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

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 author’s 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 Craniomandibular

disorders ⁄ 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

ª 2010 Blackwell Publishing Ltd

11 Was the conflict of interest stated?

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

‘Can’t 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,

case–control 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 (11–13), 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 1–5 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 SRs

included measures of psychological status, daily activ-

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

(range 2–11). The LRD scores for the SRs are as follows:

Level I–II 2 SRs

Level I-III 1 SR

Level II 16 SRs

Level II–III 1 SR

Level III 1 SR

Level II–IV 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, 19–26), 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 (11–18)

Articles included for quality assessment:

30 references (19–47, 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

ª 2010 Blackwell Publishing Ltd

Tab

le1.

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

(P<

0Æ0

01).

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

dth

ree

of

the

stu

die

sw

ere

not

RC

Ts.

Al-

An

iM

Z

2003

(19)

Qu

alita

tive

SR

of

12

RC

Ts

Myofa

scia

lpain

496

pati

en

ts

I1:

Occ

lusa

l

applian

ce

C1:

Oth

er

treatm

en

t

(bio

feedback

,ja

w

exerc

ises,

acu

pu

nct

ure

)

C2:

No

treatm

en

t

C3:

Pla

cebo

Pain

redu

ctio

n

Jaw

moti

on

I1n

obett

er

than

C1

I1so

mew

hat

bett

er

than

C2

I1n

obett

er

than

C3

AM

STA

R6

LR

DII

A:

Th

ere

isin

suffi

cien

tevid

en

ceeit

her

for

or

again

stth

eu

seof

stabil

isati

on

spli

nt

thera

py

over

oth

er

act

ive

inte

rven

tion

sfo

rth

etr

eatm

en

tof

tem

poro

man

dib

ula

rm

yofa

scia

lpain

.H

ow

ever,

itappears

that

stabilis

ati

on

spli

nt

thera

py

may

be

ben

efi

cialfo

rre

du

cin

gpain

severi

tyat

rest

an

don

palp

ati

on

an

ddepre

ssio

nw

hen

com

pare

dto

no

treatm

en

t.

R:

Incl

uded

stu

die

sw

ere

small.

Pati

en

tm

ate

rial

was

hete

rogen

eou

s.O

utc

om

em

easu

res

vari

ed

betw

een

stu

die

s.Sh

ort

-term

follow

-up.

Excl

usi

on

,in

clu

sion

,an

ddia

gn

ost

iccr

iteri

a

not

clearl

ydefi

ned.

Fors

sell

H

2004

(20)

Qu

alita

tive

SR

of

20

RC

Ts

TM

D

1138

pati

en

ts

I1:

Occ

lusa

l

applian

ce

I2:

Occ

lusa

l

adju

stm

en

t

C1:

Oth

er

treatm

en

t

(bio

feedback

,ja

w

exerc

ises,

acu

pu

nct

ure

)

C2:

No

treatm

en

t

C3:

Pla

cebo

Pain

redu

ctio

n

Glo

bal

impro

vem

en

t

Cli

nic

al

exam

inati

on

Depre

ssio

nsc

ale

Con

tradic

tory

resu

lts

for

I1

com

pare

dw

ith

C1–C

3

I2n

obett

er

than

C1

or

C2

AM

STA

R7

LR

DII

A:

Occ

lusa

lsp

lin

tsyie

lded

equ

ivoca

lre

sult

s.E

ven

for

the

most

stu

die

dare

a,

stabilis

ati

on

spli

nts

for

myofa

scia

lpain

,th

ere

sult

sdo

not

just

ify

defi

nit

e

con

clu

sion

sabou

tth

eeffi

cacy

of

splin

tth

era

py.

Th

eir

clin

ical

eff

ect

iven

ess

tore

lieve

pain

als

o

seem

sm

odest

wh

en

com

pare

dw

ith

treatm

en

t

meth

ods

ingen

era

l.N

on

eof

the

occ

lusa

l

adju

stm

en

tst

udie

spro

vid

ed

evid

en

cesu

pport

ing

the

use

of

this

treatm

en

tm

eth

od.

R:

Incl

uded

stu

die

ssm

all,

oft

en

not

bli

nded,

hete

rogen

eit

yco

nce

rnin

gou

tcom

em

easu

res

an

d

con

trol

treatm

en

t.

