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

Abstract

Objective We explored the comparative effectiveness of available therapies for chronic pain associated with temporomandibular disorders (TMD). Design Systematic review and network meta-analysis of randomised clinical trials (RCTs). Data sources MEDLINE, EMBASE, CINAHL, CENTRAL, and SCOPUS were searched to May 2021, and again in January 2023. Study selection Interventional RCTs that enrolled patients presenting with chronic pain associated with TMD. Data extraction and synthesis Pairs of reviewers independently identified eligible studies, extracted data, and assessed risk of bias. We captured all reported patient-important outcomes, including pain relief, physical functioning, emotional functioning, role functioning, social functioning, sleep quality, and adverse events. We conducted frequentist network meta-analyses to summarise the evidence and used the GRADE approach to rate the certainty of evidence and categorise interventions from most to least beneficial. Results 233 trials proved eligible for review, of which 153—enrolling 8713 participants and exploring 59 interventions or combinations of interventions—were included in network meta-analyses. All subsequent effects refer to comparisons with placebo or sham procedures. Effects on pain for eight interventions were supported by high to moderate certainty evidence. The three therapies probably most effective for pain relief were cognitive behavioural therapy (CBT) augmented with biofeedback or relaxation therapy (risk difference (RD) for achieving the minimally important difference (MID) in pain relief of 1 cm on a 10 cm visual analogue scale: 36% (95% CI 33 to 39)), therapist-assisted jaw mobilisation (RD 36% (95% CI 31 to 40)), and manual trigger point therapy (RD 32% (29 to 34)). Five interventions were less effective, yet more effective than placebo, showing RDs ranging between 23% and 30%: CBT, supervised postural exercise, supervised jaw exercise and stretching, supervised jaw exercise and stretching with manual trigger point therapy, and usual care (such as home exercises, self stretching, reassurance). Moderate certainty evidence showed four interventions probably improved physical functioning: supervised jaw exercise and stretching (RD for achieving the MID of 5 points on the short form-36 physical component summary score: 43% (95% CI 33 to 51)), manipulation (RD 43% (25 to 56)), acupuncture (RD 42% (33 to 50)), and supervised jaw exercise and mobilisation (RD 36% (19 to 51)). The evidence for pain relief or physical functioning among other interventions, and all evidence for adverse events, was low or very low certainty. Conclusion When restricted to moderate or high certainty evidence, interventions that promote coping and encourage movement and activity were found to be most effective for reducing chronic TMD pain. Registration PROSPERO (CRD42021258567)

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

“…The consensus process was overseen by two experienced guideline methodologists (JWB, TA). The draft summary of findings were prepared prior to the panel meetings, following GRADE guidance from the accompanying network meta-analysis 1. Interventions were presented sequentially during the panel meetings, starting with those supported by moderate to high certainty of benefit (on pain relief or physical functioning) to lower certainty, and from low to high concerns about harms.…”

“…The linked systematic review included 210 studies (in 233 publications), of which 153 trials (8713 participants) were included in network meta-analyses 1. These trials reported the effects of 59 interventions, or combinations of interventions, when compared with placebo or sham procedures in patients with chronic pain associated with temporomandibular disorders (TMD).…”

“…Our recommendations are based on a linked systematic review and network meta-analysis (see box 1). 1 The infographic provides the recommendations together with an overview of the absolute benefits and harms of interventions for chronic pain associated with temporomandibular disorders in the standard GRADE format. Clinicians and their patients can find consultation decision aids to facilitate shared decision-making in MAGICapp (https://app.magicapp.org/#/guideline/EQ305L).…”

2024: A year to reinterpret medicine’s maladies

“…The BMJ ’s values are to be evidence based (doi:10.1136/bmj-2023-075462 doi:10.1136/bmj-2023-076226 doi:10.1136/bmj-2023-076227), patient centred (doi:10.1136/bmj.p2777), open and transparent (doi:10.1136/bmj-2023-076902), courageous (doi:10.1136/bmj.o838), and proud of our people (doi:10.1136/bmj.p2755). 10111213141516 Our purpose is to prioritise outcomes related to health and wellbeing, for people and the planet. In a year in which medical roles, medical teams, and the delivery of medical services—damaged by the maladies that run through them—must be re-examined and redefined, The BMJ ’s values and purpose would be a good starting point.…”

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. They used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to evaluate the certainty of evidence, considering the magnitude and certainty of benefit with the magnitude and certainty of harm for each intervention to generate clinical recommendations 18…”