Managing patients with chronic pain from temporomandibular disorders
The role of orthodontics in the treatment of temporomandibular disorders is rather confusing and controversial. A new clinical practice guideline has recently been published. Martyn Cobourne takes us through this important piece of work. I think that this will be as controversial as my RME and breathing post a couple of weeks ago!
Temporomandibular disorders (TMD) are the second-most common cause of chronic pain (pain that lasts for ≥3 months) after lower back pain. They are now classified as a primary pain condition in the chronic pain coding system of the International Classification of Disease. These patients can present to their doctor, dentist or a variety of specialists, including orthodontists.
A new guideline
An international clinical practice guideline has recently been developed and published in the British Medical Journal (BMJ): https://pubmed.ncbi.nlm.nih.gov/38101929/ which provides recommendations on the comparative effectiveness of available therapies for chronic pain associated with TMD. This guideline has used a wide range of expert clinicians, methodologists, and individuals with TMD. It is based upon a systematic review and network analysis (153 RCTs, 8713 participants, reporting on the effects of 59 interventions compared to placebo or sham procedures) also published in the BMJ: https://pubmed.ncbi.nlm.nih.gov/38101924/ with the guideline accompanied by a short editorial: https://www.bmj.com/content/383/bmj.p2877/
This is a high-quality piece of work and represents a best-practice template for the development of clinical guidelines and a definitive reference for the management of adults living with chronic pain associated with any type of TMD (specifically 4-6 cm on a 10 cm pain scale for ≥3 months duration). These guidelines do not apply to acute pain (≤3 months duration). They also may not apply to patients with co-morbidities, those with previous TMJ surgery, or those involved in litigation associated with their condition. They are available in an accessible format: https://www.bmj.com/content/383/bmj-2023-076227 with further data available through the MAGIC apphttps://app.magicapp.org/#/guidelines
What did they find?
The panel identified Seven patient-important outcomes to inform the recommendations: (1) pain relief (the critical outcome); (2) physical and (3) emotional functioning; (4) role functioning; (5) social functioning; (6) sleep quality; and (7) adverse events. However, a problem with many of the included trials was a lack of, or only low-level certainty reporting on adverse events or harms associated with different interventions. Therefore, consensus agreement among the authors was used to determine the risk of harm associated with each intervention.
On the basis of moderate-high certainty evidence being found on important benefits for pain relief (the critical outcome) and a consensus that most informed patients would want them and the benefits on pain relief and function likely outweigh the harms:
- Strong recommendations were made in favour of cognitive behavioural therapy (CBT) (+/- augmentation with relaxation or biofeedback therapy); therapist-assisted jaw mobilisation, manual trigger point therapy, supervised postural or jaw exercises, stretching +/- manual trigger point therapy and usual care (home exercises, stretching, reassurance and education);
- Conditional recommendations were made in favour of manipulation, supervised jaw exercises with mobilisation, CBT with NSAIDs, manipulation with postural exercise and acupuncture.
Interestingly, conditional recommendations were made against the use of reversible occlusal splints (alone or with anything else), arthrocentesis (alone or with anything else), cartilage supplement, low-level laser therapy, nerve stimulation, botulinin toxin injection, hyaluronic acid injection, corticosteroids, benzodiazepines and beta-blockers. These therapies could be considered if no others are suitable. However, people would likely not want them, and the benefits of pain relief and function are uncertain and associated with harm or burden.
Finally, strong recommendations were made against discectomy, irreversible oral splints and NSAID-opioid medication because the benefits on pain relief and function are uncertain, and they are associated with important harms.
What about orthodontics?
Orthodontic treatment is not mentioned specifically, but the presence of conditional and strong recommendations against the use of reversible and irreversible splints, respectively should be interpreted as meaning there is little evidence that occlusal change can produce pain relief or improved physical function for chronic TMD. Orthodontists should read these guidelines and consider them if they advise or manage patients presenting with chronic TMD, and they should be applied within an environment of shared decision-making with the patient.
Martyn Cobourne is Professor of Orthodontics at King’s College London. He also runs the excellent Evidence-Based Orthodontics Facebook Group and the Evidence-Based Orthodontics Course.
I find the approach to treatment of patients with TMD deeply troubling nowadays. On one hand, it does protect against the inappropriate use of certain approaches involving attempts to address occlusal issues, especially where these might be irreversible. However, it also tends to suggest avoidance of definitive diagnosis in suggesting a series of approaches that should be used irrespective to some extent in management of patients. Furthermore, results are based on samples and these obviously negate the possibility of any occlusal issue in any patient. The possibility of an occlusal issue is presented as never existing. Anyone who has been in practice long enough will know that this is not always the case, and that ALWAYS and NEVER are a dangerous approach to anything. Where should the bottom line be? I am not certain I have the answer, but careful diagnostics should lie at the heart of things at least
Call me a coward but my approach to dealing with patients with chronic TMD requesting Orthodontic treatment was to leave well alone and refer on to the appropriate Consultants!
Interesting that all of the best treatments were essentially those that would be found in medicine (as opposed to dental) based referral network. There were a total of 24 authors which included one orthodontist and one pediatric dentist, that does not indicate much of a representation as I see it. Not that this is a “Turf War’ but It would be worth tracking down the list of studies that “made the cut” and were deemed good enough to be included in the final analysis. I also had to look up exactly what a “Network Meta Analysis” actually is and while it sounds like a good tool, it seems to require more specificity at the front end and ultimately is more complex and difficult for us mere clinicians to unravel..
I say this because In my individual, anecdotal only experience, of providing a patient with a simple anterior bite plate to disarticulate the posterior teeth significantly reduces TMD pain almost overnight. I try and avoid treating TMD stuff these days but of the 100 or so I have treated over the years, I can only think of one or two that got no relief. (Got to love those retrospective clinician memory studies….) To have a treatment modality that I (and others) have found so successful to not even get an “honorable mention” in the TMD treatment “Hall of Fame” created by this article does not make sense to me.
I would hope that Professor Coburne or some other Network Meta Analysis insider might delve a bit deeper into his article and the ultimate source material for the analysis and find out why a seemingly successful treatment used for many years by many, many dentists did not make the list.