Management of chronic pain associated with temporomandibular disorders: a clinical practice guideline

Abstract

Clinical question What is the comparative effectiveness of available therapies for chronic pain associated with temporomandibular disorders (TMD)? Current practice TMD are the second most common musculoskeletal chronic pain disorder after low back pain, affecting 6-9% of adults globally. TMD are associated with pain affecting the jaw and associated structures and may present with headaches, earache, clicking, popping, or crackling sounds in the temporomandibular joint, and impaired mandibular function. Current clinical practice guidelines are largely consensus-based and provide inconsistent recommendations. Recommendations For patients living with chronic pain (≥3 months) associated with TMD, and compared with placebo or sham procedures, the guideline panel issued: (1) strong recommendations in favour of cognitive behavioural therapy (CBT) with or without biofeedback or relaxation therapy, therapist-assisted mobilisation, manual trigger point therapy, supervised postural exercise, supervised jaw exercise and stretching with or without manual trigger point therapy, and usual care (such as home exercises, stretching, reassurance, and education); (2) conditional recommendations in favour of manipulation, supervised jaw exercise with mobilisation, CBT with non-steroidal anti-inflammatory drugs (NSAIDS), manipulation with postural exercise, and acupuncture; (3) conditional recommendations against reversible occlusal splints (alone or in combination with other interventions), arthrocentesis (alone or in combination with other interventions), cartilage supplement with or without hyaluronic acid injection, low level laser therapy (alone or in combination with other interventions), transcutaneous electrical nerve stimulation, gabapentin, botulinum toxin injection, hyaluronic acid injection, relaxation therapy, trigger point injection, acetaminophen (with or without muscle relaxants or NSAIDS), topical capsaicin, biofeedback, corticosteroid injection (with or without NSAIDS), benzodiazepines, and β blockers; and (4) strong recommendations against irreversible oral splints, discectomy, and NSAIDS with opioids. How this guideline was created An international guideline development panel including patients, clinicians with content expertise, and methodologists produced these recommendations in adherence with standards for trustworthy guidelines using the GRADE approach. The MAGIC Evidence Ecosystem Foundation (MAGIC) provided methodological support. The panel approached the formulation of recommendations from the perspective of patients, rather than a population or health system perspective. The evidence Recommendations are informed by a linked systematic review and network meta-analysis summarising the current body of evidence for benefits and harms of conservative, pharmacologic, and invasive interventions for chronic pain secondary to TMD. Understanding the recommendation These recommendations apply to patients living with chronic pain (≥3 months duration) associated with TMD as a group of conditions, and do not apply to the management of acute TMD pain. When considering management options, clinicians and patients should first consider strongly recommended interventions, then those conditionally recommended in favour, then conditionally against. In doing so, shared decision making is essential to ensure patients make choices that reflect their values and preference, availability of interventions, and what they may have already tried. Further research is warranted and may alter recommendations in the future.

Management of chronic pain secondary to temporomandibular disorders: a systematic review and network meta-analysis of randomised trials

“…The accompanying BMJ Rapid Recommendation provides contextualised guidance based on this body of evidence (box 1). 16…”

“…The accompanying BMJ Rapid Recommendation provides contextualised guidance based on this body of evidence (box 1). 16 Dissemination to participants and related patient and public communities: We used MAGICapp decision aids (available at www. magicapp.org/) to facilitate conversations between healthcare providers and patients.…”

“…15 This systematic review informed a parallel guideline published in The BMJ and MAGICapp (box 1). 16…”

2024: A year to reinterpret medicine’s maladies

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Chronic pain associated with temporomandibular disorders

“…The new clinical practice guideline from Busse et al is a valuable addition to support management of chronic pain associated with TMDs 16. An international guideline development group with broad representation, including people with TMDs, methodologists, and expert clinicians, produced the guideline, based on a systematic review and network meta-analysis of all available treatment options for all subtypes of chronic TMD pain performed by Yao et al17 This included 59 interventions from 148 randomised controlled trials (RCTs) that reported on pain relief, and 26 interventions from 33 RCTs that reported on physical functioning.…”