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Dental Medicine and Oral Health Sciences

Certain psychosocial interventions may be more effective than other treatment modalities in improving pain symptoms in adults with temporomandibular disorder

Clinical Question: In adult patients with temporomandibular disorder, to what extent do psychosocial interventions compared to other treatment modalities improve their symptoms and quality of life?

Clinical Bottom Line: The results show that for certain outcomes (long-term pain and unassisted jaw opening without pain), psychosocial interventions may work better compared to other more conventional treatment modalities in improving symptoms in patients with TMD. However, certain other outcomes, including short-term pain and all three outcomes for the self-care CBT group in the study conducted by Aggarwal et al., demonstrate absence of clinically meaningful differences between both types of treatments. For most of the outcomes measured in both studies, there are no clinical implications and the results are indecisive, suggesting the need for more well-powered studies with rigorous methodology.

Evidence search:

("Temporomandibular Joint Disorders"[Mesh] OR "temporomandibular disorders"[TIAB] OR "TMD"[TIAB] or "TMJD"[tiab]) AND ("Psychotherapy"[Mesh] OR "psychotherapy"[TIAB]) AND (Consensus Development Conference[ptyp] OR Consensus Development Conference, NIH[ptyp] OR Guideline[ptyp] OR Practice Guideline[ptyp] OR Review[ptyp] OR systematic[sb] OR Meta-Analysis[ptyp]) AND ("2009/10/26"[PDat] : "2019/10/23"[PDat]).

Search date: October 23, 2019; Articles found in PubMed: 22; no additional literature sources were searched.

 

Author, year Source of evidence Population Characteristics Methods
1.

Roldán-Barraza et al., 2014

PMID: 25068215

Systematic review and meta-analysis
(Randomized Controlled Trials, 12 studies).

Population: Adults with temporomandibular disorder; Age: 34-39 years old (mean); 77%-100% F

Sample size, total:  N= 414

Location/Setting: Canada, USA, Brazil.

Search: MEDLINE; CENTRAL; EMBASE; MeSH terms and key words

Intervention: psychosocial interventions

Control: conventional treatment (occlusal splint therapy, self-care strategies)

Primary/secondary outcomes: self-reported pain, jaw opening, long-term depression, somatization

Measurement instruments:  Chronic Pain Grade Scale

Key Results

Comparison 1: Standardized “Usual Treatment” vs Psychosocial Interventions
MD (Self-Reported Pain at Short Term) = 0.05 (95% CI -0.26, 0.36);
MD (Self-Reported Pain at Long Term) = 0.11 (95% CI -0.53, 0.75);
MD (Unassisted Jaw Opening Without Pain at Short Term) = 1.66 (95% CI -5.6, 2.28);
MD (Muscle Pain at Short Term) = 0.21 (95% CI -0.03, 0.44).

Comparison 2: Tailored/patient-specific “Usual Treatment” vs Psychosocial Interventions
MD (Self-Reported Pain at Short Term) = 0.10 (95% CI -0.25, 0.46);
MD (Self-Reported Pain at Long Term) = 0.80 (95% CI 0.14, 1.46);
MD (Somatization at Long Term) = 0.40 (95% CI -0.06, 0.86);
MD (Depression at Long Term) = 0.21 (CI 95% -0.15, 0.58).

Evidence Quality

Using the Multidimensional Pain Inventory, patients exposed to psychosocial interventions had 0.8 less points of self-reported pain at long term compared with the patients exposed to patient-specific ‘usual treatment’. The results are statistically significant, clinically meaningful (Cohen’s d value threshold 0.5) and not clinically precise. This suggests that psychosocial interventions may work better than conventional treatment for this outcome, however more well-powered studies with rigorous methodology are still required.

Patients exposed to psychosocial interventions saw an increase in unassisted jaw opening without pain of 1.66mm at short term compared with the patients exposed to standardized ‘usual treatment. The results are not statistically significant, clinically meaningful (Cohen’s d value threshold 0.5) and not clinically precise. This suggests that psychosocial interventions may work better than conventional treatment for this outcome, however more well-powered studies with rigorous methodology are still required.

The results are not statistically significant, not clinically meaningful and clinically decisive for self-reported pain and muscle pain at short term for comparison 1 and self-reported pain at short term for comparison 2, suggesting that there is no difference between conventional and psychosocial interventions. All of the other outcomes assessed were not statistically significant, not clinically meaningful and not decisive, meaning more well-powered studies with rigorous methodology are required.

Strengths: RCT study designs; three data bases and two RCT registration systems, abstracts from conferences, and several relevant journals; two independent reviewers plus arbitrator; Cochrane Collaboration’s tool for risk of bias; PRISMA diagram; publication bias analysis for every outcome by using funnel plots; contacted the primary study's authors in case of risk of bias was unclear (e.g., allocation concealment); meta-analysis.

