List Meta Analisis

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Review Article Management of TMD: evidence from systematic reviews and meta-analyses T. LIST* & S. AXELSSON *Department of Stomatognathic Physiology, Faculty of Odontology, Malmo ¨ University, Malmo ¨ and The Swedish Council on Technology Assessment in Health and Care, Stockholm, Sweden 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 crite- ria and 30 were analysed: 23 qualitative SRs and seven meta-analyses. Ten SRs were related to occlu- sal appliances, occlusal adjustment or bruxism; eight to physical therapy; seven to pharmacologic treat- ment; 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 qual- ity 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 pharmacolog- ical treatments. Evidence for the effect of electro- physical 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 impos- sible. KEYWORDS: systematic review, randomised clinical trial, evidence-based medicine, treatment, assess- ment Accepted for publication 8 March 2010 Background Population-based studies among adults report that approximately 10–15% have temporomandibular dis- orders (TMD) pain and 5% a perceived need for treatment (1, 2). Several studies have pointed out that persistent and recurrent pain has a potential impact on daily life mainly in the areas of psychological discomfort, physical disability, and functional limita- tions – which leads to limitations in quality of life (3–6). Keeping current on new developments in a medical or dental field is often an imposing task for researchers and clinicians. One researcher estimated that to keep abreast of developments in his field, he would need to read about 17–20 original articles – as a daily average (7). Systematic reviews (SRs) are a cornerstone in evi- dence-based medicine. An SR is a compilation of all published research that addresses a carefully formulated question. Research results are collected based upon pre- determined inclusion and exclusion criteria; data are critically analysed and synthesised so that evidence- based conclusions on the benefit or risks of different methods can be drawn, with the final goal to improve patient care. An SR may have a qualitative approach if data from the primary studies are presented descriptively or a quantitative approach if statistical analysis has combined data in a meta-analysis. Of the over 24 ª 2010 Blackwell Publishing Ltd doi: 10.1111/j.1365-2842.2010.02089.x Journal of Oral Rehabilitation 2010 37; 430–451 Journal of Oral Rehabilitation

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  • Review Article

    Management of TMD: evidence from systematic reviews and

    meta-analyses

    T. LIST* & S. AXELSSON *Department of Stomatognathic Physiology, Faculty of Odontology, Malmo University, Malmo andThe Swedish Council on Technology Assessment in Health and Care, Stockholm, Sweden

    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 crite-

    ria and 30 were analysed: 23 qualitative SRs and

    seven meta-analyses. Ten SRs were related to occlu-

    sal appliances, occlusal adjustment or bruxism; eight

    to physical therapy; seven to pharmacologic treat-

    ment; four to TMJ and maxillofacial surgery; and six

    to behavioural therapy and multimodal treatment.

    The median AMSTAR score was 6 (range 211).

    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 qual-

    ity 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 pharmacolog-

    ical treatments. Evidence for the effect of electro-

    physical 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 impos-

    sible.

    KEYWORDS: systematic review, randomised clinical

    trial, evidence-based medicine, treatment, assess-

    ment

    Accepted for publication 8 March 2010

    Background

    Population-based studies among adults report that

    approximately 1015% have temporomandibular dis-

    orders (TMD) pain and 5% a perceived need for

    treatment (1, 2). Several studies have pointed out that

    persistent and recurrent pain has a potential impact on

    daily life mainly in the areas of psychological

    discomfort, physical disability, and functional limita-

    tions which leads to limitations in quality of life (36).

    Keeping current on new developments in a medical

    or dental field is often an imposing task for researchers

    and clinicians. One researcher estimated that to keep

    abreast of developments in his field, he would need to

    read about 1720 original articles as a daily average

    (7).

    Systematic reviews (SRs) are a cornerstone in evi-

    dence-based medicine. An SR is a compilation of all

    published research that addresses a carefully formulated

    question. Research results are collected based upon pre-

    determined inclusion and exclusion criteria; data are

    critically analysed and synthesised so that evidence-

    based conclusions on the benefit or risks of different

    methods can be drawn, with the final goal to improve

    patient care. An SR may have a qualitative approach if

    data from the primary studies are presented descriptively

    or a quantitative approach if statistical analysis has

    combined data in a meta-analysis. Of the over 24

    2010 Blackwell Publishing Ltd doi: 10.1111/j.1365-2842.2010.02089.x

    Journal of Oral Rehabilitation 2010 37; 430451

    J o u r n a l o f Oral Rehabilitation

  • instruments that have been developed to assess SR

    quality, one recent instrument deserves mention: assess-

    ment of multiple systematic reviews (AMSTAR) (8). This

    tool comprises 11 items and has good face and content

    validity for measuring methodological quality (9).

    This systematic review of published SRs that survey

    TMD management efficacy adds to these existing

    reviews by (i) synthesising recent evidence and (ii)

    assessing SR methodological quality.

    Methods

    Procedure

    Both authors selected the articles based on inclusion

    and exclusion criteria and independently read all titles

    and abstracts that were found in multiple searches to

    identify potentially eligible articles for inclusion. All

    potentially eligible SRs were then retrieved, and full-

    text articles were reviewed to determine whether they

    met inclusion criteria. Disagreement was resolved by

    discussion among the investigators. Authors were not

    contacted for missing information. The reviewers were

    experienced oro-facial pain specialist clinicians or

    methodologists in evidence-based medicine.

    The investigators independently evaluated the

    methodological quality of each identified SR using

    AMSTAR and level of research design (LRD) scoring.

    The following data were extracted: study design, diag-

    nosis, number of patients, types of intervention, outcome

    measures, results, quality score, and authors conclusion.

    Database search

    The search encompassed all the articles that were (i)

    indexed in PubMed, the Cochrane Library, and Bando-

    lier, (ii) published in English, Swedish, or German, and

    (iii) published between 1 January 1987 and 8 September

    2009. The search strategy was designed to identify SRs

    that focused on TMD management. The following search

    terms were used for PubMed: Craniomandibular disor-

    ders drug therapy [MeSH] OR Craniomandibular disor-ders surgery [MeSH] OR Craniomandibulardisorders surgery [MeSH] AND Review AND Meta-analysis [MeSH] AND Systematic review. For Coch-

    rane Library, the search strategy included the terms

    craniomandibular disorders and temporomandibular

    joint (TMJ). References in original articles and SRs were

    hand-searched to identify additional SRs.

    Inclusion criteria

    Besides the database search criteria listed previously,

    the selected articles must:

    1 Be an SR

    2 Focus on the management of TMD treatment

    Systematic reviews that covered oro-facial pain or

    TMD prevention besides TMD treatment effect were

    included.

    Exclusion criteria

    1 Dual publication

    2 Update of the SR by the same author in a later

    publication

    3 SR of orthodontic treatment focusing on develop-

    ment and not treatment of TMD

    4 Systematic reviews of SRs

    Quality assessment

    Two instruments were used to assess the methodolog-

    ical quality of the SRs: (i) AMSTAR and (ii) LRD.

    Shea et al. developed AMSTAR by evaluating the

    importance of 37 items commonly used in SR assess-

    ment and reducing these items to an 11-item instru-

    ment that addresses key domains in methodological

    qualities (8). Assessment of multiple systematic

    reviews is reported to have good face and content

    validity (9).

    Assessment of multiple systematic reviews appraises

    these key items:

    1 Was an a priori design provided?

    2 Was there duplicate study selection and data extrac-

    tion?

    3 Was a comprehensive literature search provided?

    4 Was the status of publication (i.e. grey literature)

    used as an inclusion criterion?

    5 Was a list of studies (included and excluded)

    provided?

    6 Were the characteristics of the included studies

    provided?

    7 Was the scientific quality of the included studies

    assessed and documented?

    8 Was the scientific quality of the included studies

    used appropriately in formulating conclusions?

    9 Were the methods used to combine the findings of

    studies appropriate?

    10 Was the likelihood of publication bias assessed?

    M A N A G E M E N T O F T M D 431

    2010 Blackwell Publishing Ltd

  • 11 Was the conflict of interest stated?

    Each of these 11 items was scored as Yes, No,

    Cant answer, or Not applicable.

