National Academies Press: OpenBook

Temporomandibular Disorders: Priorities for Research and Care (2020)

Chapter: 5 Caring for Individuals with a TMD

« Previous: 4 State of the Science on TMDs
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

5

Caring for Individuals with a TMD

Many patients here and around the world are lost, forgotten, and suffering. I cannot imagine that all of us here don’t share the hope that someday the approach to TMDs will be drastically different from what we have experienced, and continue to experience today.

—Michelle and Alexandra

Paired with the guilt we experience from doing “bad” things (talking too much, eating a sandwich), seeking out treatments that may help or may very well do harm, and from the stress we create that exacerbates our symptoms—this makes it particularly hard to be a TMJ sufferer.

—Sophia S.

Historically, the care of some individuals with temporomandibular disorders (TMDs), especially those with chronic and painful TMDs, has been fraught with challenges and complications. The committee identified several stumbling blocks in the evolution of effective care for individuals with a TMD, including the rise of multiple competing theories among different groups regarding what causes TMDs and how best to treat individuals with TMDs; minimal high-quality evidence about which treatments are appropriate for which patients; patient abandonment by clinicians who have exhausted their treatment capabilities; and a clouding of the role of surgery in care of patients with TMDs by harmful devices such as Proplast/Teflon- or silastic-based TMJ implants in the 1970s and 1980s.

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

This chapter discusses these challenges and describes the current state of prevention, detection, assessment, diagnosis, and treatment of TMDs. The final section of the chapter explores approaches for improving the evidence base for TMD treatments and patient care: conducting clinical trials, building a TMD patient registry, and developing clinical practice guidelines. Chapter 6 addresses other challenges to the caring for individuals with a TMD, including provider education, the medical–dental divide, the lack of access to specialty care, and payment and coverage issues.

FIRST, DO NO HARM

The multiple types of TMDs (see Chapter 2) and the extensive comorbidities often seen in patients with TMDs have posed a challenge to clinicians for decades. Correct diagnosis is the first barrier, and it is complicated further by confusing terminology and a lack of clarity about the causes and development of the disorders (see Chapter 2). As discussed in this chapter, management strategies are equally unclear, with limited or poor-quality data to support treatment decisions and siloed practices that limit the interactions of dental and medical health care professionals. Despite the best intentions of many of these professionals to improve the lives of individuals with a TMD and the positive treatment outcomes that many individuals with TMDs have achieved, significant challenges have led to inappropriate treatment and life-altering harm for some individuals.

Historically, patients suffering from a TMD have turned to dental and medical professionals for help, often to find little expertise available. Some are given non-evidence-based interventions, which can lead to a worsening of the disorder and unintended harm. One important historical example of a treatment approach that resulted in significant harm to patients involved the use of Proplast/Teflon-based implants in the temporomandibular joint (TMJ) in the 1970s and 1980s. These early TMJ implants reached the market through a streamlined regulatory pathway that required only demonstration of substantial equivalence to a device already on the market. Many patients who received Proplast/Teflon-based TMJ implants experienced serious adverse health events before the Food and Drug Administration (FDA) recalled these devices in 1990 (Ferreira et al., 2008). Because these ineffective and harmful implants have been removed from the marketplace, improved prosthetics have been developed. (See section below on implants.)

In addition to learning about this history of implants, the committee heard from many individuals with a TMD who have experienced a seemingly endless stream of interventions, continual frustration, and provider abandonment. Ineffective treatment often leads the patient to consult an increasingly diverse range of providers, and frustration and a sense of “not

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

being heard” can occur. This can be particularly true if a person’s original pain worsened or a new TMJ-related pain emerged as a result of treatment. Patients with chronic orofacial pain have said that it is important for health care professionals to be empathetic even when no effective treatments can be offered (Breckons et al., 2017). Some patients with a TMD grapple with resulting facial deformities, concerns about the long-term impact of implantable materials on physical health, and nutritional deficits. Persons with a TMD may face stigma for multiple reasons, including chronic pain, problems with chewing or speech, and alterations in their expressive facial features (see Chapter 7). Because pain is invisible, some stigma stems from a feeling of not being believed; some individuals describe being regarded as a malingerer by family, friends, or health care professionals. Given societal views regarding the importance of facial presentation, there is the additional potential toll of damaged self-concept, loss of self-esteem, and possibly shame due to changes in appearance.