Limitations: caregivers were not blinded when performing the interventions; the limited sample size of studies included; unclear risks of selection, detection, attrition and reporting bias.

 

Author, year Source of evidence Population Characteristics Methods
 

2. Aggarwal et al., 2019

 

PMID: 30620145

Systematic review and meta-analysis
(Randomized Controlled Trials, 14 studies)

Population: adults over 18 years of age with chronic orofacial pain defined as those diagnosed with the following conditions: temporomandibular disorders (TMD), atypical facial pain, atypical odontalgia and burning mouth syndrome.

Sample size: N = 143 to 779 (depending on outcome)

Location/Setting: Sweden, USA, Germany, Spain, UK. Tertiary care clinics

 

Search: Seven databases (The Cochrane Oral Health Group Trials Register, CENTRAL, MEDLINE via OVID, EMBASE via OVID, PsycINFO via OVID, WHO International Clinical Trials Registry Platform and Clinical Trials.gov.); MeSH terms and key words.

Intervention: self-care biofeedback, self-care CBT and combined self-care biofeedback and CBT.

Control: usual care (conservative treatment - education, counselling, intraoral flat plane appliance).

Primary/secondary outcomes: pain intensity, depression/anxiety, interference with life

Measurements: Visual analogue or categorical scale (pain intensity); Long and short term validated scales (depression); Brief Pain Inventory and Multidimensional Pain Inventory (interference with life). Measure of effect – mean difference (MD)

Key Results

Comparison: any self‐management intervention versus usual care outcome – pain short term (3 months or less)
MD (Combined self-care biofeedback and CBT): 0.28 [-0.06; 0.63]
MD (Self-care biofeedback): -0.44 [-1.06; 0.25]
MD (Self-care CBT): -0.17 [-0.37; 0.03]

Comparison: any self‐management intervention versus usual care outcome – pain long term (>3 months)
MD (Combined self-care biofeedback and CBT): -0.46 [-0.72; -0.20]
MD (Self-care CBT): -0.26 [-0.45; -0.07]

Comparison: any self‐management intervention versus usual care outcome – depression long term (>3 months)
MD (Combined self-care biofeedback and CBT): -0.41 [-0.68; -0.13]
MD (Self-care CBT): -0.27 [-0.49; -0.05]

Evidence Comments

For all outcomes, the results are not clinically meaningful (Cohen’s d value threshold 0.5). For pain short term, pain long term and depression long term outcomes (self-care CBT), the results are clinically precise, showing there is no difference between two interventions. For all other outcomes, the results are not clinically precise, meaning more methodologically rigorous and well-powered studies are needed.

Strengths: RCT designs; seven databases; no publication year and language restriction; reference lists of all eligible trials were checked for additional studies. PRISMA diagram; three reviewers work independently; Cochrane tool for risk of bias assessment; publication bias assessment (Egger's test); GRADE approach for evidence quality assessment, meta-analysis.

Limitations: Caregivers in the studies included could not be blinded when performing the interventions. The importance of the components within the interventions was not acknowledged, all interventions were grouped into a psychosocial intervention; high risks of bias were found in individual studies for selection, performance and attrition biases.

Applicability

Applicability: The treatment of TMD disorders has long been a multiple-modality practice using physiotherapy, splint devices, stretching programs, self-management, behavioral intervention and medication, etc. Dentists are often unsure what the best treatment modality is in terms of improving symptoms and quality of life of these patients. The generalizability of the results may be increased by the fact that the interventions were conducted in diverse clinical settings and various countries with contrasting oral health care systems. The population of the studies, which include all adults over the age of 18, and the use of multiple psychosocial intervention modalities further allow for the generalizability of the interventions. The conventional treatments for TMD, such as splint therapy, and psychosocial interventions, such as CBT, are widely available and accessible treatment modalities, including in Canadian settings. Both short-term and long-term outcomes were assessed, allowing clinicians to understand the effects of such interventions over different periods of time. Some studies included were conducted in tertiary care clinics, which may reduce the generalizability of the results as patients in these settings are likely to represent the more severe and intractable cases of chronic orofacial pain and hence share common characteristics. Moreover, before generalizing these results, more high-powered studies need to be conducted given that the results were mostly clinically inconclusive. Cost effectiveness and adverse effects of the different treatment modalities were not evaluated in either meta-analysis, and should be addressed in future studies. Overall, there is no clear benefit or harm in the use of psychosocial interventions, and it is up to the dentist and the patient to determine which is the best course of action.

Authors: Stéphanie Guay, Ryan Booth, Jessica Italia, Nathaniel Weinstein (DMD3 students)

Faculty mentor(s): Z. Khatchadourian, S. Madathil, S. Tikhonova

Acknowledgments: Martin Morris (McGill librarian)

Date: 04/19/2020

 

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