Counselling and self‐management therapies for temporomandibular disorders: a systematic review

The aim of this review was to investigate the effectiveness of counselling and other self‐management‐based therapies on muscle and temporomandibular joint (TMJ) pain relief and increasing the functional abilities of patients with temporomandibular disorders (TMD). A systematic literature review was conducted by three independent reviewers and included articles published up to 2012. PubMed and Cochrane Library electronic databases were used in addition to hand‐searching to assess clinical outcomes for counselling and self‐management approaches for TMD treatment. The review yielded 581 records that were narrowed down to 7. All included studies were classified as blind‐randomized controlled clinical trials. The selected articles analysed revealed that counselling was able to improve tenderness upon masticatory muscle palpation and maximum mouth opening with and without pain in patients with TMD, with similar results to those of interocclusal appliances approaches. Thus, counselling‐ and self‐management‐based therapies could be considered a conservative low‐cost and beneficial treatment alternative for treating TMD to potentially improve psychological domains and remove harmful behaviours for the control of the signs and symptoms of TMD.     

TMD in relation to malocclusion and orthodontic treatment

OBJECTIVE: The aim of this systematic literature review was to evaluate associations between different malocclusions, orthodontic treatment, and signs and symptoms of temporomandibular disorders (TMD). MATERIALS AND METHODS: This review was part of a project at the Swedish Council on Technology Assessment in Health Care focusing on malocclusion and orthodontic treatment from a health perspective. As a first step, the literature was searched in the Medline and Cochrane Library databases from 1966 to May 2003. A later update was made in January 2005. Human studies in English or in Scandinavian languages were included. RESULTS: Associations between certain malocclusions and TMD were found in some studies, whereas the majority of the reviewed articles failed to identify significant and clinically important associations. TMD could not be correlated to any specific type of malocclusion, and there was no support for the belief that orthodontic treatment may cause TMD. Obvious individual variations in signs and symptoms of TMD over time according to some longitudinal studies further emphasized the difficulty in establishing malocclusion as a significant risk factor for TMD. A considerable reduction in signs and symptoms of TMD between the teenage period and young adulthood has been shown in some recent longitudinal studies. CONCLUSIONS: Associations between specific types of malocclusions and development of significant signs and symptoms of TMD could not be verified. There is still a need for longitudinal studies.     

Is there an association between otologic symptoms and temporomandibular disorders?: An evidence-based review

BackgroundThe aim of this article is to discuss the scientific evidence available on the pathophysiology and management of otologic complaints in patients with temporomandibular disorders (TMDs).Types of Studies ReviewedThe authors conducted an electronic search in MEDLINE, Web of Science and ScienceDirect and retrieved all the relevant peer-reviewed journal articles available in English on the topic. No time restriction was applied.ResultsNo consensus exists on the management of otologic symptoms in patients with concomitant TMD. The scientific evidence suggests that conservative or reversible TMD therapy might provide relief. However, this evidence is scarce and low, thus further studies with larger sample sizes and better designed methodological frameworks are needed. Until such evidence is available, dentists and orofacial pain specialists should treat TMD patients using current guidelines and refer those with otologic symptoms to an otolaryngologist.Practical ImplicationsGiven the wide range of potential pathophysiologies and treatments for each otologic symptom described in the TMD patient, close collaboration with otolaryngologists is essential to achieve the best patient care.     

Prevalence of temporomandibular disorders in patients seeking orthodontic treatment: A systematic review

The objective of this systematic review was (a) to establish the prevalence of temporomandibular disorders (TMDs) in patients seeking orthodontic treatment and (b) to determine the association between the presence of TMD and sex, age and malocclusion. A systematic literature search was performed according to PRISMA guidelines from 1969 to 2019 using the PubMed and LIVIVO databases. Eight study articles met the inclusion and exclusion criteria. An additional three contributions were identified through manual searching of the reference lists of retrieved articles. The methodological quality of the 11 articles was assessed with the Joanna Briggs Institute Critical Appraisal Checklist for prevalence studies. TMD prevalence ranged from 21.1% to 73.3%. The frequency of painful TMD signs/symptoms varied from 3.4% to 65.7%, while non-painful signs/symptoms ranged from 3.1% to 40.8%. The percentage of males and females presenting with TMD varied from 10.6% to 68.1% and 21.2 to 72.4%, respectively. In all studies, TMD prevalence was higher among females. The majority of articles reported more TMD signs/symptoms in individuals older than 18 years as compared to younger ones (≤18 years). While in four studies no association between TMD and malocclusion was found, another three investigations indicated that TMD may be related to certain occlusal traits. The TMD prevalence in patients seeking orthodontic treatment was high, with many individuals presenting painful TMD signs/symptoms. Female and older patients appear to have a greater occurrence of TMD. Although no strong association between TMD and malocclusion was established, several occlusal traits were implicated.     

