furthermore, future studies should consider the level of functional impairment and use it as inclusion criterion to increase internal validity. Finally, the number of studies found in the systematic review and the reduced number of included studies show that there is a lot of information about the topic, but a small portion of it follows a methodological rigor, being in fact is reliable. It is important that further clinical trials include a comparison group (control, placebo, conventional treatment or another treatment) so that the effect of the technique is indeed evident. In case of manual therapy clinical trials, the simulation of therapy, which represents the placebo effect of the technique, is increasingly necessary.