M A N A G E M E N T O F T M D 433

ª 2010 Blackwell Publishing Ltd

Tab

le1.

(Con

tin

ued

)

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

Tu

rpJC

2004

(21)

Qu

alita

tive

SR

of

9R

CTs

Myofa

scia

lpain

482

pati

en

ts

I1:

Intr

a-o

ral

applian

ce

C1:

Oth

er

treatm

en

t

incl

udin

gpla

cebo

C2:

No

treatm

en

t

Pain

redu

ctio

n

Clin

ical

exam

inati

on

Depre

ssio

nsc

ale

I1bett

er

than

C2

I1n

obett

er

than

C1

AM

STA

R6

LR

DII

A:

Base

don

the

curr

en

tly

best

available

evid

en

ce,

itappears

that

most

pati

en

tsw

ith

mast

icato

ry

mu

scle

pain

are

help

ed

by

inco

rpora

tion

of

a

stabil

isati

on

spli

nt.

Ast

abil

isati

on

spli

nt

does

not

appear

toyie

lda

bett

er

clin

ical

ou

tcom

eth

an

a

soft

splin

t,a

non

-occ

ludin

gpala

talsp

lin

t,ph

ysi

cal

thera

py,

or

acu

pu

nct

ure

.

R:

Well-c

on

du

cted

SR

.Lim

itati

on

s:sm

all

pati

en

t

stu

die

s,ou

tcom

em

easu

res

vary

betw

een

stu

die

s,

no

lon

g-t

erm

resu

lts.

Fri

cton

J

2006

(22)

Qu

alita

tive

SR

of

39

RC

Ts

TM

D

pati

en

ts*

I1:

Sta

bilis

ati

on

spli

nt

I2:

An

teri

or

posi

tion

ing

an

d

soft

spli

nts

C1:

Pla

cebo

C2:

Oth

er

treatm

en

t

Pain

redu

ctio

nN

odif

fere

nce

betw

een

I1an

dI2

.

I1an

dC

2h

ave

sim

ilar

eff

ect

s

I2,

I1,

an

dC

1h

ave

sim

ilar

eff

ect

s

AM

STA

R4

LR

DII

A:

Sta

bilis

ati

on

splin

tsca

nre

du

ceTM

Dpain

com

pare

dto

pla

cebo

splin

ts.

Sta

bilis

ati

on

splin

ts

are

equ

ally

eff

ect

ive

inre

du

cin

gpain

com

pare

dto

ph

ysi

cal

thera

py,

acu

pu

nct

ure

an

dbeh

avio

ura

l

thera

py

inth

esh

ort

term

.Th

elo

ng-t

erm

eff

ect

sof

beh

avio

ura

lth

era

py

may

be

bett

er

than

spli

nts

in

redu

cin

gsy

mpto

ms

inm

ore

severe

pati

en

tsw

ith

psy

choso

cial

pro

ble

ms.

R:

Th

eart

icle

isan

overv

iew

an

dse

para

teart

icle

s

are

un

der

pu

bli

shin

gw

ith

deta

ils

regard

ing

meth

ods

an

dre

sult

s.

SB

U

2006

(23)

Qu

alita

tive

SR

of

3SR

san

d

3R

CTs

TM

D

2299

pati

en

ts

I1:

Sta

bilis

ati

on

spli

nt

I2:

Occ

lusa

l

adju

stm

en

t

C1:

Pla

cebo

C2:

Oth

er

treatm

en

ts

C3:

No

treatm

en

t

Pain

redu

ctio

n

Clin

ical

exam

inati

on

Depre

ssio

nsc

ale

I1bett

er

than

C3

I1an

dC

2h

ave

sim

ilar

eff

ect

Resu

lts

of

I1

com

pare

dw

ith

C1

are

con

tradic

tory

I2an

dC

1h

ave

sim

ilar

eff

ect

AM

STA

R6

LR

DI–

II

A:

Occ

lusa

lapplian

ces

gave

bett

er

pain

redu

ctio

n

than

no

treatm

en

t.Tre

atm

en

tw

ith

occ

lusa

l

appli

an

ceh

ad

sim

ilar

eff

ect

as

oth

er

thera

pie

s

wh

ere

as

the

eff

ect

com

pare

dw

ith

pla

cebo

was

con

tradic

tory

.N

ost

udy

fou

nd

occ

lusa

l

adju

stm

en

tto

be

eff

ect

ive

com

pare

dto

aco

ntr

ol.