Manual therapy for the management of pain and limited range of motion in subjects with signs and symptoms of temporomandibular disorder: a systematic review of randomised controlled trials

There is a lack of knowledge about the effectiveness of manual therapy (MT) on subjects with temporomandibular disorders (TMD). The aim of this systematic review is to synthetise evidence regarding the isolated effect of MT in improving maximum mouth opening (MMO) and pain in subjects with signs and symptoms of TMD. MEDLINE^®, Cochrane, Web of Science, SciELO and EMBASE^™ electronic databases were consulted, searching for randomised controlled trials applying MT for TMD compared to other intervention, no intervention or placebo. Two authors independently extracted data, PEDro scale was used to assess risk of bias, and GRADE (Grading of Recommendations Assessment, Development and Evaluation) was applied to synthetise overall quality of the body of evidence. Treatment effect size was calculated for pain, MMO and pressure pain threshold (PPT). Eight trials were included, seven of high methodological quality. Myofascial release and massage techniques applied on the masticatory muscles are more effective than control (low to moderate evidence) but as effective as toxin botulinum injections (moderate evidence). Upper cervical spine thrust manipulation or mobilisation techniques are more effective than control (low to high evidence), while thoracic manipulations are not. There is moderate‐to‐high evidence that MT techniques protocols are effective. The methodological heterogeneity across trials protocols frequently contributed to decrease quality of evidence. In conclusion, there is widely varying evidence that MT improves pain, MMO and PPT in subjects with TMD signs and symptoms, depending on the technique. Further studies should consider using standardised evaluations and better study designs to strengthen clinical relevance.     

Management of temporomandibular disorders: a rapid review of systematic reviews and guidelines

Temporomandibular disorders (TMD) impact a significant proportion of the population. Given the range of management strategies, contemporary care should be evidence-informed for different TMD types. A knowledge-to-action rapid review of systematic reviews published in the past 5 years and guidelines published in the past 10 years concerning the management of TMD was conducted. The Cochrane, Embase, MEDLINE, PEDro, and PubMed databases were searched. A qualitative data analysis was undertaken, with quality assessment completed using the AMSTAR 2 checklist. In total, 62 systematic reviews and nine guidelines considering a range of treatment modalities were included. In concordance with current guidelines, moderate evidence supports a multi-modal conservative approach towards initial management. Contrary to existing guidelines, occlusal splint therapy is not recommended due to a lack of supporting evidence. The evidence surrounding oral and topical pharmacotherapeutics for chronic TMD is low, whilst the evidence supporting injected pharmacotherapeutics is low to moderate. In concordance with current guidelines, moderate quality evidence supports the use of arthrocentesis or arthroscopy for arthrogenous TMD insufficiently managed by conservative measures, and open joint surgery for severe arthrogenous disease. Based on this, a management pathway showing escalation of treatment from conservative to invasive is proposed.     

Association of malocclusion and functional occlusion with subjective symptoms of TMD in adults: results of the Study of Health in Pomerania (SHIP)

An analysis of exclusively representative population-based studies on adults has shown that only few and inconsistent associations could be detected between malocclusions and clinical signs of temporomandibular disorders (TMD)--and none for functional occlusion factors (occlusal interferences, non-working side contacts, etc). The aim of this study was to analyze associations between morphologic occlusion as well as factors of functional occlusion and subjectively perceived symptoms of TMD--again on the basis of the population-based Study of Health in Pomerania (SHIP), providing a sample of 4310 subjects (out of 7008 subjects yielding a response rate of 68.8%) aged 20 to 81 years, and other international representative studies from the systematic review. Besides occlusal factors also parafunctions and socioeconomic status (SES) were taken into account (including age and sex). Multiple logistic regression analysis was used--adjusted for SES. In this study, none of the occlusal factors were significantly associated with the indication of more frequent subjective TMD symptoms. However, the parafunction "frequent clenching" was connected with subjective TMD symptoms (odds ratio = 3.4). Compared with other population-based studies few and (across studies) inconsistent associations between malocclusions and subjective TMD symptoms could be ascertained. No significant associations of factors of functional occlusion with TMD symptoms were identifiable.     

