Die Diagnose „craniomandibuläre Dysfunktion“ (CMD) ist nicht mehr als eine ungerichtete Grobverortung eines heterogenen und multifaktoriellen Komplexes aus schmerzhaften und nichtschmerzhaften, behandlungsbedürftigen und nichtbehandlungsbedürftigen klinischen Symptomen. Keinesfalls wird der (Dys)funktionszustand des craniomandibulären Systems (CMS) damit ausreichend genau beschrieben. Um konkrete Therapiestrategien ableiten zu können, bedarf es der präzisen Bezeichnung klinischer und/oder pathologischer Zustände mit reproduzierbaren und einheitlichen Diagnosen. In der Diagnoseklassifikation des craniomandibulären Systems (DC-CMS) wurden nach aktuellem Kenntnisstand (zahn‑)medizinisch relevante „CMD-Diagnosen“ in einem hierarchisch strukturierten und codierten Mehrebenenmodell organisiert und inhaltlich beschrieben. Auf dieser Basis kann nach problemorientierter Diagnostik der (Dys)funktionszustand des CMS behandlungsorientiert und korrekt dokumentiert werden. Einer konsequenten anatomischen Grundordnung folgend, ist ausgehend von bestimmten Leitsymptomen die Ableitung entsprechender Leitstruktur(en) und damit eine Kategorisierung als myogene (Myopathie), arthrogene (Arthropathie) und/oder okklusogene (Okklusopathie) CMD möglich. Fachfremde Diagnosen werden in der DC-CMS als Komorbidität gelistet.

Zur Erfassung der Leitsymptome der kraniomandibulären Dysfunktion (CMD), Detektion betroffener Leitstrukturen und korrekten Deutung pathophysiologischer Zusammenhänge ist eine gerichtete Diagnostik notwendig. Erst nach Differenzierung der dominierenden Beschwerdekomponente als myogen (Myopathie), arthrogen (Arthropathie), okklusogen (Okklusopathie) und/oder Co-Morbidität, der Erkennung möglicher parafunktioneller Aktivitäten und deren Einordnung als mögliche Beschwerdetrigger oder -unterhalter können Behandlungsansätze konzipiert oder bei Nichtbehandlungsbedarf Überbehandlungen vermieden werden. Um eine Chronifizierung von Schmerzen und damit eine Verschlechterung der Prognose zu vermeiden, sollte möglichst frühzeitig eine problemorientierte und adäquate Therapie eingeleitet werden. Grundsätzlich sind bei der Behandlung der CMD weiterhin konservative und möglichst reversible Ansätze, ggf. in einem multimodalen Therapiekonzept, anzustreben. Lediglich bei arthrogenen Erkrankungen zeichnet sich ein Paradigmenwechsel hin zum frühzeitigeren Einsatz minimal-invasiver chirurgischer Maßnahmen ab.

Conservative treatment of craniomandibular disorders (CMD) requires target-oriented diagnostics, comprising assessment of lead symptoms and detection of affected lead-structures to allow for a valid interpretation of the pathophysiological context. A thorough differentiation of the dominant complaints into the categories myogenic (myopathy), arthrogenic (arthropathy), occlusogenic (occlusopathy), and/or comorbidities, supplemented by an assessment of potential parafunctional activities and their respective appraisal as possible triggers or perpetuating factors, will enable establishment of individualized treatment strategies or avoid overtreatment where dental or maxillofacial treatment options are not indicated, e.g., in the case of comorbidities. The objective of CMD treatment nowadays is prevention of chronic pain, which is associated with a poor long-term outcome. Therefore, adequate treatment modalities focused on the individual problems need to be applied as early and as efficiently as possible. Treatment of CMD should follow the traditional principle of "as conservative as possible", based on reversible and non-invasive approaches, and make use of multimodal treatment options in an interdisciplinary setting where applicable. Only for arthropathies a paradigm shift is visible, with minimally invasive surgery increasingly now ranking among the first-line therapeutic options.