R:

Revie

wers

an

dau

thors

are

iden

tica

lpers

on

s

T . L I S T & S . A X E L S S O N434

ª 2010 Blackwell Publishing Ltd

Tab

le1.

(Con

tin

ued

)

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

Sta

pelm

an

H

2008

(24)

Qu

alita

tive

SR

of

5R

CTs

TM

D

Bru

xis

m

Ten

sion

-type

headach

e(T

TH

)

Mig

rain

e

190

pati

en

ts

I1:

NTI

spli

nt

C1:

Fla

tocc

lusa

l

spli

nt

C2:

Ble

ach

ing

tray

EM

Gact

ivit

y

Poly

som

nogra

ph

ic

evalu

ati

on

Pain

inte

nsi

ty

Jaw

open

ing

Com

fort

An

alg

esi

c

con

sum

pti

on

Redu

cin

gE

MG

act

ivit

y:

I1m

ore

eff

ect

ive

than

C1

Impro

vem

en

tin

pain

redu

ctio

n:

resu

lts

for

I1

com

pare

dw

ith

C1

are

con

tradic

tory

Tre

ati

ng

TTH

an

d

mig

rain

e:

I1m

ore

eff

ect

ive

than

C2

Fiv

ere

port

sof

com

pli

cati

on

sor

side-e

ffect

s

report

ed

for

I1

AM

STA

R7

LR

DII

A:

NTI-

tss

devic

es

may

be

succ

ess

fully

use

dto

man

age

bru

xis

man

dTM

Ds.

To

avoid

pote

nti

al

un

wan

ted

eff

ect

s,it

shou

ldbe

chose

non

lyif

a

pati

en

tw

ill

be

com

pli

an

tw

ith

foll

ow

-up.

Tw

oof

five

stu

die

sfo

cuse

don

treatm

en

tof

TM

D.

Overa

ll,

small

gro

ups,

media

nof

14

part

icip

an

ts

ineach

gro

up.

As

advers

eeven

tsw

ere

report

ed

for

I1,

an

dI1

was

not

more

eff

ect

ive

than

C1,

on

lyli

mit

ed

indic

ati

on

isw

arr

an

ted.

R:

Well-c

on

du

cted

SR

.Lim

itati

on

sare

small

stu

die

s.M

eth

odolo

gic

al

weakn

ess

es

inpri

mary

stu

die

ssu

chas

hete

rogen

eit

yco

nce

rnin

g

ou

tcom

em

easu

res

an

ddia

gn

ost

iccr

iteri

a.

Koh

H

2009

(26)

SR

an

d

meta

-an

aly

sis

of

6R

CTs

TM

D

392

pati

en

ts

I1:

Occ

lusa

l

adju

stm

en

t

C1:

Pla

cebo,

no

treatm

en

tor

reass

ura

nce

Glo

bal

sym

pto

ms

Reli

ef

of

headach

e

Qu

ality

of

life

No

dif

fere

nce

betw

een

I1an

dC

1

AM

STA

R10

LR

DII

A:Th

ere

isan

abse

nce

ofevid

en

ce,fr

om

RC

Ts,

that

occ

lusa

ladju

stm

en

ttr

eats

or

pre

ven

tsTM

D.

Occ

lusa

ladju

stm

en

tca

nn

ot

be

reco

mm

en

ded

for

man

agem

en

tor

pre

ven

tion

of

TM

D.

R:

Sm

all

stu

die

s,dia

gn

ost

iccr

iteri

ain

acc

ura

te.

Ou

tcom

em

easu

res

poorl

ydefi

ned.

Marc

edo

CR

2009

(27)

SR

an

d

meta

-an

aly

sis

of

5R

CTs

Bru

xis

m

63

pati

en

ts

I1:

Occ

lusa

lsp

lin

t

I2:

Oth

er

appli

an

ces

I3:

Oth

er

thera

pie

s

C1:

No

treatm

en

t

Sle

ep

vari

able

s:e.g

.