Need for occlusal therapy and prosthodontic treatment in the management of temporomandibular disorders. Part I. Occlusal interferences and occlusal adjustment

This review, divided into two parts, evaluates the literature on the relationship between dental occlusion and temporomandibular disorders (TMD) and the need for occlusal therapy in the management of TMD. The first part of the review focuses on the aetiological importance of occlusal interferences and the place of occlusal adjustment in the management and prevention of signs and symptoms of TMD. This has long been a controversial issue, which has not yet been resolved. The literature does not give strong support for the role of occlusion in the aetiology of TMD. Experienced clinicians also repudiate the need for occlusal adjustment in the management of TMD, whereas (less experienced) general dentists adhere to a concept focusing on the occlusion in diagnosis and treatment of TMD. There is a consensus that generalized prophylactic occlusal adjustment is not justified. There is an obvious need for research with evidence-based methods, to be able to answer the many remaining questions in this field.     

Otologic symptoms of temporomandibular disorder and effect of orofacial myofunctional therapy

The aim of this study was to investigate the frequency of otologic symptoms and their relationship to orofacial signs and symptoms of temporomandibular disorder (TMD), and the effect of orofacial myofunctional therapy. The study was conducted on eight asymptomatic subjects (Group C) and 20 subjects with articular TMD, randomly distributed over two groups: one treated using orofacial myofunctional therapy (OMT Group) and a control group with TMD (Group CTMD). Patient selection was based upon the Research Diagnostic Criteria for TMD (RDC/TMD). All subjects submitted to a clinical examination with self-reporting of symptom severity, and to orofacial myofunctional and electromyographic evaluation at diagnosis and again, at the end of the study. Correlations were calculated using the Pearson test and inter- and intragroup comparisons were made (p < 0.05). In the diagnosis phase, subjects with TMD reported earache (65%), tinnitus (60%), ear fullness (90%), and 25% of the asymptomatic subjects reported tinnitus. The otologic symptoms were correlated with tenderness to palpation of the temporomandibular muscles and joints and with orofacial symptoms. Only the OMT group showed a reduction of otologic and orofacial symptoms, of tenderness to palpation and of the asymmetric index between muscles. OMT may help with muscle coordination and a remission of TMD symptoms.     

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提要：颞下颌关节紊乱病（TMD）是口腔临床常见病之一，其治疗方法众多。咬合板作为一种保守、可逆的治疗方法被广泛应用在TMD的治疗上。然而，各类咬合板治疗TMD的疗效尚不完全明确，本文结合近年来国内外文献对其进行综述。     

Prevalence of whiplash trauma in TMD patients: a systematic review

The purpose of this systematic review was to describe the prevalence of whiplash trauma in patients with temporomandibular disorders (TMDs) and to describe clinical signs and symptoms in comorbid TMD/whiplash compared with TMD localised to the facial region. A systematic literature search of the PubMed, Cochrane Library and Bandolier databases was carried out for articles published from 1 January 1966 to 31 December 2012. The systematic search identified 129 articles. After the initial screening of abstracts, 32 articles were reviewed in full text applying inclusion and exclusion criteria. Six studies on the prevalence of neck trauma in patients with TMD met the inclusion criteria and were included in the review. Two of the authors evaluated the methodological quality of the included studies. The reported prevalence of whiplash trauma ranged from 8·4% to 70% (median 35%) in TMD populations, compared with 1·7–13% in the non‐TMD control groups. Compared with patients with TMD localised to the facial region, TMD patients with a history of whiplash trauma reported more TMD symptoms, such as limited jaw opening and more TMD pain, and also more headaches and stress symptoms. In conclusion, the prevalence of whiplash trauma is higher in patients with TMD compared with non‐TMD controls. Furthermore, patients with comorbid TMD/whiplash present with more jaw pain and more severe jaw dysfunction compared with TMD patients without a history of head–neck trauma. These results suggest that whiplash trauma might be an initiating and/or aggravating factor as well as a comorbid condition for TMD.     

