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James Fricton DDS, MS Professor University of Minnesota School of Dentistry HealthPartners Research Foundation Minnesota Head & Neck Pain Clinic
QuestionsaboutTMDTreatments
What treatments have an active therapeutic effect beyond placebo? How well does a treatment work compared to another treatment or no treatment? What patient characteristics or diagnostic subtype does the treatment work best with? What are the risks/ adverse events related to treatment and do the benefits outweigh the risks? What factors contribute to delayed healing and recovery
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ReviewingtheTMDscientificliterature
Clinicians are faced a confusing array of available literature if they choose to make evidence-based clinical decisions 44 or more different TMD treatments with over 150 clinical trials with diversity in;
Study designs Treatment techniques Study populations Outcome measures Success rates
MethodsforSystematicReviewof TMDTreatment Identify either meta-analysis of RCT or treatments with at least one randomized clinical trial (RCTs) Compare the outcomes and characteristics of RCTs Evaluate the quality of methods used in each RCT Capture results qualitatively and quantitatively Conduct meta-analysis and Forrest Plot when possible
Acknowledgements
Contributors James Fricton, D.D.S., M.S. Edward Wright D.D.S., M.S. John Look, D.D.S., Ph.D. Robert Rosenbaum D.M.D. Hong Chen D.D.S. Karen Decker R.P.T. Maureen Lang D.D.S., M.S. James Luderitz D.D.S., M.S. Mariona Mulet D.D.S., M.S. Francisco Alencar D.D.S.,M.S. Wei Ouyang D.D.S., M.S. Gary Anderson D.D.S.,M.S. Consultants Kathy Robbins, B.A. Informatics Richard Niederman, D.D.S, Ph.D. Wenjun Kang M.S. Informatics Sponsors American Academy of Orofacial Pain NIDCRs TMJ Implant Registry and Repository NIH-NIDCR Contract No. N01-DE-22635 NIH-NIDCR R01 No. DE11252-03 University of Minnesota School of Dentistry
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Splint Therapy
Splints have been suggested to provide protection to muscles and joints and help reduce oral habits
Type of Splint (7 RCTs: Quality=0.51) Hard Stabilization Splints Soft Splints Pain relief compared to placebo? 3+ 3=
1+
No placebo controlled RCTs conducted on repositioning splints, anterior bite plane, or other splints.
Forest plot from meta-analysis comparing active splints vs placebo splints (n=344)
Results show slight overall trend towards splint
Odds ratio and 95% confidence interval
Ekberg et al 1998, 1999 Raphael et al 2001 Ekberg et al 2003 Dao et al 1994 Rubinoff et al 1987 Wassell et al 2004
Favors placebo
Favors splint
Conclusion: Stabilization splints are better than placebo when used with more severe TMD patients and while sleeping at night.
Fricton, J, Look, JO, Wright, E, Alencar, F, Chen, H, Lang, M, Ouyang, W, Velly, AM. Systematic Review of Intraoral Orthopedic Appliance for Temporomandibular Disorders: 51 RCTs Reviewed. J Orofacial Pain 24:23754.2010.
Stabilization Splint
Design: Maxillaryormandibularfullcoverage Adjustment:evenposteriorcontactatclosure,anterior guidance,andcanineguidanceorgroupfunctioninlateral excursionswithnobalancingsidecontacts. Constructedtoguidedjawpositionandposturalrestposition (reclinedandsitting) Betterresultifitiscombinedothertreatmentmodalities(self care,exercise,behavioraltherapy) Worksbestinpatientswithhighlevelsofpainbutcanbeused withalllevelsofseverity
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TMJD
14 14
TMJD
20 18
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Occlusal dysharmony is only an associated factor in many cross sectional and longitudinal studies
(NS, P.05)
(NS, P.05)
(NS, P.05)
Occlusal Therapy
Occlusal treatmentsuchasocclusal adjustment,restorativedentistryand orthodontics(9RCTs)hasbeen suggestedtoprovideocclusal stability forthemusclesandjointandreduce eccentricforces
Type of Occlusal Treatment (4 RCTs: Quality=0.47) Occlusal Adjustment Restorative Dentistry (On-lays) Pain relief compared to placebo? 1 study + 2 studies =
1 study +
No RCTs conducted on orthodontics, orthognathic surgery, full crowns, or other occlusal treatments.
Forest plot from meta-analysis comparing occlusal adjustment vs placebo adjustment for TMD treatment (n=182) Results shows no overall difference between groups
Odds ratio and 95% confidence interval
Favors placebo
Fricton, J. Current Evidence Providing Clarity in Management of Temporomandibular Disorders: A Systematic Review of Randomized Clinical Trials for Intra-oral Appliances and Occlusal Therapies. Journal of Evidence based Dentistry. March issue, Vol 6, issue 1, pp 48-52, 2006
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Therapeutic Exercises
Jaw exercise (13 RCTs) has been found to improve range of motion of muscles and joints, relax muscles, improve posture and encourage healing
Type of Exercise (5 RCTs: Quality=0.62) Stretching exercise Resistance exercise Posture training Pain relief compared to placebo? 2+ 1= 1+ 1+
Forest plot from meta-analysis comparing exercise vs placebo for TMD treatment (n=150) Results shows exercise over placebo
Odds ratio and 95% confidence interval
Burgess et al. 1988 Dall Arancio et al. 1993 Minakuchi et al. 2004 Shata et al. 2000
Favors placebo
Favors exercise
Conclusion: Exercise show greater improvement than placebo in treating TMD pain and headache. Stretching and posture exercise should be used in cases of myofascial pain and TMJ pain disorders with limited range of motion.