OBJECTIVES:Cognitive-behavioral treatment has proven efficacy for chronic temporomandibular disorder (TMD). However, most patients receive dental treatment that may not address psychological comorbidities often present in TMD. The aim of the present study was to evaluate the efficacy of biofeedback-based cognitive-behavioral treatment (BFB-CBT) versus dental treatment with occlusal splint (OS). Moreover, changes in nocturnal masseter muscle activity (NMMA) were investigated.METHODS:Fifty-eight patients with chronic TMD were randomly assigned to receive either 8 weekly sessions of BFB-CBT or 8 weeks of OS treatment. Diagnoses were established using Research Diagnostic Criteria for TMD. Pain intensity and disability were defined as primary outcomes. Secondary outcomes included emotional functioning, pain coping, somatoform symptoms, treatment satisfaction, and adverse events. NMMA was assessed during 3 nights pretreatment and posttreatment with portable devices. Follow-up assessment took place 6 months after the treatment.RESULTS:Both treatments resulted in significant reductions in pain intensity and disability, with similar amounts of clinically meaningful improvement (45% for BFB-CBT and 48% for OS). Patients receiving BFB-CBT showed significantly larger improvements in pain coping skills. Satisfaction with treatment and ratings of improvement were higher for BFB-CBT. Effects were stable over 6 months, and tended to be larger in the BFB-CBT group for all outcomes. No significant changes were observed in NMMA.DISCUSSION:The fact that BFB-CBT resulted in larger improvements in pain coping skills, and was well accepted by the patients, underlines the importance and feasibility of psychological treatments in the clinical management of TMD.

Objective: Temporomandibular disorders (TMD) have often been related to sleep bruxism and elevated nocturnal masseter muscle activity (NMMA). However, previous studies have revealed controversial results, and the role of somatization, depression and anxiety has not been studied in this context. The aim of this study was to investigate the association between NMMA and pain intensity: TMD related symptoms, somatoform symptoms, depression, and anxiety in chronic TMD.Methods: Thirty-six subjects with chronic painful TMD, 34 subjects with pain free bruxism, and 36 healthy controls recorded their nocturnal masseter muscle activity during three consecutive nights with portable devices. In addition, participants completed pain diaries and questionnaires. Diagnoses were established using the research diagnostic criteria for TMD.Results: Subjects with chronic TMD reported a reduced general health state (p<.001), higher levels of somatoform symptoms (p<.001), depression (p<.05), and anxiety (p<.001) compared to control subjects with or without sleep bruxism. The amount of NMMA did not differ significantly between the groups. In subjects with TMD, pain intensity was not related to NMMA. However, higher NMMA was related to higher intensity of jaw related symptoms such as headache or tinnitus, and higher somatization in general.Conclusion: Chronic TMD is associated with elevated levels of psychopathology. These findings suggest a common link between NMMA, somatization, and symptom intensity in chronic TMD. (C) 2012 Elsevier Inc. All rights reserved.

Temporomandibular disorders (TMD) are a painful condition present in 3% of the population. The aim of the present study was to develop a biofeedback-based cognitive-behavioral treatment for chronic TMD (BFB-KVT) and to evaluate its effectiveness compared to dental treatment. A total of 26 patients suffering from chronic TMD were randomly assigned to either BFB-KVT (n=15) or occlusal splint treatment (n=11). Preliminary data showed that both treatments reduced pain intensity and jaw disability. Greater improvement of pain-related disability was found for BFB-KVT, and its acceptance by the patients was higher. The proposed protocol appears to be an effective treatment for chronic TMD. The evaluation in a larger sample and of long-term efficacy will follow.

Kraniomandibuläre Dysfunktionen (CMD), gekennzeichnet durch Schmerzen in Kiefermuskulatur und -gelenken, stellen bei 3% der Bevölkerung ein behandlungsbedürftiges Problem dar. Ziele der vorgestellten Studie waren die Entwicklung eines Biofeedback-gestützten kognitiv-verhaltenstherapeutischen Behandlungsmanuals (BFB-KVT) und dessen Evaluation im Vergleich zur zahnmedizinischen Standardbehandlung im Rahmen einer randomisierten kontrollierten Studie.