EM

Gact

ivit

y,

aro

usa

lin

dex

Report

of

bru

xis

m

by

part

ner

Tooth

wear

No

dif

fere

nce

betw

een

I1an

dI2

inth

e

meta

-an

aly

sis

of

aro

usa

lin

dex.

No

dif

fere

nce

betw

een

I1an

dC

1

for

tooth

wear

face

ts

No

dif

fere

nce

betw

een

I1an

dI3

for

TM

Dpain

AM

STA

R9

LR

DII

A:

Th

ere

isn

ot

suffi

cien

tevid

en

ceto

state

that

the

occ

lusa

lsp

lin

tis

eff

ect

ive

for

treati

ng

sleep

bru

xis

m.

Indic

ati

on

of

its

use

isqu

est

ion

able

con

cern

ing

sleep

ou

tcom

es,

bu

tit

may

be

that

there

are

som

eben

efi

tsco

nce

rnin

gto

oth

wear.

R:

Sm

all

stu

die

s,m

eth

odolo

gic

al

weakn

ess

es

in

pri

mary

stu

die

s

M A N A G E M E N T O F T M D 435

ª 2010 Blackwell Publishing Ltd

occlusal appliances on sleep bruxism (27), and one the

effect of occlusal appliances on attrition (28). Six SRs

reported that occlusal appliances and other therapies

had similar effect, three that occlusal appliances were

better than no treatment, and four that there was no

difference between occlusal appliances and non-occlud-

ing splints (placebo). One SR reported stabilisation

splints and anterior positioning and soft splints to yield

similar results, while one SR reported anterior posi-

tioning splints to be more effective than stabilisation

splints. One SR reported contradictory results in a

comparison of nociceptive trigeminal inhibition (NTI)

splints and occlusal appliances. Several complications

and adverse events were documented for the NTI-tss

device. Three SRs reported no difference in outcome

between occlusal adjustments and control treatment.

Eight SRs evaluated various physical treatments in

patients with TMD (Table 2). Of these SRs, six assessed

acupuncture (23, 29–32), three jaw exercises (23, 33,

34), two manual therapy (33, 34), and three various

forms of electrical therapy (30, 34). Three SRs reported

that acupuncture was better than no treatment, four

SRs that acupuncture and other therapies yielded

similar results, and one SR that acupuncture and

placebo treatment had similar results. Two SRs found

no support for acupuncture treatment.

As for the other types of physical treatment, three

SRs reported that jaw exercises were better than

controls, and two SRs found postural training to be

better than no treatment. No SR indicated that electro-

physical modalities such as TENS, laser, and ultrasound

were effective in reducing pain.

Seven SRs evaluated various pharmacological treat-

ments in patients with TMD, atypical facial pain,

trigeminal neuralgia, and burning mouth syndrome

(23, 35–40) (Table 3). One SR reported anti-epileptic

drugs to be more effective than placebo in patients

with trigeminal neuralgia. In patients with TMD,

pharmacological treatment that was found to be more

effective than placebo was analgesics (two SRs),

clonazepam or diazepam (three SRs), antidepressants

(four SRs), and hyaluronate (one SR). This last SR also

reported hyaluronate and glycocorticoid to produce a

similar effect. Three SRs reported amitriptyline to have

a moderate effect in patients with atypical facial pain.

Two SRs reported the use of botulinum toxin in

patients with pain or masseter hypertrophy. One SR

reported positive outcome based upon one RCT,

whereas the other SR found no studies that met itsTab

le1.

(Con

tin

ued

)

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

van

¢tSpij

ker

A

2007

(28)

Qu

ali

tati

ve

SR

of

33

stu

die

s

2st

udie

sre

late

dto

Inte

rven

tion

beca

use

of

bru

xis

m.

1R

CT

an

d1

case

seri

es.

27

pati

en

ts

I1:

Occ

lusa

l

appli

an

ce

C1:

no

treatm

en

t

Att

riti

on

I1re

du

ces

att

riti

on

com

pare

dw

ith

C1.