Thanks to a combination of factors—patient advocacy groups such as The TMJ Association bringing concerns regarding harmful treatment to the forefront, the appearance of rigorous outcomes evaluation, honest results reporting by leaders in the TMD research community, and improvements in the basic science understanding of TMD—the field of TMD care has slowly become more evidence based; however, variations in care practices still exist. The recognition that some TMDs are systemic pain conditions with local manifestations around the TMJ, rather than a primarily orthopedic condition, has resulted in a shift away from surgery as a first-line treatment for most patients. As with the similar evolution of the management of low back pain (Deyo et al., 2014), surgery remains a critical component of TMD care for properly selected patients, but it is the primary treatment for few. Improvements in the understanding of joint physiology and in the diagnosis of TMD have supported these changes, bringing emphasis to holistic, patient-centered treatment and the avoidance of multiple and non-indicated invasive procedures.

When assessing the impact of disease management on the lives of patients, it is important to remember that harm can be caused either directly or indirectly. In the assessment of literature pertaining to treatments for individuals with TMDs, rarely can a small research study prove direct harm; rather, the outcome measure typically relates to treatment effectiveness. Proving direct harm from an intervention usually requires very large and well-designed studies—a rarity in the world of TMDs. Many treatment studies of TMDs have been generally poor with regard to adverse event collection methods and reporting (Gewandter et al., 2015). Moreover, indirect harm can also be caused by ineffective treatments. Most notably, the pursuit of ineffective treatment delays the receipt of optimal management. This delay can create disability, as preventing the exacerbation of symptoms and

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

dysfunction is lost. Furthermore, providing ineffective treatments can instill false hope in suffering individuals and their families as well as increase the costs of health care. It is through this lens that the committee examines management options for patients with TMDs in this chapter.

Chapter 6 discusses improvements needed in the health care management of individuals with TMDs including the proposal of centers of excellence for TMD care. The establishment of professional societies, such as the American Academy of Orofacial Pain, has helped to advance greater understanding and adoption of the role of scientific evidence in making clinical decisions by dentists and physical therapists who treat TMDs. Yet, many challenges remain in the optimization of TMD care. Among them is the minimal amount of high-quality data to guide clinical decision making, particularly regarding what treatment approaches are best for each specific type of TMD. This leaves well-meaning providers without reliable treatment strategies. When dentists and physicians feel handicapped by this lack of clarity, they must always fall back on their core principle of primum non nocere, “first, do no harm.” Cautious and collaborative management is the rule.

PREVENTION AND EARLY DETECTION

The cornerstone of the progressive management of disease is prevention. Some individuals with a TMD report a history of non-painful TMJ mechanical dysfunction and joint noise, often in their teenage years. While many patients who describe these findings will not progress to painful TMD, some individuals will experience a significant escalation of the pain and disability with no obvious external impetus or event. The committee received reports from individuals with a TMD who experienced a physical trauma to the TMJ area or face, a prolonged or unanticipated dental procedure that sparked their TMD pain, or no particular event that led to their TMD. Primary prevention strategies are handicapped by the lack of research aimed at more fully understanding the role of various physical traumas or prolonged dental experiences in leading to chronic, painful TMDs in some individuals.

With so little known about the causes and development of TMDs, primary prevention strategies have focused mainly on behaviors such as eating soft food and avoiding items like apples or large sandwiches that require excessive jaw opening. Although commonly suggested as a potential cause, no studies have implicated routine orthodontic treatment in the development of a TMD. Major head trauma may not be preventable, but it may be reduced by traffic safety and substance abuse laws. Minor jaw trauma has also been proposed as an etiologic mechanism of TMDs, and it may be avoidable via educational strategies. Examples of such minor trauma are

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

a traumatic intubation during an operation, excessively long restorative dental treatment requiring sustained wide mouth opening, poorly designed intraoral splint therapies, and similar interventions. While no data have confirmed that any symptoms from these minor traumatic events signify that these events have an etiological role in the development of TMDs, educating providers about these possible risks and about strategies to avoid such trauma when possible may be beneficial. For instance, dentists can offer a simple bite prop during longer dental treatments that require wide mouth opening.

