Temporomandibular Disorders Priorities for Research and Care (2020) / Chapter Skim
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5 Caring for Individuals with a TMD
5 Caring for Individuals with a TMD
Pages 197-254
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From page 197... ...
, especially those with chronic and painful TMDs, has been fraught with challenges and complications. The committee identified several stumbling blocks in the evolution of effective care for individuals with a TMD, including the rise of multiple competing theories among different groups regarding what causes TMDs and how best to treat indi viduals with TMDs; minimal high-quality evidence about which treatments are appropriate for which patients; patient abandonment by clinicians who have exhausted their treatment capabilities; and a clouding of the role of surgery in care of patients with TMDs by harmful devices such as Proplast/ Teflon- or silastic-based TMJ implants in the 1970s and 1980s.
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From page 198... ...
in the 1970s and 1980s. These early TMJ implants reached the market through a streamlined regulatory pathway that required only demonstration of substantial equivalence to a device already on the market.
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Patients with chronic orofacial pain have said that it is important for health care professionals to be empathetic even when no effective treatments can be offered (Breckons et al., 2017)
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The establishment of professional societies, such as the American Academy of Orofacial Pain, has helped to advance greater understanding and adoption of the role of scientific evidence in making clinical decisions by dentists and physical therapists who treat TMDs. Yet, many challenges remain in the optimization of TMD care.
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From page 201... ...
For instance, dentists can offer a simple bite prop during longer dental treatments that require wide mouth opening. Another prevention strategy is early recognition and management of the biological and psychosocial contributors to TMDs, including comorbid medical conditions such as juvenile idiopathic arthritis and other rheumatologic diseases.
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ASSESSMENT AND DIAGNOSIS OF TMDs Following the publication of the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) (see Chapter 2)
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Actions for overcoming barriers to implementing the biopsychosocial model in clinical practice settings are being explored (Sharma et al., 2019)
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TMD TREATMENTS There are a wide variety of potential treatments for TMD, including self-management, physical therapy, medications, occlusal adjustments, intra ral appliances, and surgery. Evidence-based clinical practice guide o lines for the treatment of TMDs do not currently exist, despite the fact that treatment is common.
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Recent systematic reviews are included where available as are Cochrane Collaboration reviews and meta-analyses; a frequent conclusion in the systematic reviews regarding clinical trials of treatments for TMDs is that methodological quality is generally low. The treatments in this section are organized by type of intervention as follows: (1)
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First, some patients and health care professionals may believe that selfmanagement means that patients should cope with their conditions primarily on their own. Instead, self-management is best understood and practiced as a way of expanding the patient's agency over his or her condition and its treatment, in partnership with medical specialists and others in their network.
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A professional is often in a better position to tailor training to the participants' needs and past experiences, to provide knowledgeable feedback, and to recommend novel approaches that the participants might not have considered. Evidence of efficacy A number of meta-analyses and systematic reviews have examined the effectiveness of self-management approaches for chronic pain conditions in general (Hoffman et al., 2007; Williams et al., 2012; Morley et al., 2013; Pike et al., 2016)
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with setbacks Litt et • Rationale for CBT and using EMG 6 sessions Compared to the al., 2010 biofeedback approach Delivered by control group, • Relaxation training master's-level the group that • EMG biofeedback to reduce therapists with received CBT skills masseter muscle activity experience in training showed • Habit modification to reduce CBT steeper decreases clenching and bruxing in pain over time, • Cognitive restructuring to identify particularly for and change overly negative those who were low thoughts in somatization or • Stress management training high in readiness or • Home practice assignments self-efficacy. Ferrando • Rationale for combined CBT- 6 sessions Compared to the et al., hypnosis approach Delivered by control group, the 2012 • Functional analysis to identify master's-level group that received antecedents and consequences of psychologist a CBT intervention problem behaviors/patterns with experience that included • Hypnosis training to enhance in CBT hypnosis showed relaxation, positive mood, and the higher improvement use of imagery in frequency in • Hypnosis to support self-suggestions pain and emotional for pain relief, reduction of pain and distress.
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Several key findings emerged from that systematic review. First, at longterm follow-up, therapist-guided self-management was significantly more effective than control conditions in reducing pain intensity, depression, ctivity interference, and muscle palpation pain.