-Fricton, J, Velly, A. Ouyang W., Look, J. Does exercise therapy improve headache? A systematic review with meta-analysis. Current Pain & Headache Reports 13(6):413-419, 2009.
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Strength of evidence: +++= > 4 positive RCTs, ++= 2 to 4 positive RCTs + =1 positive RCT, += conflicting evidence, - = negative RCTs, NA= no RCTs conducted
Forest plot from meta-analysis comparing CBT vs placebo for TMD treatment (n=633)
Odds ratio and 95% confidence interval
Bussone et al. 1998 Fichtel et al. 2004 Larsson et al. 2005 Loew et al. 2000 Wahlund et al. 2003
Favors placebo
Favors CBT
Conclusion: Cognitive behavioral treatments including oral habit instruction, relaxation, or biofeedback should be considered for TMD patients with self reported day or night oral habits or objective indications of them, anxiety, stress, feeling hurried as contributing factors.
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Splints (42 RCTs) Physical medicine and exercise (52 RCTs) Therapeutic Injections and acupuncture (21 RCTs)
stabilization and repositioning appliances, hard and soft PT modalities, stretching, function, posture, conditioning Trigger point injections, Botox injections, TMJ joint injections, acupuncture
Psychological therapies (21 RCTs) Cognitive-behavioral treatment, Biofeedback, Relaxation Pharmacologic therapy (44 RCTs) NSAIDS, acetominophen, tricyclics, SSRIs, muscle relaxants, benzodiazepines, corticosteroids, glucosamine/ chrondroitin, and opioids
Efficacy* +++
Comments
Consistent evidence for short-term efficacy of
reducing mild to moderate TMJD pain and tension type headache +++
Consistent evidence for TMJD pain, but their
++
type headache
Some evidence supporting use but evidence is
lacking for their mechanism of action, their relative efficacy, and their indications
TMJD pain.
Strength of evidence: +++ = > 4 positive RCTs, ++= 2 to 4 positive RCTs + =1 positive RCT, +- = conflicting evidence, - = negative RCTs, NA= no RCTs conducted
reduction
slower onset for relief than NSAIDs but also
pain but have insufficient evidence for the use in chronic TMJD pain or headache
Strength of evidence: +++ = > 4 positive RCTs, ++= 2 to 4 positive RCTs + =1 positive RCT, += conflicting evidence, - = negative RCTs, NA= no RCTs conducted
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Forest plot from meta-analysis comparing NSAIDs vs Acetominophen for TMJD/ headache pain (n=1434)
Odds ratio and 95% confidence interval
Schachtel et al., 1996 and Mehlisch et al., 1998 Packman et al. 2000 Steiner and Lange 1998
Favors Acetominophen
Favors NSAID
Conclusion: Plot shows a statistically significant net benefit (P < 0.01) associated with single oral doses of the nonsteroidal anti-inflammatories, ibuprofen or ketoprofen, when compared to acetaminophen
Forest plot from meta-analysis comparing Tricyclics vs Placebo for TMJD/ headache pain (n=484)
Odds ratio and 95% confidence interval
Bendtsen et al., 1996 Gobel et al., 1994 Holroyd et al., 2001 Langemark et al. 1990 Pfaffenrath et al. 1994
Favors Placebo
Favors Tricyclic
Conclusion: there is an overall trend towards showing favorable effects of the tricyclics compared to placebo (P = 0.368).
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Analgesic Abuse Headache I feel a lot better since I ran out of those pills you gave me.
TakeHome:TheNeedforIntegrative Care
What treatments have an active therapeutic effect beyond placebo? Splints, Exercise, Medication, and Behavioral therapy all have significant effects. They have a synergistic effect if used together in a multimodal approach to treatment Thus, use a team with complex patients Establish a problem list and treatment plan upfront
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(IRIS)thatintegratesinvestigators,staff,subjects,andproviders toconductpracticebasedresearch
SponsoredbyNIH/NINRRC201194201,Jacko PIand
NIH/NIDCRN0122635,FrictonPI
Usedbyassociationsand providergroupstobetterunderstand
theirclinicalpractices,theirpatients,andtoextendtheircare intothepatientslife.
NetworkPortals
InvestigatorPortal
SubjectPortal
PractitionerPortal
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New approach to healthcare Health providers are informed by each person's unique clinical, genetic, and personal characteristics Allows individualized care based on these factors Predict susceptibility and course of disease, improve treatment outcomes, and reduce adverse events
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