Another prevention strategy is early recognition and management of the biological and psychosocial contributors to TMDs, including comorbid medical conditions such as juvenile idiopathic arthritis and other rheumatologic diseases. While juvenile idiopathic arthritis can affect any synovial joint, the TMJ can be disproportionally involved. Across all subtypes of juvenile idiopathic arthritis, the rate of TMJ involvement ranges from 39 to 75 percent (Resnick et al., 2016). In a study of adult patients with a history of childhood juvenile idiopathic arthritis, 62 percent reported TMJ pain, 43 percent had functional limitation of the jaw, and 76 percent had lower facial asymmetry (Resnick et al., 2017). Recent work on increased recognition and early diagnosis of TMJ involvement (Resnick et al., 2016) has led to more aggressive treatment with medications that target the inflammation caused by the condition, which may decrease the incidence of future TMDs in this population. A similar push toward the early diagnosis and management of other factors that cause or contribute to TMDs may decrease future morbidity.

The early treatment of malocclusion through orthodontic treatments was previously considered a viable preventive treatment for TMDs. However, the evidence was clear decades ago that orthodontic repositioning of teeth does not prevent the onset of a TMD (McNamara, 1997). Nevertheless, some dentists have the outdated belief that orthodontic treatment will prevent TMDs.

Prevention must not stop at the onset of a TMD. While data are starting to emerge from observational studies regarding the premorbid risk factors for TMDs (Ohrbach et al., 2020), there is little evidence concerning the early recognition and prevention of TMDs, so much of the prevention effort must take place after diagnosis. In a patient who has already developed the symptoms of a TMD, the prevention strategy becomes aimed at avoiding the progression of the disorder from a localized issue of the TMJ to a systemic pain condition that also affects regions of the body outside of the face. This secondary prevention approach requires close collaboration between the individual and his or her health care professional to avoid over-treatment, iatrogenic harm, or an aggravation of a TMD and to identify self-care or other interventions that may decrease the negative impact of the

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

disorder on that individual. Finally, in those patients who have developed TMDs along with widespread or multiple-site pain, a tertiary prevention strategy aims to minimize escalation to high-impact pain, which causes disability that limits work productivity and the ability to enjoy life.

ASSESSMENT AND DIAGNOSIS OF TMDs

Following the publication of the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) (see Chapter 2), a central concern was whether the DC/TMD in its present form is appropriate for clinical use. One question common to various critiques is: When is a diagnostic system “good enough” to rely on for clinical diagnosis? Part of the answer revolves around the further question: What is the alternative? Clinical dentists have reported, across many countries and health care systems, not using the DC/TMD because they deem it to be too complicated or incapable of diagnosing all TMDs. As noted in Chapter 2, there are more than 30 specific TMDs. Furthermore, some of these TMDs will occur simultaneously in the same patient. At present there is no empirical evidence indicating which treatments are most effective for a given DC/TMD classification.

A limitation common to all classification systems is that biology and pathology are continuously variable, while classification systems, in order to enhance their reliability and validity, construct disorders with fixed boundaries. Individuals will have disorders that fall outside the classification boundaries. For pain disorders, there may be notable variability around an identified phenotype, which may require particularly diffuse boundaries for a given diagnosis. Users of the diagnostic test need to have excellent decision-making skills as well as tools that can aid in those decisions. Challenges to using a diagnostic system such as the DC/TMD in clinical care include:

  • The need for clinicians to have diagnostic tests that are simple and fast;
  • Current reimbursement schedules for dentists that are focused on oral examination;
  • Substantial clinical time required for a comprehensive history and adequate physical examination;
  • Limitations in training on TMDs;
  • The difficulties that clinicians face in having the time to consider the clinical implications of reliability and validity, the probabilistic basis underlying sensitivity and specificity, and the base rate influence on predictive values, with regard to whether a diagnostic test is useful; and
  • The current lack of formal decision rules to assist clinicians.
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

No system can substitute for the provider’s critical decision-making skills, but decision making is greatly enhanced when reliable and valid procedures are used and when decision-making tools are built for practical use in clinical situations (Kassirer and Kopelman, 1991). Implementation research is needed, as discussed in Chapter 4, to assist clinicians in assessing complex disorders such as TMDs.

