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Research

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

BMJ 2023; 383 doi: https://doi.org/10.1136/bmj-2023-076226 (Published 15 December 2023) Cite this as: BMJ 2023;383:e076226

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Chronic pain associated with temporomandibular disorders

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

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  1. Liang Yao, postdoctoral researcher12,
  2. Behnam Sadeghirad, assistant professor12,
  3. Meixuan Li, doctoral candidate34,
  4. Jing Li, methodologist34,
  5. Qi Wang, doctoral candidate1,
  6. Holly N Crandon, MBiotech candidate56,
  7. Grace Martin, medical student7,
  8. Rebecca Morgan, assistant professor18,
  9. Ivan D Florez, associate professor91011,
  10. Birk Stokke Hunskaar, medical student12,
  11. Jeff Wells, otolaryngologist13,
  12. Sara Moradi, masters student114,
  13. Ying Zhu, methodologist1,
  14. Muhammad Muneeb Ahmed, medical student7,
  15. Ya Gao, doctoral candidate3,
  16. Liujiao Cao, doctoral candidate15,
  17. Kehu Yang, professor34,
  18. Jinhui Tian, professor3,
  19. Jialing Li, associate professor16,
  20. Linda Zhong, associate professor17,
  21. Rachel J Couban, librarian14,
  22. Gordon H Guyatt, distinguished professor1,
  23. Thomas Agoritsas, general internist and associate professor11819,
  24. Jason W Busse, professor1214
  1. 1Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
  2. 2Department of Anesthesia, McMaster University, 1280 Main St. West, Hamilton, Ontario, Canada
  3. 3Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
  4. 4Health Technology Assessment Centre, Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China.
  5. 5Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
  6. 6Institute for Management and Innovation, University of Toronto, Mississauga, Ontario, Canada
  7. 7Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
  8. 8School of Medicine, Case Western Reserve University, Cleveland, OH, USA
  9. 9Department of Pediatrics, University of Antioquia, Medellin, Colombia.
  10. 10School of Rehabilitation Science, McMaster University, Hamilton, Canada.
  11. 11Pediatric Intensive Care Unit, Clínica Las Americas, Medellin, Colombia
  12. 12Institute of Health and Society, University of Oslo, Oslo, Norway
  13. 13Department of Otolaryngology-Head and Neck Surgery, Cleveland Clinic, Cleveland, OH, USA
  14. 14Michael G. DeGroote National Pain Centre, McMaster University, Hamilton, Ontario, Canada
  15. 15West China School of Nursing/West China Hospital, Sichuan University, Chengdu, China
  16. 16Department of Orthodontics, Nanjing Stomatological Hospital, Medical School of Nanjing University, China
  17. 17School of Biological Sciences, Nanyang Technological University, Singapore
  18. 18Division of General Internal Medicine, Department of Medicine, University Hospitals of Geneva, Geneva, Switzerland
  19. 19The MAGIC Evidence Ecosystem Foundation, Oslo, Norway
  1. Correspondence to: K Yang, Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China,730000; yangkh{at}lzu.edu.cn
  • Accepted 9 November 2023

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)

Footnotes

  • Contributors: LY, BS, and MXL contributed equally to the study and are joint first authors. LY, BS, TA, and JWB conceived and designed the study. RJC searched electronic databases for eligible trials. LY, MXL, JL, QW, HC, GM, RM, BSH, JW, SM, YZ, MMA, YG, LC, LDZ, and IDF screened the studies and abstracted data. LY carried out the statistical analysis. YL, BS, and JWB interpreted the data. LY, BS, and JWB drafted the manuscript. All authors critically revised the article for important intellectual content and gave final approval for the article. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

  • Funding: This study was supported by a grant from the Chronic Pain Centre of Excellence for Canadian Veterans. JWB is supported, in part, by a Canadian Institutes of Health Research Canada Research Chair in Prevention and Management of Chronic Pain. The funding organisations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form and declare: no financial support from any industry for the submitted work; no other relationships or activities that could appear to have influenced the submitted work.

  • Transparency: All authors affirm that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

  • 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. The MAGICapp decision aids were co-created with people living with chronic pain. We also plan to use social media, the websites of our organisations and pain related associations or societies to disseminate our findings.

Data availability statement

Details of the characteristics of the included studies were shared in the supplementary materials. The study specific data included in the meta-analysis can be obtained from the first author at yaol12@mcmaster.ca.

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