    The LRD assesses internal validity of the primary

    studies based on design. The research design levels are

    structured hierarchically according to evidence strength

    (10):

    1 Systematic review of randomised clinical trials (RCTs)

    2 Randomised clinical trial

    3 Study without randomisation, such as a cohort study,

    casecontrol study

    4 A non-controlled study, such as cross-sectional study,

    case series, case reports

    5 Narrative review or expert opinion

    Reliability of quality assessment

    Both authors independently assessed SR quality to

    determine inter-test reliability. The inter-reliability of

    the two authors in assessing the quality of the SRs was

    calculated with kappa-statistics. All articles were dis-

    cussed to verify appraisal process until consensus was

    reached. Disagreements on individual item scores were

    resolved with discussion.

    Results

    Thirty-eight SRs were read in full text; 30 of these were

    included in this SR: 23 were qualitative SRs and seven

    were meta-analyses. Eight SRs were excluded after

    reading because upon closer scrutiny, they did not fulfil

    the inclusion criteria: three SRs had been updated in

    more recent SRs by the same author (1113), one study

    did not focus on TMD management (14), two SRs

    focused on development of TMD following orthodontic

    intervention (15, 16), and two SRs were SRs of SRs (17,

    18) (Fig. 1).

    Tables 15 list characteristics and assess quality of the

    included SRs. Although the most common diagnosis in

    the SRs was TMD, more specific TMD diagnoses such as

    disc displacements and myofascial pain were sometimes

    also reported. Two SRs focused on bruxism. Although it

    is in the TMD domain, bruxism differs from other TMD

    diagnoses: although it may be accompanied by pain,

    bruxism is not related to pain in many cases. The

    number of patients ranged from 0 to 7173 in the SRs.

    Twenty-nine SRs had pain intensity or pain reduction

    as primary outcome measures, 25 of the SRs reported

    clinical outcome measures such as jaw movement and

    tenderness pain on palpation, and 10 of the SRsincluded measures of psychological status, daily activ-

    ities, or quality of life. The median AMSTAR score was 6

    (range 211). The LRD scores for the SRs are as follows:

    Level III 2 SRs

    Level I-III 1 SR

    Level II 16 SRs

    Level IIIII 1 SR

    Level III 1 SR

    Level IIIV 9 SRs

    The SRs were divided into five treatment groups:

    1 Occlusal appliances, occlusal adjustment, and bruxism

    2 Physical treatment [acupuncture, transcutaneous

    electrical nerve stimulation (TENS), exercise, and

    mobilisation]

    3 Pharmacologic treatment

    4 TMJ and maxillofacial surgery

    5 Behavioural therapy and multimodal treatment

    Ten SRs evaluated occlusal appliances, occlusal

    adjustment, or bruxism (Table 1). Eight of these con-

    cerned TMD treatment (12, 1926), one the effect of

    Computerised search of databases, reference checking, abstracts:

    PubMed: 602 references Cochrane library: 19 references Bandolier: 1 reference Handsearch: 3 references

    625 references

    Abstracts excluded: 587 references

    Screening of articles applying inclusion criteria: 38 references

    Abstracts excluded: 8 references (1118)

    Articles included for quality assessment:

    30 references (1947, 65) (23) reported two SRs

    Fig. 1. Flow diagram of references included and excluded in the

    systematic review.

    T . L I S T & S . A X E L S S O N432

    2010 Blackwell Publishing Ltd

  • Table

    1.

    Ch

    ara

    cteri

    stic

    sof

    syst

    em

    ati

    cre

    vie

    ws

    (SR

    s)of

    occ

    lusa

    lappli

    an

    ces,

    occ

    lusa

    ladju

    stm

    en

    t,an

    dort

    hodon

    tic

    treatm

    en

    t

    Au

    thors

    ,year,

    refe

    ren

    ce

    Stu

    dy

    desi

    gn

    ,

    dia

    gn

    osi

    s,an

    d

    no.

    of

    pati

    en

    ts

    Inte

    rven

    tion

    (I)

    an

    dco

    ntr

    ol

    (C)

    gro

    ups

    Ou

    tcom

    e

    measu

    res

    Resu

    lts

    Qu

    ality

    score

    Au

    thors

    (A

    )co

    ncl

    usi

    on

    s

    Revie

    wers

    (R

    )co

    mm

    en

    ts

    San

    taca

    tteri

    na

    A

    1998

    (25)

    SR

    an

    d

    Meta

    -an

    aly

    sis

    of

    6R

    CTs

    Dis

    cdis

    pla

    cem

    en

    t

    wit

    hre

    du

    ctio

    n

    212

    pati

    en

    ts

    I1:

    Occ

    lusa

    l

    applian

    ce

    I2:

    reposi

    tion

    ing

    spli

    nt

    Pain

    redu

    ctio

    n

    TM

    Jcl

    ick

    I2bett

    er

    than

    I1

    for

    pain

    redu

    ctio

    n

    an

    dTM

    Jcl

    ick.

    AM

    STA

    R2

    LR

    DII

    -IV

    A:

    Aco

    mpari

    son

    betw

    een

    the

    two

    kin

    ds

    of

    treatm

    en

    th

    as

    dem

    on

    stra

    ted

    that

    the

    reposi

    tion

    ing

    spli

    nt

    ism

    ore

    eff

    ect

    ive

    both

    inth

    e

    reso

    luti

    on

    of

    the

    art

    icu

    lar

    clic

    kan

    din

    the

    reso

    luti

    on

    of

    the

    pain

    (P50%

    Tri

    gem

    inal

    neu

    ralg

    ia:

    I1si

    gn

    ifica

    ntl

    ybett

    er

    than

    C1

    TM

    D:

    modera

    te

    evid

    en

    ceth

    at

    I2an

    d

    I3are

    bett

    er

    than

    C1

    Aty

    pic

    al

    faci

    al

    pain

    :a

    modera

    teeff

    ect

    of

    I3

    com

    pare

    dw

    ith

    C1

    AM

    STA

    R4

    LR

    DII

    A:

    Apart

    from

    stu

    die

    son

    trig

    em

    inal

    neu

    ralg

    ia,

    there

    islitt

    leevid

    en

    cefo

    rph

    arm

    aco

    thera

    py

    in

    oro

    -faci

    al

    pain

    .

    R:

    Som

    eof

    the

    stu

    die

    ssh

    ow

    ed

    adif

    fere

    nce

    com

    pare

    dw

    ith

    con

    trols

    .Lim

    itati

    on

    sin

    the

    pri

    mary

    stu

    die

    sw

    ere

    small

    gro

    ups,

    hete

    rogen

    eou

    sou

    tcom

    em

    easu

    res,

    an

    dn

    o

    lon

    g-t

    erm

    foll

    ow

    -up.

    Lis

    tT

    2003

    (36)

    Qu

    ali

    tati

    ve

    SR

    of

    11

    RC

    Ts

    TM

    D,

    aty

    pic

    al

    faci

    al

    pain

    ,

    bu

    rnin

    gm

    ou

    th

    syn

    dro

    me

    368

    pati

    en

    ts

    I1:

    An

    alg

    esi

    cs

    I2:

    An

    tidepre

    ssan

    ts

    I3:

    Ben

    zodia

    zepin

    es

    I4:

    Mis

    cell

    an

    eou

    s

    (cort

    icost

    ero

    ids,

    sodiu

    m

    hyalu

    ron

    ate

    ,

    sum

    atr

    ipta

    n,

    coca

    ine)

    C1:

    Pla

    cebo

    Pain

    redu

    ctio

    n

    Glo

    bal

    impro

    vem

    en

    t

    Depre

    ssio

    nsc

    ale

    TM

    Dan

    daty

    pic

    al

    faci

    al

    pain

    :fe

    w

    stu

    die

    sfo

    un

    dbett

    er

    eff

    ect

    of

    I1-I

    4

    com

    pare

    dw

    ith

    C1

    Bu

    rnin

    gm

    ou

    th:

    I2=

    C1

    AM

    STA

    R7

    LR

    DII

    A:Th

    eco

    mm

    on

    use

    of

    an

    alg

    esi

    csin

    TM

    D,A

    FP,

    an

    dB

    MS

    isn

    ot

    support

    ed

    by

    scie

    nti

    fic

    evid

    en

    ce.