A clinical assessment for TMDs should include talking with the patient to hear the history of the symptoms and problems, an examination, special tests such as imaging when indicated, and psychosocial assessment (Schiffman et al., 2014). A pain history is recommended as a necessary part of the DC/TMD (Schiffman et al., 2014). This requires knowledge of differential diagnoses and of pain characteristics (Blau, 1982). An adequate pain history provides the necessary level of detail within each of the following attributes: timing (onset, duration, periodicity); location and radiation; quality and severity; relieving and aggravating factors (e.g., the effect of hot or sweet foods, prolonged chewing, eating, brushing of teeth, touching the face, weather, physical activity, posture, stress, and fatigue); associated factors (e.g., taste, salivary flow, clenching, bruxing habits, locking or clicking of jaw joint, altered sensation, and nasal, eye, or ear symptoms); other pain conditions (e.g., headaches, back pain, chronic widespread pain, and fibromyalgia); and other aspects of pain (e.g., sleep, mood, concentration, beliefs, and the quality of life). In diagnosing a pain disorder, the pain history is key because there are no confirmatory examination procedures or tests; to diagnose a specific type of TMD this history is also critical because only the history can provide the necessary information to guide prognosis and treatment selection.

While medical history taking is part of most practitioners’ training, taking a pain history may not be, and a psychosocial history is quite often outside a practitioner’s skills, or it may be set aside due to time constraints. Moreover, it may be difficult for a dentist to assess psychosocial status, as patients often regard it as unexpected if not inappropriate in a dental setting, while dentists often regard it as not part of dentistry. Actions for overcoming barriers to implementing the biopsychosocial model in clinical practice settings are being explored (Sharma et al., 2019).

The current standard for an examination pertinent to TMDs includes specific tests of the masticatory system and, when indicated, TMJ imaging. The examination should assess facial symmetry and extraoral soft tissues, jaw mobility and functional impact (e.g., limited mouth opening), possible disc disorders (TMJ noises, condylar deflection while opening during the acute stage), and the overall pattern of replication of pain from jaw mobility testing and extraoral muscle palpation. As described by Schiffman and colleagues (2014), an evaluation for overt changes in the stability of the occlusion as a consequence of degenerative joint changes is warranted as

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

part of an initial examination. The clinical tests and imaging protocols and interpretation standards are well described (Ahmad et al., 2009; Li et al., 2012).

To address the time limitations faced by the practicing dentist, a brief form of the DC/TMD examination procedures is currently being developed by an international group via the International Network for Orofacial Pain and Related Disorders Methodology. The brief procedures are expected to yield sufficient examiner reliability and diagnostic validity for the diagnosis of DC/TMD pain disorders. The reliability and validity of the clinical procedures for internal displacements and degenerative joint disease of the TMJ are expected to remain poor, and clinical decision-making skills will be required, as they are now, to decide when the history and clinical examination need to be accompanied by imaging of the TMJ. For the uncommon TMDs, other clinical tests are required (Peck et al., 2014), but these are not yet operationalized and hence not considered reliable. Nevertheless, these indicated tests represent the current best practice for the assessment of the uncommon TMDs.

Conclusion 5-1: Clinical assessment using the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) allows for the identification of patients with temporomandibular disorders ranging from simple to complex presentations, and the DC/TMD is appropriate for use in a range of clinical settings. Ideally, the DC/TMD would be used during the first patient visit and selectively thereafter for monitoring treatment progress.