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First, there is a need to involve patients, their families, health care professionals, and other key stakeholders in the review and evaluation of current TMD self-management materials and resources and peer-led and therapist-led self-management training proto cols. Such a review could lead to the development of updated and tailored self- anagement materials.
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Conclusion 5-2: Self-management and patient education can be important components of care of temporomandibular disorders (TMDs)
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A Cochrane review (Luther et al., 2010) found that there were insufficient data avail able to inform clinical practice on the effectiveness of orthodontic treatments in reducing TMD symptoms.
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Intraoral Appliances (Splints) Intraoral appliances, or laboratory-fabricated devices that fit over the teeth, are known by a wide variety of names such as splints, stabilization appliances, occlusal splints, occlusal appliances, interocclusal splints, fully balanced splints, repositioning splints, bruxism splints, nightguards, and several names denoting the commercial vendors of particular splint designs; the selected name usually relates to the perceived mechanism of action, for which evidence remains absent.
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BOX 5-2 Challenges Facing the Application of Evidence-Based Dentistry for Temporomandibular Disorders (TMDs) Two studies of intraoral appliances illustrate some of the significant challenges associated with applying evidence-based dentistry for TMDs: (1)
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In the first study, 200 patients with myofascial pain of the masticatory uscles m (either temporomandibular joint [TMJ] arthralgia or disc displacement with reduc tion)
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For other chronic pain conditions, like fibro yalgia and low back pain, clinical practice guidelines recommend m
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. • Jaw stretching exercises: Some clinical trials show that home exercise aimed at stretching the soft tissue around the jaw muscles increases jaw opening and may decrease pain.
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A recent systematic review found that manual therapy (soft tissue mobilization) can produce a clinically significant reduction in pain (Armijo-Olivo et al., 2016)
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. The review concluded that while dry needling and local anesthetic injections seem promising, there is a need to conduct randomized clinical trials with larger sample sizes and longer follow-up times to truly evaluate the effectiveness of these techniques.
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. Because evidence-based dietary guidelines for patients with chronic orofacial pain do not exist, clinicians may provide customized advice for individuals based on the challenges they report (Durham et al., 2015; Nasri-Heir et al., 2016)
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A brief summary of select pharmacological approaches to TMD pain relief and relevant studies is presented below. Non-steroidal anti-inflammatory drugs (NSAIDs)
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. However, a recent systematic review on the efficacy of anticonvulsants on orofacial pain found limited to moderate evidence supporting the use of anticonvulsants for treatment of patients with orofacial pain disorders (Martin and Forouzanfar, 2011)
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are also recommended for treating patients with orofacial muscle spasms, though the quality of the evidence for the efficacy of these drugs is weak. A 2009 Cochrane review cited two randomized controlled trials reporting the use of cyclobenzaprine for the treatment of myofascial pain.
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While this study, and others, indicated success in using botulinum toxin Type A to unload, or temporarily paralyze, the muscle and relieve the jaw joint, The TMJ Asso ciation issued caution to individuals with TMD pursuing treatment with botulinum toxin Type A due to the loss of bone strength resulting from the treatment in rabbits. There is concern for the health of the TMJ in humans using botulinum toxin Type A in the long term given the osteoporotic condition of the TMJ in rabbits (The TMJ Association, 2016)
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The idea behind this intervention is to flush viscous synovium and inflammatory mediators from the joint and to release joint adhesions via hydraulic pressure. Arthrocentesis has been shown to be effective in relieving pain and improving mouth opening in patients with temporomandibular disc displacements (Dimitroulis et al., 1995; Nitzan and Price, 2001; Nitzan et al., 2017)
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. TMJ implants will be discussed further in the next section.