    R:

    Th

    est

    udie

    sare

    too

    hete

    rogen

    eou

    sto

    dra

    w

    an

    yco

    ncl

    usi

    on

    sfr

    om

    .

    SB

    U

    2006

    (23)

    Qu

    ali

    tati

    ve

    SR

    of

    1SR

    an

    d

    13

    RC

    Ts

    TM

    D,

    aty

    pic

    al

    faci

    al

    pain

    ,

    bu

    rnin

    gm

    ou

    th

    syn

    dro

    me

    968

    pati

    en

    ts

    I1:

    An

    alg

    esi

    cs

    I2:

    An

    tidepre

    ssan

    ts

    I3:

    Ben

    zodia

    zepin

    es

    I4:

    Mis

    cell

    an

    eou

    s

    (cort

    icost

    ero

    ids,

    sodiu

    m

    hyalu

    ron

    ate

    ,

    sum

    atr

    ipta

    n,

    capsa

    icin

    ,

    botu

    lin

    um

    toxin

    )

    C1:

    Pla

    cebo

    Pain

    redu

    ctio

    nTM

    Dan

    daty

    pic

    al

    faci

    al

    pain

    :fe

    w

    stu

    die

    sfo

    un

    dbett

    er

    eff

    ect

    of

    I1I4

    com

    pare

    dw

    ith

    C1

    For

    bu

    rnin

    gm

    ou

    th,

    I=

    C1

    AM

    STA

    R6

    LR

    DI

    II

    A:

    Stu

    die

    son

    ph

    arm

    aco

    logic

    al

    treatm

    en

    tof

    TM

    D,

    aty

    pic

    al

    faci

    al

    pain

    ,an

    dbu

    rnin

    gm

    ou

    th

    syn

    dro

    me

    report

    con

    tradic

    tory

    resu

    lts.

    No

    con

    clu

    sion

    sca

    nbe

    dra

    wn

    as

    the

    stu

    die

    sare

    hete

    rogen

    eou

    sre

    gard

    ing

    dia

    gn

    osi

    san

    d

    treatm

    en

    tm

    eth

    od.

    R:

    Revie

    wers

    an

    dau

    thors

    are

    iden

    tica

    lpers

    on

    s

    M A N A G E M E N T O F T M D 439

    2010 Blackwell Publishing Ltd

  • Table

    3.

    (Con

    tinued

    )

    Au

    thors

    ,year,

    refe

    ren

    ce

    Stu

    dy

    desi

    gn

    ,

    dia

    gn

    osi

    s,an

    d

    no.

    of

    pati

    en

    ts

    Inte

    rven

    tion

    (I)

    an

    dco

    ntr

    ol

    (C)

    gro

    ups

    Ou

    tcom

    e

    measu

    res

    Resu

    lts

    Qu

    ali

    ty

    score

    Au

    thors

    (A

    )co

    ncl

    usi

    on

    s

    Revie

    wers

    (R

    )co

    mm

    en

    ts

    Sh

    iZC

    2009

    (37)

    SR

    an

    d

    meta

    -an

    aly

    sis

    of

    7R

    CTs

    TM

    D,

    rheu

    mato

    id

    art

    hri

    tis

    364

    pati

    en

    ts

    I1:

    Hyalu

    ron

    ate

    I2:

    Hyalu

    ron

    ate

    +

    Art

    hro

    scopy

    lavage

    C1:

    Pla

    cebo

    C2:

    Gly

    coco

    rtic

    oid

    C3:

    Art

    hro

    scopy

    lavage

    Sym

    pto

    ms

    (e.g

    .pain

    ,

    Cli

    nic

    al

    exam

    inati

    on

    Advers

    eeven

    ts

    Lon

    g-t

    erm

    eff

    ect

    s

    favou

    rI1

    com

    pare

    d

    toC

    1

    I1h

    ad

    the

    sam

    e

    lon

    g-t

    erm

    eff

    ect

    son

    sym

    pto

    ms

    an

    dcl

    inic

    al

    sign

    sco

    mpare

    dto

    C2

    Com

    pari

    ng

    I1to

    C3,

    resu

    lts

    were

    inco

    nsi

    sten

    t

    AM

    STA

    R11

    LR

    DII

    A:

    Th

    ere

    isin

    suffi

    cien

    tco

    nsi

    sten

    tevid

    en

    ceto

    support

    or

    refu

    teth

    eu

    seof

    hyalu

    ron

    ate

    for

    treati

    ng

    pati

    en

    tsw

    ith

    TM

    D.

    R:

    Meth

    odolo

    gic

    al

    weakn

    ess

    es

    of

    pri

    mary

    stu

    die

    ssu

    chas

    dia

    gn

    ost

    iccr

    iteri

    aof

    TM

    Dan

    d

    ou

    tcom

    em

    easu

    res

    inth

    est

    udy.

    Al-

    Mu

    harr

    aqi

    MA

    2009

    (38)

    SR

    an

    d

    meta

    -an

    aly

    sis

    of

    RC

    Ts

    No

    stu

    die

    s

    incl

    uded

    Mass

    ete

    r

    hypert

    roph

    y

    0pati

    en

    ts

    I1:

    Botu

    lin

    um

    toxin

    C1:

    Pla

    cebo

    Self

    -report

    ed

    faci

    al

    appeara

    nce

    Pain

    an

    d

    dis

    com

    fort

    167

    refe

    ren

    ces

    were

    retr

    ieved,

    bu

    tn

    on

    e

    matc

    hed

    the

    incl

    usi

    on

    crit

    eri

    a.

    AM

    STA

    R7

    LR

    DII

    A:

    No

    ran

    dom

    ised

    tria

    lon

    the

    effi

    cacy

    of

    intr

    a-m

    usc

    ula

    rin

    ject

    ion

    sof

    botu

    lin

    um

    toxin

    wit

    hbil

    ate

    ral

    ben

    ign

    mass

    ete

    rh

    ypert

    roph

    y

    was

    iden

    tifi

    ed.

    R:

    No

    tren

    dof

    the

    eff

    ect

    can

    be

    dra

    wn

    beca

    use

    all

    stu

    die

    sw

    ere

    excl

    uded.

    Casc

    os-

    Rom

    ero

    J

    2009

    (39)

    Qu

    alita

    tive

    SR

    of

    1SR

    ,

    1R

    CT

    an

    d1

    case

    co

    ntr

    ol

    stu

    dy

    TM

    D

    pati

    en

    ts*

    I1:

    An

    tidepre

    ssan

    ts

    C1:

    Pla

    cebo

    Pain

    I1bett

    er

    than

    C1

    AM

    STA

    R4

    LR

    DI

    III

    A:

    Th

    eu

    seof

    tric

    ycl

    ican

    tidepre

    ssan

    tsfo

    rth

    e

    treatm

    en

    tof

    TM

    Dis

    reco

    mm

    en

    ded.

    R:

    Syn

    thesi

    sof

    resu

    lts

    from

    pri

    mary

    stu

    die

    sare

    mis

    sin

    g,

    an

    dth

    ere

    fore

    ,beca

    use

    of

    lim

    itati

    on

    s

    inth

    eSR

    ,it

    isdif

    ficu

    ltto

    dra

    wan

    y

    con

    clu

    sion

    s.

    Ihde

    S2007

    (40)

    Qu

    alita

    tive

    SR

    of

    1R

    CT

    an

    d

    10

    case

    seri

    es

    TM

    D

    Bru

    xis

    m

    Mass

    ete

    r

    hypert

    roph

    y

    Oro

    -man

    dib

    ula

    r

    dyst

    on

    ia

    402

    pati

    en

    ts

    I1:

    Botu

    lin

    um

    toxin

    C1

    Pla

    cebo

    Pain

    redu

    ctio

    n

    Jaw

    open

    ing

    Fu

    nct

    ion

    al

    impro

    vem

    en

    t

    Aest

    heti

    cre

    sult

    I1bett

    er

    than

    C1

    for

    redu

    cin

    gpain

    base

    d

    on

    on

    eR

    CT.

