Effects of Massage Therapy and Occlusal Splint Usage on Quality of Life and Pain in Individuals with Sleep Bruxism.
Cid Andre Fidelis de Paula Gomes, PT, Yasmin El-Hage, MSc, [...], and Daniela Aparecida Biasotto-Gonzalez, MD
Abstract
Purpose: The aim of the present study was to investigate the effects of massage therapy on the masticatory muscles and occlusal splint usage on quality of life and pain in individuals with sleep bruxism. Method: A randomized, controlled, blinded, clinical trial was conducted involving 78 volunteers aged 18 to 40 years with sleep bruxism. Quality of life and pain assessments were performed. Results: Significant differences (p < 0.05) were found on the physical functioning, general health state, vitality, role emotional and mental health subscales. A large effect size was found for all treatment protocols with regard to pain. The largest effect was found in the combined treatment group. Conclusions: The findings of the present study reveal that the occlusal splint usage alone led to improvements in components of quality of life among individuals with sleep bruxism. Moreover, both treatments (occlusal splint usage and massage therapy on the masticatory muscles) led to a reduction in pain.
Keywords: Physical Therapy Modalities, Orthodontic Appliances, Bruxism
Sleep bruxism is a movement disorder characterized by the involuntary grinding and/or clenching of one's teeth during sleep1). This disorder causes tooth wear and can trigger headache, temporomandibular disorder and pain in the masticatory muscles, especially upon waking2). Despite the well-defined symptoms, the etiology of sleep bruxism remains unknown3). However, central dopaminergic and serotonergic systems may play a role in the physiopathology of this disorder as well as the physiology of jaw movements during sleep4).
As a multifactor disorder, multidisciplinary approaches should be employed, involving a team made up of a dentist, physiotherapist and other health professionals who work to avoid the consequences of bruxism and reduce its symptoms5,6). One of the most often employed dental resources for the treatment of sleep bruxism is an occlusal splint, which is a muscle-relaxing appliance that protects the teeth and diminishes the symptoms of bruxism7). In physical therapy, massage is performed to prevent the formation of adherences of the connective tissue, increase the production and circulation of endogenous opioids, increase local blood flow, eliminate catabolites and reduce muscle pain8).
Individuals with a diagnosis of temporomandibular disorder, including sleep bruxism, should receive treatment involving different forms of care, as psychological aspects and quality of life are compromised in comparison to individuals without this disorder9,10). However, the literature is unclear on the use of therapies, especially physical therapy, for individuals with sleep bruxism and more randomized, controlled trials are needed to clarify these issues11).
The aim of the present study was to investigate the effects of massage therapy on the masticatory muscles and occlusal splint usage on quality of life and pain in individuals with sleep bruxism. The hypothesis is that individuals with sleep bruxism who receive massage therapy combined with occlusal splint usage experience a greater reduction in pain intensity and an improvement in quality of life.
Methods
Study design
A randomized, controlled, blinded, clinical trial was carried out. The evaluators and researchers in charge of the data analysis were blinded to the allocation of the individuals to the different groups.
One hundred twenty-two women aged 18 to 40 years with sleep bruxism were recruited from the university community of the city of the inclusion criteria were a diagnosis of sleep bruxism by an experienced dentist based on the criteria of the International Classification for Sleep Disorders of the American Academy of Sleep Medicine1), self-reported awake bruxism, documented by a positive response to a question developed by Pintado et al. (1997)12), and a minimum pain intensity score of 3 on a 11-point numerical rating scale (NRS)13). The following were the exclusion criteria: missing teeth; current use of an orthodontic appliance; history of systemic or joint disease; current use of analgesic, anti-inflammatory agent or muscle relaxant; and currently undergoing physical therapy. After the application of these criteria, 22 volunteers were excluded (Fig. 1).
Flowchart of study
The procedures of the present study received approval from the Human Research Ethics Committee of (protocol number 133012). This study is registered with Clinical-Trials.gov (NCT01874041). To participate, all volunteers signed a statement of informed consent.
One hundred women with a diagnosis of sleep bruxism were randomly allocated to the following four groups: massage therapy (n = 25), occlusal splint (n = 25), massage therapy + occlusal splint (n = 25) and control group (n = 25). Randomization was performed using opaque envelopes containing information stipulating to which group each participant belonged. Dropouts occurred during the experiment, resulting in a final sample of 78 women (Fig. 1).