Management of TMD: evidence from systematic reviews and meta‐analyses

Summary This systematic review (SR) synthesises recent evidence and assesses the methodological quality of published SRs in the management of temporomandibular disorders (TMD). A systematic literature search was conducted in the PubMed, Cochrane Library, and Bandolier databases for 1987 to September 2009. Two investigators evaluated the methodological quality of each identified SR using two measurement tools: the assessment of multiple systematic reviews (AMSTAR) and level of research design scoring. Thirty‐eight SRs met inclusion criteria and 30 were analysed: 23 qualitative SRs and seven meta‐analyses. Ten SRs were related to occlusal appliances, occlusal adjustment or bruxism; eight to physical therapy; seven to pharmacologic treatment; four to TMJ and maxillofacial surgery; and six to behavioural therapy and multimodal treatment. The median AMSTAR score was 6 (range 2–11). Eighteen of the SRs were based on randomised clinical trials (RCTs), three were based on case–control studies, and nine were a mix of RCTs and case series. Most SRs had pain and clinical measures as primary outcome variables, while few SRs reported psychological status, daily activities, or quality of life. There is some evidence that the following can be effective in alleviating TMD pain: occlusal appliances, acupuncture, behavioural therapy, jaw exercises, postural training, and some pharmacological treatments. Evidence for the effect of electrophysical modalities and surgery is insufficient, and occlusal adjustment seems to have no effect. One limitation of most of the reviewed SRs was that the considerable variation in methodology between the primary studies made definitive conclusions impossible.     

Temporomandibular disorders and dental occlusion. A systematic review of association studies: end of an era?

To answer a clinical research question: ‘is there any association between features of dental occlusion and temporomandibular disorders (TMD)?’ A systematic literature review was performed. Inclusion was based on: (i) the type of study, viz., clinical studies on adults assessing the association between TMD (e.g., signs, symptoms, specific diagnoses) and features of dental occlusion by means of single or multiple variable analysis, and (ii) their internal validity, viz., use of clinical assessment approaches to TMD diagnosis. The search accounted for 25 papers included in the review, 10 of which with multiple variable analysis. Quality assessment showed some possible shortcomings, mainly related with the unspecified representativeness of study populations. Seventeen (N = 17) articles compared TMD patients with non‐TMD individuals, whilst eight papers compared the features of dental occlusion in individuals with TMD signs/symptoms and healthy subjects in non‐patient populations. Findings are quite consistent towards a lack of clinically relevant association between TMD and dental occlusion. Only two (i.e., centric relation [CR]‐maximum intercuspation [MI] slide and mediotrusive interferences) of the almost forty occlusion features evaluated in the various studies were associated with TMD in the majority (e.g., at least 50%) of single variable analyses in patient populations. Only mediotrusive interferences are associated with TMD in the majority of multiple variable analyses. Such association does not imply a causal relationship and may even have opposite implications than commonly believed (i.e., interferences being the result, and not the cause, of TMD). Findings support the absence of a disease‐specific association. Based on that, there seems to lack ground to further hypothesise a role for dental occlusion in the pathophysiology of TMD. Clinicians are encouraged to abandon the old gnathological paradigm in TMD practice.     

Occlusal adjustment for treating and preventing temporomandibular joint disorders

To assess the effectiveness of occlusal adjustment (OA) for treating temporomandibular disorders (TMD) in adults and preventing TMD. The Cochrane Controlled Trials Register, MEDLINE and EMBASE were comprehensively searched using the Cochrane methods. Reports and review articles were retrieved. Unpublished reports or abstracts were considered from the SIGLE database. All randomized or quasi-randomized controlled trials comparing OA with placebo, reassurance or no treatment in adults with TMD. The outcomes were global measures of symptoms, pain, headache and limitation of movement. Data collection and analysis followed the Cochrane Oral Health Group's statistical guidelines. Results showed no difference between OA and control group in symptom-based outcomes for treatment or incidence of symptoms for prevention. There is no evidence that OA treats or prevents TMD. OA cannot be recommended for the management or prevention of TMD. Future trials should use standardized diagnostic criteria and outcome measures when evaluating TMD.     