    No

    syn

    thesi

    sof

    resu

    lts.

    AM

    STA

    R3

    LR

    DII

    -IV

    A:

    Botu

    lin

    um

    toxin

    appears

    rela

    tive

    safe

    an

    d

    eff

    ect

    ive

    intr

    eati

    ng

    chro

    nic

    faci

    al

    pain

    ass

    oci

    ate

    dw

    ith

    mast

    icato

    ryh

    ypera

    ctiv

    ity.

    R:

    Meth

    odolo

    gic

    al

    lim

    itati

    on

    sin

    the

    SR

    .

    Resu

    lts

    on

    lyre

    late

    toon

    eR

    CT

    stu

    dy.

    Syn

    thesi

    sof

    resu

    lts

    mis

    sin

    gso

    aco

    ncl

    usi

    on

    of

    the

    eff

    ect

    of

    Botu

    lin

    um

    toxin

    isdif

    ficu

    ltto

    dete

    rmin

    e

    AM

    STA

    R,

    ass

    ess

    men

    tof

    mu

    ltip

    lesy

    stem

    ati

    cre

    vie

    ws;

    LR

    D,

    level

    of

    rese

    arc

    hdesi

    gn

    ;R

    CT,

    ran

    dom

    ised

    clin

    ical

    tria

    ls;

    TM

    D,

    tem

    poro

    man

    dib

    ula

    rdis

    ord

    ers

    .

    *Nu

    mber

    of

    pati

    en

    tsn

    ot

    report

    ed.

    T . L I S T & S . A X E L S S O N440

    2010 Blackwell Publishing Ltd

  • Table

    4.

    Ch

    ara

    cteri

    stic

    sof

    syst

    em

    ati

    cre

    vie

    ws

    (SR

    s)of

    the

    TM

    Jan

    dm

    axillo

    faci

    al

    surg

    ery

    Au

    thors

    ,year,

    refe

    ren

    ce

    Stu

    dy

    desi

    gn

    ,

    dia

    gn

    osi

    s,an

    d

    no.

    of

    pati

    en

    ts

    Inte

    rven

    tion

    (I)

    an

    d

    con

    trol

    (C)

    gro

    ups

    Ou

    tcom

    e

    measu

    res

    Resu

    lts

    Qu

    ali

    ty

    score

    Au

    thors

    (A

    )co

    ncl

    usi

    on

    s

    Revie

    wers

    (R

    )co

    mm

    en

    ts

    Rest

    on

    JT

    2003

    (41)

    SR

    an

    d

    meta

    -an

    aly

    sis

    of

    30

    stu

    die

    s(3

    RC

    Ts

    an

    d27

    un

    con

    troll

    ed

    stu

    die

    s)

    Dis

    cdis

    pla

    cem

    en

    t

    wit

    hre

    du

    ctio

    n,

    Dis

    cdis

    pla

    cem

    en

    t

    wit

    hou

    tre

    du

    ctio

    n

    1463

    pati

    en

    ts

    I1:

    Art

    hro

    cen

    tesi

    s

    I2:

    Art

    hro

    scopy

    I3:

    Dis

    c

    repair

    reposi

    tion

    ing

    I4:

    Dis

    cect

    om

    y

    Pain

    redu

    ctio

    n

    Glo

    bal

    impro

    vem

    en

    t

    Jaw

    mobil

    ity

    Dis

    cdis

    pla

    cem

    en

    t

    wit

    hre

    du

    ctio

    n:

    I2an

    dI3

    com

    para

    ble

    resu

    lts

    Dis

    cdis

    pla

    cem

    en

    t

    wit

    hou

    tre

    du

    ctio

    n:

    Sim

    ilar

    resu

    lts

    for

    I1,

    I2,

    an

    dI3

    AM

    STA

    R4

    LR

    DII

    IV

    (most

    stu

    die

    s,

    level

    IV)

    A:

    Su

    rgic

    al

    treatm

    en

    tappears

    topro

    vid

    eso

    me

    ben

    efi

    tto

    pati

    en

    tsre

    fract

    ory

    ton

    on

    -su

    rgic

    al

    thera

    pie

    s.Th

    em

    ost

    reli

    able

    evid

    en

    cesu

    pport

    sth

    e

    eff

    ect

    iven

    ess

    of

    art

    hro

    cen

    tesi

    san

    dart

    hro

    scopy

    for

    pati

    en

    tsw

    ith

    dis

    cdis

    pla

    cem

    en

    tw

    ith

    redu

    ctio

    n.

    R:

    Meth

    odolo

    gic

    al

    weakn

    ess

    es

    of

    pri

    mary

    stu

    die

    s

    such

    as

    hete

    rogen

    eou

    spati

    en

    tm

    ate

    rial,

    ou

    tcom

    e

    measu

    res

    not

    clearl

    ydefi

    ned,

    an

    dm

    ajo

    rity

    of

    the

    stu

    die

    sw

    ere

    not

    RC

    Ts.

    Kro

    pm

    an

    sTJ

    1999

    (42)

    Qu

    alita

    tive

    SR

    of

    24

    stu

    die

    s(6

    RC

    Ts

    an

    d6

    case

    co

    ntr

    ol

    an

    d12

    un

    con

    troll

    ed

    stu

    die

    s)

    Dis

    cdis

    pla

    cem

    en

    t

    wit

    hou

    tre

    du

    ctio

    n

    4916

    pati

    en

    ts

    I1:

    Art

    hro

    scopy

    I2:

    Art

    hro

    cen

    tesi

    s

    I3:

    Ph

    ysi

    cal

    thera

    py

    (e.g

    .exerc

    ise,

    mass

    age,

    TE

    NS)

    C1:

    Pla

    cebo

    C2:

    No

    treatm

    en

    t

    Pain

    inte

    nsi

    ty

    Jaw

    fun

    ctio

    n

    Jaw

    mobil

    ity

    No

    syn

    thesi

    sof

    resu

    lts

    pre

    sen

    ted

    AM

    STA

    R2

    LR

    DII

    IV

    A:

    No

    dis

    tin

    gu

    ish

    ing

    eff

    ect

    son

    jaw

    mobil

    ity,

    jaw

    fun

    ctio

    n,

    or

    pain

    inte

    nsi

    tyw

    as

    seen

    betw

    een

    art

    hro

    scopic

    surg

    ery

    ,art

    hro

    cen

    tesi

    s,an

    dph

    ysi

    cal

    thera

    py

    inpati

    en

    tsw

    ith

    perm

    an

    en

    t

    tem

    poro

    man

    dib

    ula

    rjo

    int

    dis

    cdis

    pla

    cem

    en

    t.

    R:

    Meth

    odolo

    gic

    al

    weakn

    ess

    es

    of

    pri

    mary

    stu

    die

    s

    such

    as

    dia

    gn

    ost

    iccr

    iteri

    aof

    TM

    Dan

    dou

    tcom

    e

    measu

    res

    inth

    est

    udy.

    Am

    ajo

    rity

    of

    the

    stu

    die

    s

    are

    LR

    Dle

    vel

    IV,

    an

    dth

    ere

    fore

    ,it

    not

    poss

    ible

    to

    dra

    wan

    ycl

    ear

    con

    clu

    sion

    sfr

    om

    this

    SR

    .

    Abra

    ham

    sson

    C

    2007

    (44)

    Qu

    alita

    tive

    SR

    of

    3

    case

    co

    ntr

    ol

    stu

    die

    s

    280

    pati

    en

    ts

    I1:

    Bil

    ate

    ral

    sagit

    tal

    spli

    tan

    do

    rLe

    Fort

    Iost

    eoto

    my

    C1:

    No

    treatm

    en

    t

    Self

    -report

    of

    sym

    pto

    ms

    Cli

    nic

    al

    exam

    inati

    on

    Con

    tradic

    tory

    resu

    lts

    insi

    gn

    s

    an

    dsy

    mpto

    ms

    AM

    STA

    R8

    LR

    DII

    I

    A:

    Beca

    use

    of

    few

    stu

    die

    sw

    ith

    un

    am

    big

    uou

    s

    resu

    lts

    an

    dh

    ete

    rogen

    eit

    yin

    stu

    dy

    desi

    gn

    ,th

    e

    scie

    nti

    fic

    evid

    en

    cew

    as

    insu

    ffici

    en

    tto

    evalu

    ate

    the

    eff

    ect

    sth

    at

    ort

    hogn

    ath

    icsu

    rgery

    had

    on

    TM

    D.

