Abstract
Introduction:
Temporomandibular disorders (TMDs) are public health problem that can considerably affect quality of life. In particular, chronic situations are a challenge for the involved health teams, as they demand care related to central mechanisms and are not always well understood. Since the discovery of the endocannabinoid system and other systems controlled or influenced by it, many studies have reported positive and promising results. Currently, revisions of legislation regarding the use of cannabis and its derivatives in different parts of the world have allowed us to advance scientifically. The treatment of pain using cannabinoid substances can be of great value for the development of drugs that allow significant advancements in the therapy of patients with pain syndromes, particularly in cases of difficult control.
Methods:
A case of chronic TMD with several previous interventions was presented who was treated with full-spectrum cannabidiol. Treatment period—started December 13, 2021, continuous use.
Results:
Excellent results and remarkable improvement yielded in the patient's quality of life.
Conclusions:
Refractory cases can benefit from the use of medicinal cannabis, but further studies are needed to confirm the efficacy and safety of these drugs to long-term treatment.
Introduction
Temporomandibular disorders (TMDs) can be considered a public health problem, with an estimated prevalence of ∼31% in the adult population and 11% among children and adolescents. 1 As TMDs are complex, the identification of their etiology and the most appropriate therapeutic modalities for each case remains a great challenge. As a multifactorial condition, treatment of TMDs has multiple classification proposals, and the most commonly accepted and universalized is the diagnostic criteria (DC) for TMD, addressing muscle and joint disorders. In addition, it addresses Axis II, with psychosocial conditions involved. 2
Some of these conditions, for certain phenotypes, can become chronic and require interventions in the central mechanisms of pain, due to central sensitization and possible associated comorbidities. 3
The discovery of the human endocannabinoid system and positive research results for various diseases have encouraged us to further their studies.
A search was performed in the PubMed, SciELO, and LILACS databases, about the pharmacology and therapeutic use of cannabinoid substances in pain. Keywords such as Cannabis sativa, tetrahydrocannabinol (THC), cannabidiol (CBD), sativexR, cannadorR, cannabinoids, endocannabinoid, pain, and neuropathic pain were used in these searches.
Synthetic cannabinoids and C. sativa extracts have demonstrated an analgesic effect in several clinical trials, suggesting an important role in the treatment of pain, particularly in neuropathic pain. 4 Regarding pain control, some evidence already exists, suggesting the use of such products for conditions such as multiple sclerosis, fibromyalgia, cancer pain, rheumatologic pain, and neuropathies, with safe and promising protocols.5–8
Regarding its use for chronic pain, the literature has also reported encouraging results.4,9,10
Publications addressing the use of cannabinoids in TMD and orofacial pain are few, nevertheless, the studies have demonstrated good results. Thus, interest on the use of cannabinoids in TMD and orofacial pain has been increasing.11–14
Case Report
The patient was a 36-year-old woman with a history of chronic and bilateral temporomandibular joint (TMJ) pain from 14 years of age, no parafunctional habits. Her TMJ had worsening function, with cycles of improvement but no complete remission.
Her previous treatments included the use of several occlusal splints, occlusal adjustments, physiotherapy, acupuncture, and pharmacotherapy.
On clinical examination using the visual analog scale, she reported pain of intensity 09 in the left TMJ and 05 in the right TMJ, myalgia intensity of 06 in the left masseter body, and 03 in the horizontal beam of the left temporal, discomfort on palpation of the sternocleidomastoid bilaterally; spontaneous opening of 32 mm, with pain from 26 mm onward and assisted opening of 34 mm, with a rigid terminal sensation. No headache was reported. A click on opening and closing of the left TMJ and slight bilateral crepitation were observed.
Using the DC for TMD diagnostic flowchart, the patient was initially diagnosed with arthralgia with local myalgia in the right masseter and temporalis muscles.
Data on medical history, diagnosis of attention deficit hyperactivity disorder (ADHD), medical follow-up, use of methylphenidate (continuous use) were collected. TMJ magnetic resonance imaging was requested, with T1, T2, and PD protocols, without contrast, which revealed disk displacement with reduction; change in shape with the presence of osteophyte in the left side; and change in shape in the right side, suggestive of a degenerative process for both sides.
The final diagnosis was disk displacement with reduction in the left side, associated with bilateral degenerative joint disease, bilateral arthralgia, and local myalgia in the left masseter and temporalis.
The initial treatment according to the treatment proposal was as follows. Steroidal anti-inflammatory drugs betamethasone dipropionate 5 mg/mL and betamethasone disodium phosphate 2 mg/mL, 1 mL intramuscularly was injected. Two weekly sessions of photobiomodulation were conducted, with low-level laser, output power of 100 mW, near-infrared, with total delivered energy of 4 J per point, in four points in the TMJ+one retrodiscal point, through external auditory meatus, 4 J near-infrared in myalgia points. A stabilizer splint was placed. After controlling for acute inflammation, arthrocentesis associated with viscosupplementation was performed.
After 5 weeks, the patient reported relief from muscle pain and complete remission of pain in the right TMJ, although the pain intensity of 7 in the left TMJ remained.
The patient was then admitted to the hospital for arthrocentesis and viscosupplementation, and this hospitalization was recommended for the patient's anxiety condition (ADHD and aichmophobia).