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. TMJ Implants Patients with bony ankylosis, condylar injuries, developmental abnormalities, functional deformity, severe inflammatory conditions, and/or painful or dysfunctional internal derangements after failed conservative and surgical treatment, all of whom have not responded to less invasive treatments, may be candidates for a TMJ replacement with alloplastic implants (Sidebottom et al., 2008; NICE, 2014)
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Walter Lorenz Total Biomet Microfixation, P020016 September 21, 2005 Temporomandibular Joint Inc. (Jacksonville, FL, Replacement System USA)
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Three approaches for doing so are discussed here: conducting clinical trials, building a patient registry, and developing and implementing clinical practice guidelines. Conducting Clinical Trials Randomized controlled trials (RCTs)
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. Opportunity for a National TMD Clinical Trials Consortium Bringing together researchers through a national TMD clinical trials consortium could provide opportunities to improve the quality of clinical studies of TMD treatments.
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. Ongoing IMMPACT develop ments will continue to provide guidance for the best approaches to measuring and assessing pain in clinical trials for TMD treatments.
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National TMJ Implant Registry and Repository at the University of Minnesota Alloplastic TMJ implants are Class III devices, the most complex and highest risk devices regulated by the Center for Devices and Radiological Health (CDRH)
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In 2002, NIDCR recognized the need for further examination of TMJ implants and the reasons for their failures and awarded funding to the University of Minnesota School of Dentistry to develop a national TMJ implant registry and repository (Myers et al., 2006)
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The TMD CRN aims to do the following: • Create a standardized data infrastructure, • Develop new and more effective ways to incorporate patient and real-world evidence data in clinical trials, • Support the design of predictive analytics algorithms, • Foster evidence-based protocols and best practices for inclusion into health care, and • Promote collaborative multidisciplinary research (MDEpiNet, 2019c)
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Developing and Implementing Clinical Practice Guidelines There are currently no formal clinical practice guidelines that provide evidence about effective TMD treatments, for whom or for what specific types of TMDs particular treatments may be effective, and criteria for when to escalate treatment beyond the initial conservative approaches. Given the historical misunderstanding of TMDs and misguided treatment approaches that have led to iatrogenic harm for some, and as current diagnosis and treatment remains disparate and heterogeneous, TMD clinical practice guidelines are greatly needed.
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choice in the management of temporomandibular joint disorders. • There is a lack of evidence that temporomandibular joint disorders (defined as musculoskeletal disorders, not the lesion of traumatic occlusion)
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. The published letters in support of the guideline were from orofacial pain dental providers and indicated that the clinical data point to the majority of patients with TMDs benefiting from "reversible, nonsurgical, non-orthodontic treatment, for a fraction of the cost" (JADA, 2010, p.
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In contrast to the general guidelines discussed above, clinical practice guidelines are "statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options" (IOM, 2011, p.
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. Currently, there is minimal robust, high-quality evidence on which to draw in developing clinical practice guidelines.
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Conclusion 5-6: Evidence-based clinical practice guidelines from a trusted source are needed to effectively manage care for indi viduals with a temporomandibular disorder. New research should be tightly linked to the goal of producing evidence for developing clinical practice guidelines.
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Systematic reviews and methodologically rigorous new studies are needed. Conclusion 5-6: Evidence-based clinical practice guidelines from a trusted source are needed to effectively manage care for indi viduals with a temporomandibular disorder.
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2017. Parameters of care: Clinical practice guidelines for oral and maxillofacial surgery.
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2015. Botulinum toxin therapy for temporomandibular joint disorders: A systematic review of randomized controlled trials.
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2012. Low back pain: Clinical practice guidelines linked to the International Classifica tion of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association.
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2006. Current evidence providing clarity in management of temporomandibular disorders: Summary of a systematic review of randomized clinical trials for intra-oral appliances and occlusal therapies.
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2015. Reporting of adverse events and statistical details of efficacy estimates in randomized clinical trials of pain in temporo mandibular disorders: Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks systematic review.
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Cochrane Database of Systematic Reviews CD006830.
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2012. Ultrasonography for detection of disc displacement of temporomandibular joint: A systematic review and meta-analysis.
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2018. Effects of glucosamine supplements on painful temporomandibular joint osteoarthritis: A systematic review.
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2018. Clinical practice guidelines for the management of non specific low back pain in primary care: An updated overview.
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2003. Clinical evaluation of amitriptyline for the control of chronic pain caused by temporomandibular joint disorders.
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. Cochrane Database of Systematic Reviews 11:CD012850.
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in adults. Cochrane Database of Systematic Reviews 11:D007407.
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