AM

STA

R6

LR

DII

-IV

A:

On

est

udy

was

pro

spect

ive

an

dre

port

ed

less

att

riti

on

inyou

ng

chil

dre

nw

eari

ng

bit

epla

tes

com

pare

dw

ith

subje

cts

wh

odid

not

wear

devic

es.

Ina

case

seri

es

of

pati

en

tsw

ith

severe

att

riti

on

,occ

lusa

lsp

lin

tsw

ere

fou

nd

tosl

ow

dow

nth

era

teof

tooth

wear.

R:

Sm

all

stu

die

s,m

eth

odolo

gic

al

weakn

ess

es

in

pri

mary

stu

die

s.Th

ere

sult

sse

em

toco

nfi

rm

clin

ical

experi

en

ce.

AM

STA

R,

ass

ess

men

tof

mu

ltip

lesy

stem

ati

cre

vie

ws;

LR

D,

level

of

rese

arc

hdesi

gn

;N

TI,

noci

cepti

ve

trig

em

inal

inh

ibit

ion

;R

CT,

ran

dom

ised

clin

ical

tria

l;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 N436

ª 2010 Blackwell Publishing Ltd

Tab

le2.

Ch

ara

cteri

stic

sof

syst

em

ati

cre

vie

ws

(SR

s)of

ph

ysi

cal

thera

py:

acu

pu

nct

ure

,TE

NS,

exerc

ise,

an

dm

obilis

ati

on

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

Ern

stE

1999

(29)

Qu

alita

tive

SR

of

6R

CTs

TM

D

205

pati

en

ts

I1:

Acu

pu

nct

ure

C1:

Occ

lusa

l

applian

ce

C2:

No

treatm

en

t

Pain

Inte

nsi

ty

Dail

yact

ivit

y

Glo

bal

impro

vem

en

t

Clin

ical

exam

inati

on

I1bett

er

than

C2

No

dif

fere

nce

betw

een

I1an

dC

1

AM

STA

R5

LR

DII

A:

Alt

hou

gh

all

stu

die

sagre

ew

ith

the

noti

on

that

acu

pu

nct

ure

iseff

ect

ive

for

TM

D,

this

hypoth

esi

s

requ

ires

con

firm

ati

on

thro

ugh

more

rigoro

us

invest

igati

on

s.

R:

Sh

ort

foll

ow

-up

tim

ein

two

stu

die

s.O

ne

stu

dy

report

sa

1-y

ear

follow

-up.

No

report

ed

side-e

ffect

s.

SR

base

don

thre

est

udie

sw

ith

low

qu

ali

ty.

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

Clin

ical

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

itis

not

poss

ible

todra

wan

y

con

clu

sion

s.

R:

Lim

itati

on

sin

the

SR

meth

odolo

gy

an

dth

ere

fore

dif

ficu

ltto

dra

wan

yco

ncl

usi

on

s

Rost

ed

P

1998

(31)

Qu

alita

tive

SR

of

15

RC

Ts

(7R

CTs

on

TM

D)

Acu

teto

oth

ach

e

TM

D

pati

en

ts*

I1:

Acu

pu

nct

ure

C1:

Oth

er

treatm

en

t

Pain

inte

nsi

tyN

odif

fere

nce

betw

een

I1an

dC

1

AM

STR

AR

4

LR

DII

-IV

A:

Acu

pu

nct

ure

an

dco

nven

tion

al

treatm

en

tw

ere

fou

nd

toh

ave

sim

ilar

eff

ect

.Th

eeff

ect

intr

eati

ng

TM

Dan

dfa

cial

pain

seem

sre

al,

an

dacu

pu

nct

ure

cou

ldbe

an

alt

ern

ati

ve

toco

nven

tion

al

treatm

en

t.

R:

Non

-RC

Ts

were

incl

uded

inth

eevalu

ati

on

.

Meth

odolo

gy

an

dre

sult

sn

ot

clearl

ydesc

ribed.