Malocclusions and Clinical Signs or Subjective Symptoms of Temporomandibular Disorders (TMD) in Adults

AIM AND METHOD: The objective was to determine with reference to a representative sample of 4310 men and women aged 20 to 81 (response rate 68.8%) drawn from the population-based Study of Health in Pomerania (SHIP-0) whether associations exist between malocclusions and temporomandibular dysfunctions in adults. Besides clinically investigated signs, subjectively perceived symptoms of temporomandibular disorders (TMD) were studied in each individual together with malocclusions (plus normal occlusion), functional occlusion factors, and sociodemographic parameters. A multivariate logistic regression analysis was used, adjusted for age and discriminated for gender. The results were compared with those of other population-based studies identified by a systematic review undertaken by the present authors. RESULTS: Some malocclusions were associated with signs or symptoms of TMD but tended to occur only rarely: unilateral open bite, negative overjet, and unilateral scissors-bite in men, and edge-to-edge bite in women. However, malocclusions (and functional occlusion factors) accounted for only a small part of the differences between the control population and the study population with signs or symptoms of TMD. In terms of the multifactorial problem of temporomandibular disorders they should be seen as cofactors. The results, together with those of other population-based studies, revealed no specific, i.e. recurring malocclusions (or other occlusal factors) presenting as risk markers.     

Evaluation of signs,symptoms, and occlusal factors among patients with temporomandibular disorders according to Helkimo index

Objective: This study sought to assess the clinical signs and subjective symptoms of TMD, including the occlusal condition.

Methods: Recruited individuals included 123 patients (58 men, 65 women) aged 15 to 65 years (mean 38.6 years) who had been referred to the TMD department. Helkimo dysfunction, occlusal, and anamnestic indices were used to assess signs of TMD, occlusal condition, and symptoms, respectively. Relationships of occlusal factors with signs and symptoms of TMD were evaluated by Spearman’s correlation test. Associations of TMD with sex and age distributions were assessed by Mann–Whitney and Spearman’s test, respectively.

Results: The prevalence of signs and symptoms was as high as 75%. Occlusal factors had significant associations with signs and symptoms of TMD.

Conclusion: Prevalence of TMD in the study population was high, without preference for age or sex. Occlusal factors may play a role in the etiology of TMD.     

Association of malocclusion and functional occlusion with signs of temporomandibular disorders in adults: results of the population-based study of health in Pomerania

The objective of this study was to determine whether associations exist between occlusal factors and signs of temporomandibular disorders (TMD) in adults using the population-based Study of Health in Pomerania (SHIP), Germany. A representative sample of 4310 men and women aged 20 to 81 years (response 68.8%) was investigated for TMD signs, malocclusions, functional occlusion factors, and sociodemographic parameters. Multiple logistic regression analysis, adjusted for sex, age, and socioeconomic status, was used. The results were compared with other population-based studies identified by a systematic review. Few malocclusions and no factors of functional occlusion except socioeconomic parameters were associated with TMD signs, and these associations were mostly weak. Only bilateral open bite up to three mm appeared to be clinically relevant and was associated with TMD signs (odds ratio [OR] = 4.0). This malocclusion, however, was of rare occurrence, with a prevalence of 0.3% (n = 9), and this finding was not confirmed by other representative studies. Occlusal factors examined in this study explained only a small part of the differences between normal subjects and those with TMD signs. This and other population-based studies indicate that malocclusions and factors of functional occlusion surveyed should be seen as merely cofactors in the sense of one piece of the mosaic in the multifactorial problem of temporomandibular dysfunction. Single occlusal factors that showed significant effects throughout several studies could not be detected. In view of the large number of occlusal variables already investigated, other variables including nonocclusal ones probably also play a role and should be looked at more intensely.     

Subjective reactions to intervention with artificial interferences in subjects with and without a history of temporomandibular disorders

In a previous double-blind randomized controlled study, subjects with a history of temporomandibular disorder (TMD) reacted to artificial interference with more signs of TMD than did subjects with no TMD history. In the present study, we analysed the subjective reactions of these individuals on several symptom scales. Every day during the 2-week follow-up period, the subjects rated the intensity of their symptoms on 9 VAS scales (occlusal discomfort, chewing difficulties, tender teeth, fatigue in the jaws, headache, facial pain, opening difficulty, bruxism, ear symptoms). Subjects with a history of TMD and true interferences reported stronger symptoms than subjects with no TMD history and placebo interferences. The most prominent symptoms were occlusal discomfort and chewing difficulties. The difference in outcome between the groups with and without a TMD history suggests that there are individual differences in vulnerability to occlusal interferences. It is likely that the etiological role of occlusal interferences in TMD has not been correctly addressed in previous studies on artificial interferences.