    R:

    Well

    -desi

    gn

    ed

    SR

    .M

    eth

    odolo

    gic

    al

    weakn

    ess

    es

    of

    pri

    mary

    stu

    die

    ssu

    chas

    dia

    gn

    ost

    iccr

    iteri

    aof

    TM

    Dan

    dou

    tcom

    em

    easu

    res

    inth

    est

    udy.

    M A N A G E M E N T O F T M D 441

    2010 Blackwell Publishing Ltd

  • Table

    4.

    (Con

    tinued

    )

    Au

    thors

    ,year,

    refe

    ren

    ce

    Stu

    dy

    desi

    gn

    ,

    dia

    gn

    osi

    s,an

    d

    no.

    of

    pati

    en

    ts

    Inte

    rven

    tion

    (I)

    an

    d

    con

    trol

    (C)

    gro

    ups

    Ou

    tcom

    e

    measu

    res

    Resu

    lts

    Qu

    ali

    ty

    score

    Au

    thors

    (A

    )co

    ncl

    usi

    on

    s

    Revie

    wers

    (R

    )co

    mm

    en

    ts

    Al-

    Bela

    syFA

    2007

    (43)

    Qu

    alita

    tive

    SR

    of

    19

    Stu

    die

    s

    (2R

    CTs

    an

    d6

    case

    co

    ntr

    ol

    an

    d

    11

    un

    con

    trolled

    stu

    die

    s)

    An

    chore

    ddis

    c

    ph

    en

    om

    en

    on

    ,

    Dis

    cdis

    pla

    cem

    en

    t

    wit

    hor

    wit

    hou

    t

    redu

    ctio

    n,

    capsu

    liti

    s

    syn

    ovit

    is.

    571

    pati

    en

    ts

    I1:

    Art

    hro

    cen

    tesi

    s

    C1:

    Not

    speci

    fied

    Pain

    inte

    nsi

    ty

    Jaw

    mobil

    ity

    Cli

    nic

    al

    exam

    inati

    on

    Overa

    llsu

    ccess

    vari

    ed

    betw

    een

    60%

    -100%

    .

    No

    com

    pari

    son

    betw

    een

    I1

    an

    dC

    1.

    AM

    STA

    R2

    LR

    DII

    -IV

    A:

    Th

    em

    ajo

    rity

    of

    the

    revie

    wed

    pu

    bli

    cati

    on

    sw

    ere

    pro

    spect

    ive

    case

    seri

    es

    wit

    hfl

    aw

    ed

    meth

    odolo

    gy

    an

    d,

    desp

    ite

    the

    impre

    ssio

    nth

    at

    art

    hro

    cen

    tesi

    s

    may

    be

    ben

    efi

    cial

    for

    pati

    en

    tsw

    ith

    TM

    Jcl

    ose

    d

    lock

    ,th

    ere

    have

    been

    no

    good

    pro

    spect

    ive

    ran

    dom

    ised

    clin

    ical

    tria

    lco

    nfi

    rmth

    eeffi

    cacy

    of

    the

    pro

    cedu

    re.

    R:

    Th

    eovera

    llsu

    ccess

    rate

    was

    hig

    hfr

    om

    the

    pri

    mary

    stu

    die

    s.Th

    ere

    sult

    sare

    dif

    ficu

    ltto

    inte

    rpre

    tbeca

    use

    of

    meth

    odolo

    gic

    al

    weakn

    ess

    es

    of

    pri

    mary

    stu

    die

    ssu

    chas

    dia

    gn

    ost

    iccr

    iteri

    aof

    TM

    D,

    ou

    tcom

    em

    easu

    res,

    mis

    sin

    gan

    aly

    sis

    betw

    een

    Inte

    rven

    tion

    an

    dco

    ntr

    ol

    treatm

    en

    tin

    the

    stu

    die

    s.In

    addit

    ion

    ,a

    majo

    rity

    of

    the

    stu

    die

    s

    pati

    en

    tsre

    ceiv

    ed

    com

    ple

    men

    tary

    ph

    arm

    aco

    logic

    or

    con

    serv

    ati

    ve

    treatm

    en

    tbesi

    des

    lavage.

    Th

    e

    majo

    rity

    of

    the

    stu

    die

    sare

    LR

    Dle

    vel

    IV,

    an

    d

    there

    fore

    ,it

    not

    poss

    ible

    todra

    wan

    ycl

    ear

    con

    clu

    sion

    sfr

    om

    this

    SR

    .

    AM

    STA

    R,

    ass

    ess

    men

    tof

    mu

    ltip

    lesy

    stem

    ati

    cre

    vie

    ws;

    LR

    D,

    level

    of

    rese

    arc

    hdesi

    gn

    ;R

    CT,

    ran

    dom

    ised

    clin

    ical

    tria

    ls;

    TM

    D,

    tem

    poro

    man

    dib

    ula

    rdis

    ord

    ers

    .

    T . L I S T & S . A X E L S S O N442

    2010 Blackwell Publishing Ltd

  • Table

    5.

    Ch

    ara

    cteri

    stic

    sof

    syst

    em

    ati

    cre

    vie

    ws

    (SR

    s)of

    beh

    avio

    ura

    lth

    era

    py

    an

    dm

    ult

    imodal

    treatm

    en

    ts

    Au

    thors

    ,year,

    refe

    ren

    ce

    Stu

    dy

    desi

    gn

    ,

    dia

    gn

    osi

    s,an

    dn

    o.

    of

    pati

    en

    ts

    Inte

    rven

    tion

    (I)

    an

    d

    con

    trol

    (C)

    gro

    ups

    Ou

    tcom

    e

    measu

    res

    Resu

    lts

    Qu

    ality

    score

    Au

    thors

    (A

    )co

    ncl

    usi

    on

    s

    Revie

    wers

    (R

    )co

    mm

    en

    ts

    Cri

    der

    AB

    1999

    (45)

    SR

    an

    d

    meta

    -an

    aly

    sis

    of

    13

    RC

    Ts

    an

    d

    un

    -con

    troll

    ed

    stu

    die

    s

    TM

    D

    pati

    en

    ts*

    I1:

    Ele

    ctro

    myogra

    ph

    ic

    bio

    feedback

    C1:

    Act

    ive

    con

    trol

    C2:

    No

    treatm

    en

    tor

    pla

    cebo

    Pain

    redu

    ctio

    n

    Cli

    nic

    al

    sign

    sof

    dysf

    un

    ctio

    n

    Glo

    bal

    ass

    ess

    men

    t

    Pain

    redu

    ctio

    nan

    d

    clin

    ical

    sign

    s:I1

    bett

    er

    than

    C1

    an

    dC

    2

    AM

    STA

    R4

    LR

    DII

    -IV

    A:

    Alt

    hou

    gh

    lim

    ited

    inexte

    nt,

    the

    avail

    able

    data

    support

    the

    effi

    cacy

    of

    EM

    Gbio

    feedback

    treatm

    en

    tsfo

    rTM

    D.

    R:

    Meth

    odolo

    gic

    al

    weakn

    ess

    es

    of

    pri

    mary

    stu

    die

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    rogen

    eou

    spati

    en

    t

    mate

    rial,

    ou

    tcom

    em

    easu

    res

    not

    clearl

    y

    defi

    ned,

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    dse

    vera

    lst

    udie

    sw

    ere

    not

    RC

    Ts.