SB

U

2006

(23)

Qu

alita

tive

SR

of

3

SR

san

d1

RC

T

TM

D

575

pati

en

ts

I1:

Acu

pu

nct

ure

C1:

Pla

cebo

acu

pu

nct

ure

C2:

Oth

er

treatm

en

t

C3:

No

treatm

en

t

Pain

inte

nsi

ty

Dail

yact

ivit

ies

Glo

bal

impro

vem

en

t

Clin

ical

exam

inati

on

I1bett

er

than

C3

I1an

dC

2h

ave

sim

ilar

eff

ect

I1an

dC

1h

ave

con

tradic

tory

resu

lts

AM

STA

R6

LR

DI–

II

A:

Acu

pu

nct

ure

was

fou

nd

tosh

ow

bett

er

pain

redu

ctio

nth

an

no

treatm

en

tan

dsi

mil

ar

eff

ect

com

pare

dto

oth

er

treatm

en

ts.

Com

pare

dto

pla

cebo,

the

resu

lts

are

con

tradic

tory

.

R:

Revie

wers

an

dau

thors

are

iden

tica

lpers

on

s

SB

U

2006

(23)

Qu

alita

tive

SR

of

6R

CTs

TM

D

279

pati

en

ts

I1:

Jaw

exerc

ises

I2:

Pu

lsed

radio

frequ

en

cyth

era

py

I3:

Lase

r

I4:

Pu

lsed

ele

ctro

magn

eti

c

field

s

I5:

Post

ura

l

corr

ect

ion

C1:

Min

imal

info

rmati

on

C2:

Pla

cebo

C3:

No

treatm

en

t

Pain

inte

nsi

ty

Dail

yact

ivit

ies

Clin

ical

exam

inati

on

I1bett

er

than

C1

I1–I4

no

dif

fere

nt

from

C2

I5bett

er

than

C3

AM

STA

R6

LR

DI–

II

A:

Th

eevid

en

ceto

dra

wan

yco

ncl

usi

on

sre

gard

ing

ph

ysi

cal

treatm

en

tfo

rTM

Dis

insu

ffici

en

tbeca

use

the

stu

die

sare

hete

rogen

eou

sre

gard

ing

dia

gn

osi

s

an

dtr

eatm

en

tm

eth

od.

R:

Som

eof

the

stu

die

ssh

ow

ed

adif

fere

nce

com

pare

d

wit

hco

ntr

ols

.B

eca

use

these

fin

din

gs

were

not

support

ed

by

more

stu

die

s,th

ere

isla

ckof

evid

en

ce.

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 437

ª 2010 Blackwell Publishing Ltd

Tab

le2.

(Con

tin

ued

)

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

Fin

kM

2006

(32)

Qu

alita

tive

SR

of

6R

CTs

TM

D

223

pati

en

ts

I1:

Acu

pu

nct

ure

C1:

Sh

am

acu

pu

nct

ure

C2:

Oth

er

treatm

en

t

C3:

No

treatm

en

t

Pain

inte

nsi

ty

Glo

bal

impro

vem

en

t

Dail

yact

ivit

ies

Clin

ical

exam

inati

on

Pain

thre

shold

s

I1an

dC

2h

ave

sim

ilar

eff

ect

s

No

dif

fere

nce

betw

een

I1an

dC

1

AM

STA

R7

LR

DII

A:

Th

ean

aly

sed

stu

die

son

acu

pu

nct

ure

inth

e

treatm

en

tof

TM

Dco

nfi

rmacu

pu

nct

ure

tobe

as

eff

ect

ive

as

con

serv

ati

ve

treatm

en

t.

R:

Sh

ort

follow

-up

tim

ein

thre

est

udie

s.O

ne

stu

dy

report

sa

1-y

ear

foll

ow

-up.

No

report

ed

side-e

ffect

s.

SR

base

don

thre

est

udie

sw

ith

low

an

don

ew

ith

hig

hqu

ali

ty.

McN

eely

M

2006

(33)

Qu

alita

tive

SR

of

12

RC

Ts

TM

D

480

pati

en

ts

I1:

Exerc

ise

an

d

man

ual

thera

py

I2:

Acu

pu

nct

ure

I3:

Ele

ctro

ph

ysi

cal

modali

ties

(PR

FE

,

TE

NS,

bio

feedback

,

lase

r)

C1:

Oth

er

thera

pie

s

C2:

Pla

cebo

Pain

redu

ctio

n

Jaw

mobilit

y

No

syn

thesi

sof

resu

lts

AM

STA

R7

LR

DII

A:

Th

ere

sult

ssu

pport

use

of

act

ive

an

dpass

ive

ora

l

exerc

ises

an

dexerc

ises

toim

pro

ve

post

ure

as

eff

ect

ive

inte

rven

tion

sto

redu

cesy

mpto

ms

ass

oci

ate

dw

ith

TM

D.