The massage group (n = 17 women) was submitted to three weekly 30-minture sessions of massage of the muscles of mastication over four consecutive weeks. Massage therapy was performed by a physiotherapist who had undergone a training exercise for the administration of the protocol adapted from14), involving sliding and kneading maneuvers on the masseter and temporal muscles. Sliding consisted of a unidirectional movement in which part of the therapist's hand (mainly the fingertips) was used, moving from the proximal to the distal portion of the face with constant, progressive pressure compatible with the status of each tissue. The degree of pressure varied depending on the level of pain, sensitivity and tension of each individual. Kneading consisted of a gripping maneuver of a muscle group or portion of a muscle, with intermittent movements of compression and decompression. The therapist performed circular movements with the fingertips such that the skin and subcutaneous tissues were moved over the subjacent structures. A facial massage cream was used to facilitate the manual procedures.
The occlusal splint group (n = 19 women) was submitted to treatment with an occlusal splint for four weeks. This form of treatment is indicated to promote greater stability of the joint components and is also used to establish a more favorable occlusal status, with the reorganization of neuromuscular activity, reduced hyperactivity of the muscles and the reestablishment of balanced muscle function15–17). Following the clinical exam by a dentist, the upper arch of each volunteer was molded with irreversible hydrocolloid for the fabrication of a Michigan-type occlusal splint with a flat occlusal surface, contact with the antagonist teeth and the presence of canine and protrusive guides. The volunteers were instructed to wear the splint while sleeping. Adjustments were made after two weeks by the same dentist in charge of the evaluation and splint fabrication.
The combined group (massage group + occlusal splint group) (n = 23 women) was submitted to both protocols described above.
The control group (n = 19 women) was not submitted to any form of intervention and was evaluated on two occasions, with a four-week interval between evaluations.
The Medical Outcomes Study Short Form-36 (SF-36) was administered. The participants were given a general explanation of the questionnaire, which was then self-administered in an isolated room individually by each participant before and after the treatment protocols to determine the effects on quality of life. The SF-36 has adequate reliability and validity and is indicated for the evaluation of quality of life before and after a therapeutic intervention18,19). This questionnaire is composed of 36 items distributed among eight subscales: physical functioning (10 items), role physical (4 items), bodily pain (2 items), general health state (5 items), vitality (4 items), role social (2 items), role emotional (3 items) and mental health (5 items). An additional item addresses the difference between one's current health status and health status one year earlier. In the present study, the physical functioning, role physical, general health state, vitality, role social, role emotional and mental health subscales were used. The bodily pain subscale was not used, since no criteria are found in the literature on clinical improvements using the SF-36, especially with regard to pain.
Pain was assessed using the NRS, which is an 11-point scale ranging from 0 (absence of pain) to 10 (worst imaginable pain). The respondents selected a single number that best represented their pain intensity on the day of the evaluation20). The NRS is an important parameter of clinical improvement and is highly recommended for the evaluation of therapeutic modalities21).
Statistical analysis
Data distribution was assessed using the Shapiro-Wilk test. The pre and post treatment data regarding the SF-36 subscale were compared using the Wilcoxon rank-sum test. Two-way repeated-measurements ANOVA and post-hoc tests (Tukey's HSD and Bonferroni) were used to evaluate the degree of pain among the groups considering group (massage vs. occlusal splint vs. combined vs. control) and treatment (pre-treatment vs. post treatment) factors.
All data were analyzed using SPSS 20.0 software (SPSS Inc., Chicago, USA). Cohen's d was used to calculate the effect size, which was regarded as the mean and standard deviation found after the application of the treatment protocols22). The interpretation was based on the values established by Cohen23): less than 0.2 (small effect), around 0.5 (moderate effect) and greater than 0.8 (large effect).
Results
Table 1 displays anthropometric characteristics and disease duration (mean and standard deviation) of the volunteers.
Anthropometric characteristics and disease duration (mean and standard deviation) of the volunteers in the different groups.
Table 2 displays mean SF-36 subscale scores in the different groups before and after the treatment protocols. In the intra-group analysis of the occlusal splint group, statistically significant differences were found on the physical functioning, general health state, vitality, role emotional and mental health subscales.
Initial and final SF-36 subscale scores in different groups.
In the inter-group comparisons of pain (NRS score) during the pre-treatment and post-treatment evaluations todos tratamentos apresentaram melhora significativa em relação ao grupo controle (massage vs. control: p < 0.0001; occlusal splint vs. control: p < 0.003; combined vs. control: p < 0.0001; Tukey's HSD test). The combined treatment was statistically significant better than the occlusal splint (p < 0.05 ; Tukey's HSD test).
Table 3 shows the inter-group comparisons of pain (NRS score) during the pre-treatment and post-treatment evaluations. A large effect size was found for all treatment protocols (massage: 0.86; occlusal splint: 0.95; combined: 2.51).
Mean and standard deviation of the Intra-group comparison of pain (NRS score) between pre-treatment and post-treatment evaluation.