    Jedel

    E

    2003

    (30)

    Qu

    alita

    tive

    SR

    of

    7R

    CTs

    TM

    D

    379

    pati

    en

    ts

    I1:

    Bio

    feedback

    I2:

    Acu

    pu

    nct

    ure

    I3:

    TE

    NS

    C1:

    No

    treatm

    en

    t

    C2:

    Oth

    er

    treatm

    en

    t

    Self

    -report

    ed

    sym

    pto

    ms

    Pain

    inte

    nsi

    ty

    Cli

    nic

    al

    exam

    inati

    on

    No

    evid

    en

    ceof

    an

    eff

    ect

    for

    an

    y

    treatm

    en

    tm

    ode

    AM

    STA

    R3

    LR

    DII

    A:

    Th

    est

    udie

    sw

    ere

    hete

    rogen

    eou

    sw

    ith

    low

    qu

    ali

    ty,

    an

    dth

    ere

    fore

    ,it

    isn

    ot

    poss

    ible

    to

    dra

    wan

    yco

    ncl

    usi

    on

    s.

    R:

    Lim

    itati

    on

    sin

    the

    SR

    meth

    odolo

    gy

    an

    d

    there

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    ficu

    ltto

    dra

    wan

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    ncl

    usi

    on

    s

    Cri

    der

    AB

    2005

    (46)

    Qu

    alita

    tive

    SR

    of

    6R

    CTs

    TM

    D

    449

    pati

    en

    ts

    I1:

    Bio

    feedback

    train

    ing

    I2:

    Bio

    feedback

    train

    ing

    +C

    BT

    I3:

    Bio

    feedback

    -

    ass

    iste

    dre

    laxati

    on

    train

    ing

    I4:

    Alt

    ern

    ati

    ve

    treatm

    en

    t

    C1:

    Sh

    am

    treatm

    en

    t

    C2:

    No

    treatm

    en

    t

    Pain

    inte

    nsi

    ty

    Glo

    bal

    impro

    vem

    en

    t

    Lim

    itati

    on

    inja

    w

    fun

    ctio

    n

    Depre

    ssio

    n

    Cli

    nic

    al

    exam

    inati

    on

    I1w

    as

    superi

    or

    to

    C1

    inon

    eof

    two

    RC

    Ts

    I2w

    as

    sign

    ifica

    ntl

    y

    bett

    er

    than

    C2

    an

    dI4

    I3w

    as

    bett

    er

    than

    C2

    I3w

    as

    bett

    er

    than

    I4in

    on

    eof

    two

    RC

    Ts

    AM

    STA

    R3

    LR

    DII

    II

    I

    A:

    Bio

    feedback

    train

    ing

    wit

    hadju

    nct

    ive

    CB

    T

    was

    report

    ed

    tobe

    an

    effi

    caci

    ou

    str

    eatm

    en

    tfo

    r

    TM

    D;

    both

    bio

    feedback

    train

    ing

    as

    the

    sole

    inte

    rven

    tion

    an

    dbio

    feedback

    -ass

    iste

    d

    rela

    xati

    on

    train

    ing

    are

    pro

    bably

    effi

    caci

    ou

    s

    treatm

    en

    ts.

    R:

    Sm

    all

    stu

    die

    s,n

    olo

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    erm

    follow

    -up.

    Meth

    odolo

    gic

    al

    lim

    itati

    on

    sin

    SR

    .

    SB

    U(2

    3)

    Qu

    alita

    tive

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    of

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    s

    an

    d6

    RC

    Ts

    TM

    D

    XX

    pati

    en

    ts

    I1:

    CB

    T

    I2:

    Bio

    feedback

    I3:

    Edu

    cati

    on

    I4:

    Edu

    cati

    on

    +h

    om

    e

    inst

    ruct

    ion

    C1:

    Bri

    ef

    info

    rmati

    on

    C2.

    No

    treatm

    en

    t

    C3:

    Con

    ven

    tion

    al

    treatm

    en

    t

    Pan

    inte

    nsi

    ty

    Dail

    yact

    ivit

    ies

    Depre

    ssio

    n

    Sle

    ep

    qu

    ali

    ty

    I1w

    as

    bett

    er

    than

    C1

    an

    dC

    3

    I2w

    as

    bett

    er

    than

    C2

    I3w

    as

    sim

    ilar

    toI4

    AM

    STA

    R6

    LR

    DI

    II

    A:

    Beh

    avio

    ura

    ltr

    eatm

    en

    tsu

    chas

    bio

    feedback

    an

    dC

    BT

    have

    bett

    er

    eff

    ect

    than

    no

    treatm

    en

    t.

    R:

    Revie

    wers

    an

    dau

    thors

    are

    iden

    tica

    lpers

    on

    s

    M A N A G E M E N T O F T M D 443

    2010 Blackwell Publishing Ltd

  • Table

    5.

    (Con

    tinued

    )

    Au

    thors

    ,year,

    refe

    ren

    ce

    Stu

    dy

    desi

    gn

    ,

    dia

    gn

    osi

    s,an

    dn

    o.

    of

    pati

    en

    ts

    Inte

    rven

    tion

    (I)

    an

    d

    con

    trol

    (C)

    gro

    ups

    Ou

    tcom

    e

    measu

    res

    Resu

    lts

    Qu

    ali

    ty

    score

    Au

    thors

    (A

    )co

    ncl

    usi

    on

    s

    Revie

    wers

    (R

    )co

    mm

    en

    ts

    McN

    eely

    M

    2006

    (33)

    Qu

    ali

    tati

    ve

    SR

    of

    4R

    CTs

    TM

    D

    207

    pati

    en

    ts

    I1:

    CB

    T

    I2:

    Bio

    feedback

    I3:

    Rela

    xati

    on

    C1:

    Occ

    lusa

    lsp

    lin

    t

    C2:

    No

    treatm

    en

    t

    Pain

    redu

    ctio

    n

    Jaw

    mobil

    ity

    Pain

    redu

    ctio

    n:

    I1

    bett

    er

    than

    C2

    I2si

    mil

    ar

    eff

    ect

    toC

    1

    I2an

    dI3

    sim

    ilar

    eff

    ect

    AM

    STA

    R7

    LR

    DII

    A:Pro

    gra

    mm

    es

    involv

    ing

    rela

    xati

    on

    tech

    niq

    ues

    an

    dbio

    feedback

    ,ele

    ctro

    myogra

    ph

    ictr

    ain

    ing,

    an

    dpro

    pri

    oce

    pti

    ve

    re-e

    du

    cati

    on

    may

    be

    more

    eff

    ect

    ive

    than

    pla

    cebo

    treatm

    en

    tor

    occ

    lusa

    l

    spli

    nts

    .

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    Stu

    die

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    ad

    small

    nu

    mbers

    of

    part

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    an

    ts

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    tcom

    em

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    res

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    ydefi

    ned,

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    isdif

    ficu

    ltto

    dra

    wan

    yco

    ncl

    usi

    on

    s.

    Tu

    rpJ

    2007

    (47)

    Qu

    ali

    tati

    ve

    SR

    of

    11

    RC

    Ts

    TM

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    Dis

    cdis

    pla

    cem

    en

    t

    wit

    hou

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    du

    ctio

    n,

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    hpain

    TM

    Dpain

    ,w

    ith

    ou

    t

    majo

    r

    psy

    cholo

    gic

    al

    sym

    pto

    ms

    TM

    Dpain

    ,w

    ith

    majo

    r

    psy

    cholo

    gic

    al

    sym

    pto

    ms

    895

    pati

    en

    ts

    I1:

    Sim

    ple

    treatm

    en

    t

    I2:

    Mu

    ltim

    odal

    treatm

    en

    t

    Pain

    inte

    nsi

    ty

    Gra

    ded

    Ch

    ron

    ic

    Pain

    Sca

    le

    An

    alg

    esi

    c

    con

    sum

    pti

    on

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    cholo

    gic

    statu

    s

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    thre

    shold

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    cdis

    pla

    cem

    en

    t

    wit

    hou

    tre

    du

    ctio

    n

    wit

    hpain

    :I1

    =I2

    .

    TM

    Dpain

    ,w

    ith

    ou

    t

    majo

    r

    psy

    cholo

    gic

    al

    sym

    pto

    ms:

    I1=

    I2

    TM

    Dpain

    ,w

    ith

    majo

    r

    psy

    cholo

    gic

    al

    sym

    pto

    ms:

    I2bett

    er

    than

    I1.