Th

ere

isin

adequ

ate

info

rmati

on

toeit

her

support

or

refu

teu

seof

acu

pu

nct

ure

inTM

Dtr

eatm

en

t.Th

ere

isn

oevid

en

ce

tosu

pport

use

of

ele

ctro

ph

ysi

calm

odaliti

es

tore

du

ce

TM

Dpain

.

R:M

eth

odolo

gic

alw

eakn

ess

es

of

pri

mary

stu

die

ssu

ch

as

dia

gn

ost

iccr

iteri

aof

TM

D,

ou

tcom

em

easu

res

an

d

chose

nco

ntr

ols

lim

itco

ncl

usi

on

sin

the

stu

dy.

Medli

cott

MS

2006

(34)

Qu

alita

tive

SR

of

24

RC

Ts

an

d6

un

con

troll

ed

stu

die

s

TM

D

1071

pati

en

ts

I1:

Exerc

ise

I2:

Man

ual

thera

py

I3:

Ele

ctro

thera

py

(ult

raso

un

d,

TE

NS,

lase

r,PR

FE

)

I4:

Rela

xati

on

train

ing

an

d

edu

cati

on

C1:

Occ

lusa

lsp

lin

t

C2:

Pla

cebo

C3:

Wait

ing-l

ist

Pain

inte

nsi

ty

Glo

bal

impro

vem

en

t

Clin

ical

exam

inati

on

Jaw

mobilit

y

Pre

ssu

repain

thre

shold

No

syn

thesi

sof

resu

lts

AM

STA

R5

LR

DII

-IV

A:

Act

ive

exerc

ise

an

dm

an

ual

mobil

isati

on

may

be

eff

ect

ive.

Post

ura

ltr

ain

ing

may

be

use

din

com

bin

ati

on

wit

hoth

er

inte

rven

tion

s,as

indepen

den

teff

ect

sof

post

ura

ltr

ain

ing

are

un

kn

ow

n.

Mid

-lase

rth

era

py

may

be

more

eff

ect

ive

than

oth

er

ele

ctro

thera

py

modaliti

es.

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

lsp

lin

ts.

Com

bin

ati

on

sof

act

ive

exerc

ise,

man

ual

thera

py,

post

ura

lco

rrect

ion

,an

d

rela

xati

on

tech

niq

ues

may

be

eff

ect

ive.

R:

Beca

use

of

the

hete

rogen

eou

spopu

lati

on

an

dto

dif

fere

nce

sin

dia

gn

osi

san

dou

tcom

em

easu

res,

itn

ot

poss

ible

todra

wan

ycl

ear

con

clu

sion

sfr

om

this

SR

.

TE

NS,

tran

scu

tan

eou

sele

ctri

cn

erv

est

imu

lati

on

;PR

FE

,pu

lsed

radio

frequ

en

cyen

erg

y;

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 N438

ª 2010 Blackwell Publishing Ltd

Tab

le3.

Ch

ara

cteri

stic

sof

syst

em

ati

cre

vie

ws

(SR

s)of

ph

arm

aco

logic

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

Som

mer

C

2002

(35)

Qu

ali

tati

ve

SR

of

27

RC

Ts

TM

D,

trig

em

inal

neu

ralg

ia,

aty

pic

al

faci

al

pain

931

pati

en

ts

I1:

Carb

am

aze

pin

,

bacl

ofe

n,

lam

otr

igin

e

I2:

Clo

naze

pam

,

Dia

zepam

I3:

Am

itri

pty

lin

e

C1:

Pla

cebo

Pain

redu

ctio

n

>50%

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

I1–I4

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

ª 2010 Blackwell Publishing Ltd

Tab

le3.

(Con

tin

ued

)

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

ª 2010 Blackwell Publishing Ltd

Tab

le4.

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

d⁄o

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

ª 2010 Blackwell Publishing Ltd

Tab

le4.