Discussion
In the present study, the use of an occlusal splint alone led to improvement in components of quality of life related to physical (physical functioning, general health, vitality) and emotional (role emotional and mental health) characteristics in women with sleep bruxism. These findings are in agreement with data described by Fischer et al. (2008)24), who also found improvements in quality of life indicators. However, the occlusal splint was only used for four weeks in the present investigation, which is three weeks less than the period of usage in the study cited. Moreover, these same authors24) found no significant changes in the general health, role emotional and mental health subscales of the SF-36, whereas improvements were found in these three subscales in the present investigation (Table 2). This divergence seems to demonstrate that quality of life indicators exhibit specificities related to the population investigated and the time elapsed since the diagnosis, as the sample in the refereed study24) was made up of only individuals with chronic pain and the present sample included individuals with acute pain (less than one month since the onset of symptoms).
The authors of the present study believed that massage therapy on the masticatory muscles in combination with occlusal splint usage would lead to improvements in quality of life indicators. However, such improvements were only found in the group submitted to occlusal splint usage alone. The authors believe that the isolated use of an occlusal splint provided greater protection against aggression to the teeth caused by sleep bruxism25) with a consequent reduction in muscle pain and an increase in functionality26), resulting in improvements in quality of life. In contrast, massage therapy only reduced the pain symptoms related to sleep bruxism (Table 2). The use of an occlusal splint offers protection against tooth wear and the loss of the vertical dimension6,27), allowing improved performance regarding functional activities and a reduction in signs of emotional stress, which are commonly associated with sleep bruxism28).
The combination of the two therapeutic modalities (massage therapy and occlusal splint therapy) was expected to lead to an improvement in quality of life evaluated using the SF-36 questionnaire. However, significant changes in the scores on the subscales of this questionnaire only occurred in the group submitted to occlusal splint therapy (Table 2). This may be related to the fact that the volunteers in the combined therapy group had a longer time since the diagnosis of sleep bruxism (Table 1) and perhaps required a longer therapy time than that employed in the present study.
The present findings demonstrate that both treatments analyzed led to a reduction in pain, with the greatest reduction found in when the treatments were combined (Table 3). Massage therapy and occlusal splint usage are employed to stimulate local blood flow and the transport of nutrients, reestablish normal muscle status by avoiding hyperactivity and reduce pain29–33). Thus, the combination of these two therapies is highly recommended, as demonstrated by the lack of improvement in symptoms in the control group at the final evaluation.
The findings with regard to pain demonstrate a large clinical effect size, especially in the group that received the combined therapies. According to Cleland et al. (2008)21), the minimum clinically important difference in NRS score is 1.3 points, which occurred in the combined therapy group.
There are a number of limitations in the present study that should be recognized. We attempted to investigate two characteristics that are under-studied in an isolated fashion, especially during clinical interventions for the treatment of temporomandibular disorders. Both quality of life and pain are important parameters of clinical improvement. Further studies should be conducted correlating these parameters with functional evaluations, such as masticatory muscle strength and range of motion of the temporomandibular joint. Individuals with sleep bruxism can experience muscle and/or joint impairment, which characterize this condition as a multifactor disorder34). Further studies should be carried out on both occlusal splint usage and massage therapy (either isolated or combined) involving specific diagnostic subgroups and addressing the time elapsed since diagnosis as well as the anatomic structures affected (muscles and/or joint), which was not performed in the present investigation.
Conclusion
Based on the findings of the present study, occlusal splint usage alone led to improvements in components of quality of life among individuals with sleep bruxism. Moreover, both treatments (occlusal splint usage and massage therapy on the masticatory muscles) led to a reduction in pain, with a greater reduction achieved when these two treatment modalities were combined.
Article information
J Jpn Phys Ther Assoc. 2015; 18(1): 1–6.
PMCID: PMC4691579
PMID: 26733760
Cid Andre Fidelis de Paula Gomes, PT,1 Yasmin El-Hage, MSc,1,# Ana Paula Amaral, PT,1 Carolina Marciela Herpich, PT,1 Fabiano Politti, MD,1 Sandra Kalil-Bussadori, MD,1 Tabajara de Oliveira Gonzalez, MD,1 and Daniela Aparecida Biasotto-Gonzalez, MD1
1) Nove de Julho University
Correspondence to: Yasmin El-Hage, Nove de Julho University, BRAZIL SP São Paulo Rua Profa. Maria José Barone Fernandes, 300 Vila Maria # e-mail: moc.liamg@oisif.egah
Received 2014 Jun 9; Accepted 2014 Dec 4.
Copyright 2015, JAPANESE PHYSICAL THERAPY ASSOCIATION
Articles from Journal of the Japanese Physical Therapy Association are provided here courtesy of Japanese Society of Physical Therapy
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