    AM

    STA

    R4

    LR

    DII

    A:

    Cu

    rren

    tre

    searc

    hsu

    ggest

    sth

    at

    indiv

    idu

    als

    wit

    hou

    tm

    ajo

    rpsy

    cholo

    gic

    alsy

    mpto

    ms

    do

    not

    requ

    ire

    more

    than

    sim

    ple

    thera

    py.In

    con

    trast

    ,

    pati

    en

    tsw

    ith

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    rpsy

    cholo

    gic

    al

    involv

    em

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    tn

    eed

    mu

    ltim

    odal,

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    rdis

    cipli

    nary

    thera

    peu

    tic

    stra

    tegie

    s.

    R:

    Meth

    odolo

    gic

    al

    weakn

    ess

    es

    of

    pri

    mary

    stu

    die

    ssu

    chas

    dia

    gn

    ost

    iccr

    iteri

    aof

    TM

    D,

    poor

    desc

    ripti

    on

    of

    how

    the

    treatm

    en

    tw

    as

    con

    du

    cted,

    an

    dou

    tcom

    em

    easu

    res

    inth

    e

    stu

    dy

    AM

    STA

    R,ass

    ess

    men

    tof

    mu

    ltip

    lesy

    stem

    ati

    cre

    vie

    ws;

    CB

    T,co

    gn

    itiv

    ebeh

    avio

    ura

    lth

    era

    py;LR

    D,le

    velof

    rese

    arc

    hdesi

    gn

    ;R

    CT,ra

    ndom

    ised

    clin

    icaltr

    ials

    ;TM

    D,te

    mporo

    man

    dib

    ula

    r

    dis

    ord

    ers

    .

    *Nu

    mber

    of

    pati

    en

    tsn

    ot

    report

    ed.

    T . L I S T & S . A X E L S S O N444

    2010 Blackwell Publishing Ltd

  • inclusion criteria because of limitations in the quality

    of the studies.

    Three SRs evaluated surgical treatment of the TMJ in

    patients with disc displacements (4143) and one SR

    orthognathic surgery in patients with TMD (44)

    (Table 4). In patients with disc displacements with

    reduction, one SR reported similar treatment effects for

    arthrocentesis, arthroscopy, and discectomy. In patients

    with disc displacement without reduction, one SR

    reported similar effect for arthrocentesis, arthroscopy,

    and physical therapy. One SR reported overall high

    success rate for arthrocentesis but made no comparison

    of arthrocentesis with other interventions. In patients

    with TMD pain, one SR reported contradictory results

    following orthognathic surgery. But all SRs included in

    these SRs had low levels of evidence.

    Five SRs evaluated the treatment of various behavio-

    ural therapies in patients with TMD (23, 30, 33, 45, 46),

    and one SR analysed the effect of multimodal and

    simple treatment in TMD (47) (Table 5). Biofeedback

    was reported to be (i) better than active control or no

    treatment (two SRs), (ii) better than no treatment

    when administered in combination with cognitive

    behavioural therapy (CBT) or relaxation (two SRs),

    and (iii) similar in effect compared with relaxation

    training (one SR). Cognitive behavioural therapy was

    reported to be (i) better than conventional treatment

    (two SRs) and (ii) better than no treatment (one SR).

    Education at the clinic and education at the clinic

    combined with home exercises produced similar results.

    In patients with disc displacement without reduction

    and pain and in patients with TMD pain without major

    psychological symptoms, no difference in outcome was

    found between simple treatment and multimodal

    treatment (one SR). But in patients with TMD pain

    and major psychological symptoms, multimodal treat-

    ment was found to be better than simple treatment.

    The overall inter-reliability agreement of the two

    authors in assessing the quality of the SRs was 070 andfree-marginal kappa 067. Figure 2 presents percentageof primary studies cited in one or more of the different

    SRs for each treatment area.

    Reference cited number of times

    Occlusal appliance Occlusal adjustment Bruxism6

    6

    SR, 55 studies 4 SR, 12 studies 2 SR, 6 studies

    143%

    225%

    318%

    49%

    55%

    158%2

    17%

    317%

    48%

    167%

    233%

    Acupuncture Physical treatment Pharmacologic treatmentSR, 10 studies 4 SR, 26 studies 7 SR, 60 studies

    140%

    210%

    30%

    410%

    540%

    172%

    212%

    38%

    48%

    162%

    220%

    35%

    413%

    TMJ and maxillofacial surgery Behavioral therapy and4 SR, 54 studies Multimodadal treatment

    6 SR, 30 studies

    181%

    215%

    34%

    136%

    233%

    317%

    47%

    57%

    12345

    Fig. 2. Percentage of same primary

    study cited in one or more of the

    different systematic reviews, for each

    treatment area.

    M A N A G E M E N T O F T M D 445

    2010 Blackwell Publishing Ltd

  • Discussion

    Systematic reviews are a synthesis and critical assess-

    ment of primary studies, or even other SRs, and they

    play an important role in evidence-based decision

    making. The SR has the benefit that it provides a

    systematic overview of what has been published on a

    specific issue and what current trends are, such as the

    effect of various treatment modes in the management

    of TMD. Because the conclusions in our study are based

    on several SRs published by independent researchers,

    findings are well supported.

    Because many researchers and practitioners may not

    have time to read SRs much less all the primary

    studies on which these SRs are based a systematic

    review of these SRs may (i) give a valuable, time-saving

    overview of a specific issue, (ii) provide a pool of

    references of SRs and of primary studies that have been

    quality assessed, and (iii) serve as a useful tool for

    giving undergraduate students an understanding of

    how to conduct systematic literature searches and

    quality assessments of a topic.

    Studies have indicated that it is difficult to change

    competences and knowledge that a dentist learned in

    undergraduate dental education (48). It is therefore

    important to implement SRs in undergraduate teaching

    so that students understand evidence-based medicine

    (49).

    The results of the SRs are impacted by the quality of

    the primary studies included in the review. However, the

    methodological quality of the SR should not be affected

    by flaws in the primary studies, as long as these flaws are

    reported, commented on and sufficiently regarded in the

    conclusions. One SR resulted in no included studies but

    it was included because it reflected our second aim, to

    assess the methodological quality of SRs (38).

    In AMSTAR, one key item is whether the scientific

    quality of the included SRs was assessed and docu-

    mented The most commonly used quality assessment

    tool used in the SRs was the Jadad score (50). Grades of

    Recommendation Assessment, Development and Eval-

    uation (GRADE) is a recently developed tool for

    assessing the synthesised evidence for specified out-

    come measures. As one of the aims of this study was to

    detect trends in the evidence base regarding the overall

    effect of different methods for treating TMD, we

    decided that introducing GRADE in this context would

    give too detailed information for this purpose (51).

    A concern in this SR was that 30% of the SRs included

    case series, that is, no control group, which limits the

    conclusions of the SR. Several leading scientific journals

    have made a united effort to provide guidelines for how

    a clinical trial should be conducted in the CONSORT

    statement (52). These guidelines can be used as a

    checklist for avoiding pitfalls in conducting clinical

    trials.

    Our SR found inconsistencies in several SRs con-

    cerning diagnosis. Temporomandibular disorders were

    inconsistently defined in the primary studies but, more

    importantly, also in the SRs reviewed here. Similar

    results were reported for radiographic findings in TMD

    (53). The classification that has been found to provide

    acceptable reliability and validity and is commonly used

    in TMD research is the research diagnostic criteria for

    temporomandibular disorders (RDC TMD) (54, 55).The future challenge is to convince researchers to use

    the diagnostic system with the best evidence accept-

    able sensitivity and specificity (56).