(Con

tin

ued

)

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

ª 2010 Blackwell Publishing Ltd

Tab

le5.

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

ssu

chas

hete

rogen

eou

spati

en

t

mate

rial,

ou

tcom

em

easu

res

not

clearl

y

defi

ned,

an

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

fore

dif

ficu

ltto

dra

wan

yco

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

ng-t

erm

follow

-up.

Meth

odolo

gic

al

lim

itati

on

sin

SR

.

SB

U(2

3)

Qu

alita

tive

SR

of

2SR

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

ª 2010 Blackwell Publishing Ltd

Tab

le5.

(Con

tin

ued

)

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

.

R:

Stu

die

sh

ad

small

nu

mbers

of

part

icip

an

ts

an

dou

tcom

em

easu

res

were

poorl

ydefi

ned,

soit

isdif

ficu

ltto

dra

wan

yco

ncl

usi

on

s.

Tu

rpJ

2007

(47)

Qu

ali

tati

ve

SR

of

11

RC

Ts

TM

D:

Dis

cdis

pla

cem

en

t

wit

hou

tre

du

ctio

n,

wit

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

Psy

cholo

gic

statu

s

Pain

thre

shold

Dis

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

majo

rpsy

cholo

gic

al

involv

em

en

tn

eed

mu

ltim

odal,

inte

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

ª 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 (41–43) 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 0Æ70 and

free-marginal kappa 0Æ67. Figure 2 presents percentage

of 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%

1

2

3

4

5

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

ª 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

ª 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 40–80% 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. <5) and (ii) was based

upon non-randomised studies. In SRs where AMSTAR

scores ranged between 5 and 10, the results were

similar, regardless of quality. It has been emphasised

that a clinical trial should follow strict rules; likewise an

SR should be conducted in a standardised manner.

Occlusal appliances, occlusal adjustment, and bruxism

Several of the SRs concluded that management of TMD

with a stabilisation splint worn at night is likely to lead

to short-term improvement when compared with no

treatment, but is inconclusive compared with placebo

(non-occluding palatinal splint). In the short term,

stabilisation splints were equally effective in reducing

TMD pain compared to other treatment modalities such

as physical medicine, behavioural medicine, and acu-

puncture treatment. Overall, documentation on the

long-term pain-relieving effect of occlusal appliances is

limited, as it is for patient compliance in occlusal

appliance treatment. Few SRs reported data on adverse

events related to the use of occlusal appliances. The

major concern with adverse events has been related to

partial non-occluding splints such as the NTI, where the

design of the splint may contribute to tooth pain and

occlusal changes (24).

One SR evaluated the use of splints in bruxism,

which was assessed as number of bruxism episodes per

hour [electromyographic (EMG) activity] and episodes

with grinding noises. The SR found no significant

differences between occlusal splints, no treatment, and

palatinal splints. Small sample size was one explanation

for the lack of significance between outcomes which

the authors of the SR emphasised (27). It should also be

emphasised that some primary studies, particularly

those that use polysomnographic registration, are

technically very difficult to conduct on large patient

samples. One SR examined tooth attrition related to

bruxism, and based on two small studies, found that

occlusal appliances retarded wear.

No SR found evidence that occlusal adjustments are

more or less effective than placebo in the treatment of

TMD pain. All SRs were restrictive in recommending

the use of occlusal adjustments for treatment for TMD

pain, especially because this therapy is non-reversible.

Physical therapy (acupuncture, TENS, exercise, and

mobilisation)

Most SRs found evidence that acupuncture is better

than no treatment and comparable to other forms of

conservative treatment. But because of methodological

shortcomings, MacPherson et al. recommended specific

guidelines to improve the quality of intervention

primary studies; before effectiveness of acupuncture

can be determined more primary studies are needed

(58). Few SRs reported any adverse events or side-

effects from acupuncture treatment. In treatment of

patients with TMD, side-effects seem to be rare or

complications only minor (59). MacPherson et al. came

to similar conclusions concerning use of acupuncture in

general for pain treatment in a large population group

(60). Major adverse events are very rare, but because

some have occurred following acupuncture treatment,

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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 classification

system 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: Thomas.list@mah.se

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