Regarding the procedure, arthrocentesis was performed using a single-needle technique and saline solution (9% sodium chloride), followed by viscosupplementation with 10 mg/1 mL of sodium hyaluronate, with the patient under general anesthesia. The patient was discharged from the hospital on the same day.
After 1 week, photobiomodulation and control were performed again after observing that the spontaneous opening was 38 mm; however, the pain in the left TMJ remained at intensity 4.
Thus, owing to the difficulty of repeating the hospital procedure and in an attempt to provide an even better result for the patient, the use of phytocannabinoids was proposed. The patient received information regarding the risks and benefits of using cannabinoids for chronic pain and promptly accepted the proposal. Since the patient also had a diagnosis of attention deficit and hyperactivity disorder, we request the agreement of her doctor before starting the treatment with CBD.
Regarding the CBD therapy, following all the procedures required by the current Brazilian legislation and by the National Health Surveillance Agency, the patient received authorization to import full-spectrum CBD oil, 15 mL/900 mg, with certified organic hemp oil, distilled from full-spectrum hemp extract, upon the authors' recommendation.
The CBD therapy was started on December 13, 2021, with one sublingual drop, corresponding to 1.5 mg CBD, once a day, before bedtime. After 2 days, one sublingual drop was added before lunchtime. After another 2 days, two drops before lunchtime and two drops before bedtime were added, totaling to 6 mg of CBD per day.
At the 1-week follow-up, the patient reported complete remission of symptoms, and an important improvement in sleep quality. The reported side effects were only mild diarrhea in the first 3 days, which was controlled with probiotics.
Thus, in view of the results, the authors opted to maintain the current therapeutic regimen. During the 4 weeks of therapy, photobiomodulation was used only in the left TMJ. As the patient no longer presented with any symptoms, the photobiomodulation was suspended, maintaining the use of the stabilizer splint at the patient's request.
At the 3- and 6-month follow-ups, the patient continued with the same dosage and was completely asymptomatic, reporting an overall improvement in her quality of life (Table 1).
Care Timeline
CBD, cannabidiol.
In the patient's words: Amazing how in a few days with practically no side effects (except for 3 days of moderate diarrhea), my pains went away and never came back. I don't plan on going without my Cannabidiol (CBD) oil for a long time.
Discussion
The discovery of the psychoactive properties of cannabis and its cultivation may be much older than was assumed. Paleobotanical studies have suggested that cannabis was already present in Central Asia ∼11,700 years ago. Some historians believe that the Chinese Emperor Shén Nóng, known as “the divine pharmacist,” used cannabis ∼2000 years BC. Records of the topical use of cannabis as an anti-inflammatory agent are present in Egyptian papyri dating back to 1500 BC. 15
Its use by Queen Victoria as a pain reliever and Empress Elizabeth of Austria for cough and as an appetite stimulant, recommended by their royal doctors, ushered in the so-called golden age of medical cannabis, with the obstacle that the component responsible for addiction, THC, had not yet been isolated. 15
The isolation of the structure of the plant's main phytocannabinoid, THC, by Drs. Mechoulam and Gaoni in Israel in the 1960s shed new light on its legal use. The search for cannabinoid receptors in animal and human models led to the discovery that the authors have an endocannabinoid system, including the production of endocannabinoids, such as arachidonoylethanolamide, named Anandamide. Thus, new therapeutic possibilities have arose for the isolated or combined use of some of >100 cannabinoids present in the plant. 15
CBD is the second most abundant component in cannabis plants. Numerous studies have reported the effects of CBD on pain, anxiety, depression, inflammation, neuropathic pain, and epilepsy through specific molecular mechanisms. 16
As for TMDs, their multifactorial condition and their biopsychosocial character suggest possible mechanisms that could lead certain individuals to chronicity. Genetic predisposition, hormonal factors, micro- and macrotraumas, in addition to behavioral and emotional components, suggest that there are benefits in central interventions in these cases. 17
CBD has demonstrated safe and satisfactory results for the control of chronic pain18,19 and has long been considered a nonpsychoactive substance that may benefit the control of pain and inflammation. 20 It is important to emphasize that when using cannabinoid therapy, the protocols must be individualized, according to the clinical response of each patient. There is even a phrase that is often used among prescribers: start low and go slow.
As for orofacial pain, bruxism, and TMD, few studies have been conducted to date, although all studies have reported positive effects.11–13
Conclusion
Conservative treatment for the vast majority of cases presents excellent results. However, refractory cases can benefit from the use of CBD, with or without THC. In this case report, the benefits of using full-spectrum CBD oil, with medium-term follow-up, on quality of life were excellent. However, further studies are needed to confirm the efficacy and safety of these drugs, especially in relation to long-term treatment.
Footnotes
Authors' Contributions
J.P.C.T. contributed to conceptualization, investigation, writing—original draft, and writing—review and editing. M.D.S.T. was involved in data curation, visualization, writing—original draft, and writing—review and editing. D.F.L.M.O. and E.E.F. contributed to formal analysis, visualization, writing—original draft, and writing—review and editing. S.d.M.R. was in charge of supervision, writing—original draft, and writing—review and editing.
Informed Consent
The patient signed the consent form authorizing this case report.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.
Abbreviations Used
References
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