    In this SR, a large variety of outcome measures were

    used, and instrument reliability and validity were often

    not described. It is essential that evidence be based on

    measures that are important indicators of patient health

    and that are not surrogate endpoints. For example, pain

    reduction and daily functioning are more important

    aspects in an evaluation than clicking sounds, deviation

    in mm, or tenderness on palpation. Clinical trials and

    SRs must begin meeting international standards, and

    clinical scientists must begin designing and reporting

    such trials. To create a core of common outcome

    measures in the field of pain, Dworkin et al. and a

    consensus group undertook to put together the

    Initiative on Methods, Measurements, and Pain Assess-

    ment in Clinical Trials (IMMPACT) (57). IMMPACT

    recommendations include the following domains:

    pain, physical functioning, emotional functioning,

    participant rating of improvement and satisfaction

    with treatment, symptoms and adverse events, and

    participant disposition.

    It is also important that (i) these measures are

    expressed in clinically relevant terms such as numbers

    of responders and non-responders to treatment, for

    example, number of patients with >30% pain reduction

    and (ii) data are presented in a transparent manner, so

    that mathematical syntheses or meta-analyses of the

    results may be conducted. In this review, only a few of

    the SRs had conducted a meta-analysis because of

    heterogeneity of the original data or methodological

    differences such as variability of measures. In future,

    T . L I S T & S . A X E L S S O N446

    2010 Blackwell Publishing Ltd

  • the ability to synthesise the results of several primary

    studies would allow more accurate assessment of

    treatment efficacy and treatment effectiveness. This

    approach would allow the continuous update of RCTs

    in meta-analyses, which would (i) limit the number of

    qualitative SRs and (ii) allow more accurate, overall

    assessment of treatment result.

    Quality assessment

    In this SR, AMSTAR scores ranged from 2 to 11. But it is

    important to point out that item scores are not equal in

    weight; for example, characteristics of included SRs and

    conflict of interest statement have different weights.

    With its focus on study design, the LRD was used to

    supplement AMSTAR in SR quality assessment. Use of

    both instruments was essential to gain perspective on

    SR quality.

    The number of SRs evaluated in the various treatment

    groups ranged from 10 for occlusal splint, occlusal

    adjustment, and bruxism to 4 for TMJ and maxillofacial

    surgery. In each treatment area, a small number of well-

    designed primary studies overlapped and were cited in

    several of the SRs that covered that area. But 4080% of

    the primary studies did not overlap between different

    SRs and were only cited once (Fig. 2). Variations

    between the SRs in aims, inclusion criteria, and time of

    data collection may explain this lack of overlap. Despite

    these differences, conclusions drawn in several of the

    SRs for a specific treatment form had similar evidence.

    Thus, synthesising evidence from several SRs can also be

    a tool for validation of this kind of meta-research.

    A general impression from this study was that

    strength of evidence of an SR was weak if the SR (i)

    had a low AMSTAR score (e.g.

  • it is strongly recommended that those practicing acu-

    puncture have good theoretical knowledge and training

    in the therapy (61).

    Next to information, patient education, and occlusal

    appliance, jaw exercises are a common form of TMD

    treatment (62). One SR found active exercise and

    postural training to be effective in treatment of TMD

    pain but no evidence for the effectiveness of various

    electrical modalities. Overall, few primary studies have

    been published and more research is needed to estab-

    lish the efficacy of the various physical treatment

    modalities, including acupuncture.

    Pharmacologic treatment

    Several SRs indicated that analgesics, antidepressants,

    diazepam, hyaluronate, and glycocorticoid may be

    effective in TMD pain. Few primary studies were well

    designed with a relevant follow-up time, so the main

    conclusion in the SR was that results were heteroge-

    neous, and no conclusions could be drawn. But it is

    important to differentiate between lack of evidence and

    evidence for lack of effect. Because of current limitations in

    knowledge of pharmacologic effects on TMD pain, only

    comparisons between similar pain conditions such as

    backache or tension-type headache can be made. In

    several chronic pain conditions, drugs such as analge-

    sics, opioids, antidepressants, and anti-epileptics have

    been found to be effective in relieving pain (63); these

    drugs would probably be effective in TMD pain.

    Important endpoints such as numbers needed to treat

    (NNT) and numbers needed to harm (NNH) were rare

    in these primary studies, despite being recommended

    for use in pharmacologic treatment studies because

    they are easy to understand and provide a clinically

    relevant measure of the success rate and rate of harm of

    an intervention (63).

    The SR on pharmacologic treatment reported minor

    adverse events. Because there is currently no criterion

    standard in the pharmacological treatment of chronic

    oro-facial pain, the positive effects of drugs must be

    weighed against possible adverse and toxic effects, and

    risk of dependency.

    TMJ and maxillofacial surgery

    The SRs of surgical treatment of TMD concluded that

    arthroscopic surgery, arthrocentesis, and physical ther-

    apy affected mandibular movement, reduction in pain

    intensity, and mandibular functioning to the same

    degree. Success rates were often high, independent of

    treatment mode. The effect of maxillofacial surgery on

    TMD pain is unclear. Many of the RCTs included in the

    SRs had low quality scores, and outcome measures were

    often coarse, which made data difficult to interpret.

    One important aspect in the evaluation of invasive

    TMJ interventions versus conservative treatment is the

    patient groups. In most TMJ surgery primary studies,

    the inclusion criterion for entering the study was

    that the patient had been refractory to conserva-

    tive treatment for 6 months, while the inclusion

    criterion for conservative treatment was pain duration

    of 6 months. So a comparison between the groups is

    inconclusive.

    More well-designed primary studies with proper

    evidence-based standards are needed to identify the

    patients who are most suited for surgical interventions.

    Behavioural therapy and multimodal treatment

    All SRs of behavioural therapy concluded that this type

    of treatment was effective in treating TMD pain. The

    treatment modalities included education, biofeedback,

    relaxation training, stress management, and CBT.

    Treatment modes were often combined, for example,

    biofeedback and relaxation could be compared with

    biofeedback and CBT, making it difficult to determine

    which part of the treatment was most important.

    Several primary studies indicated that behavioural

    therapy was as effective as other forms of conservative

    TMD treatment.

    One SR reported that most patients with TMD

    without psychological involvement benefited from

    simple treatments. Patients with TMD pain and major

    psychological disturbances were in need of a combined

    therapeutic approach. This emphasises the need for

    combining the clinical examination with a behavioural

    assessment to be able to direct the patient to the proper

    mode of treatment. The RDC TMD is a classificationsystem that uses a clinical (axis I) and a psychosocial

    assessment (axis II) to gain a more complete picture of

    the patient; Garofalo and Wesley recommended this

    approach use of a dual axis in chronic pain

    assessment (64).

    Evidence-based medicine is defined as the integration

    of best research evidence with clinical expertise and

    patient values. In future, we need to expand our

    understanding of how to:

    T . L I S T & S . A X E L S S O N448

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  • 1 Tailor treatment for the individual patient, so they

    benefit from the best treatment for them.

    2 Transfer research findings to the practicing dentist,

    because they are the main caregiver of patients with

    TMD.

    3 Balance our judgment of best research evidence with

    clinical expertise in the choice of treatment.

    4 Gain more information about patient preferences

    and values and what impact this has on treatment

    outcome.

    Conclusions

    There is some evidence that occlusal appliances,

    acupuncture, behavioural therapy, jaw exercises, pos-

    tural training, and some pharmacological treatments

    can be effective in alleviating pain in patients with

    TMD. Evidence is insufficient for the effect of electro-

    physical modalities and surgery. Occlusal adjustment

    seems to have no effect according to the available

    evidence. One limitation of most of the SRs reviewed

    was that the considerable variation in methodology

    between the primary studies made definitive conclu-

    sions impossible.

    Acknowledgments

    To the participants of the 2009 Colloquium on Oral

    Rehabilitation in Sienna, who provided valuable feed-

    back on the manuscript.

    Declaration of interests

    Dr Axelsson is a staff member and a project director at

    the Swedish Council on Technology Assessment in

    Health Care (SBU).

    Authors contributions

    Dr List conceived the project, developed the protocol,

    conducted searches, and prepared the manuscript. Both

    authors undertook data collection and extraction. Dr

    Axelsson contributed to manuscript preparation.

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    Correspondence: Thomas List, DDS, Odont. dr, Department of

    Stomatognathic Physiology, Faculty of Odontology, Malmo Univer-

    sity, SE-205 06 Malmo, Sweden. E-mail: [email protected]

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