TMD TREATMENTS

There are a wide variety of potential treatments for TMD, including self-management, physical therapy, medications, occlusal adjustments, intraoral appliances, and surgery. Evidence-based clinical practice guidelines for the treatment of TMDs do not currently exist, despite the fact that treatment is common. In one study of people who developed a TMD, 57 percent reported having received one or more treatments during a 6-month follow-up period (Slade et al., 2016). Evidence about the safety and efficacy of these treatments is sparse; many of the research studies that have been conducted are insufficiently powered to produce solid conclusions, lack appropriate comparison or control groups, are missing standardized outcome measures, or focus on individual interventions without the context of holistic patient care.

Many studies use pain intensity or similar measures as the outcome of interest, rather than measuring such outcomes as quality of life; physical, social, and psychological well-being; or restoration of function. While

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

reducing pain is an important goal for many patients, patients may also benefit from treatments that restore their ability to live, work, and play. Similar to the evolution in understanding of outcome measures for individuals suffering from low back pain, the goals of TMD care should focus on functional rehabilitation, that is, an individual’s ability to thrive despite the presence of the disease.

The following sections describe common TMD treatments and the evidence that is available about these treatments. This section is not intended to serve as a systematic literature review, but rather as a summary of published data. Recent systematic reviews are included where available as are Cochrane Collaboration reviews and meta-analyses; a frequent conclusion in the systematic reviews regarding clinical trials of treatments for TMDs is that methodological quality is generally low.

The treatments in this section are organized by type of intervention as follows: (1) psychological/behavioral/self-management, (2) physical, (3) complementary, (4) pharmacological, and (5) interventional. It is important to note that most current TMD treatments lack strong evidence to support or reject their use. The two exceptions to this rule are (1) self-management, for which there is strong evidence for improved outcomes in patients with chronic pain, although much of this evidence is not specific to individuals with TMDs, and (2) occlusal treatments, concerning which a large body of research exists, with the effectiveness of occlusal management in individuals with TMDs not having been consistently demonstrated.

In considering the appropriate role for evidence in making treatment decisions, strong evidence supporting the use of a particular type of treatment (e.g., self-management) and strong evidence against the use of a particular type of treatment (e.g., occlusal treatments) should be regarded as a starting point in choosing treatments in the spirit of the requirement to “do no harm.” Despite the evidence that is available, outdated beliefs about commonly recommended therapies can result in harm to individuals with a TMD. It is notable that the TMJ Patient-Led RoundTable reviewed information from 24 professional organizations claiming to diagnose and manage TMDs and found a wide variety of beliefs and guidance (Kusiak et al., 2018).

Historically, a lack of recognition and adoption of available evidence related to TMDs led many clinicians to avoid acceptance of new science which has led to poor treatment decisions and outcomes for many individuals with a TMD. When strong evidence becomes available about TMD treatments, interventions need to be implemented at the level of medical and dental school curriculum and residency. Waiting until clinicians are established in practice to try and motivate changes in their behavior may be too late. In addition, multiple system-level drivers impact the treatment approaches chosen for individuals with a TMD. The dental education and

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

care delivery has much room for improvement to (1) foster a culture of support for evidence-based treatments during training and once a dentist is in private practice, and (2) influence clinician behavior through system-level changes (e.g., paying for appropriate care and not paying for inappropriate care).

Psychological/Behavioral/Self-Management Treatments

Self-Management

Self-management, alone or in conjunction with other treatments, is a keystone of care for many chronic conditions, including TMDs (Dworkin et al., 2002; Türp et al., 2007; Greene, 2010; Kotiranta et al., 2014). Self-management refers to the tasks an individual engages in to live with a chronic condition (Adams, 2010). When one thinks of the self-management of TMDs, the tasks that typically come to mind are those related to medical management (e.g., taking one’s medications, doing jaw positioning exercises, and returning for follow-up visits). When TMD symptoms persist, however, individuals are often dealing with additional tasks such as managing their roles (e.g., as partners or workers) and managing emotions (e.g., dealing with emotional distress).

For some, the term “self-management” has negative connotations. First, some patients and health care professionals may believe that self-management means that patients should cope with their conditions primarily on their own. Instead, self-management is best understood and practiced as a way of expanding the patient’s agency over his or her condition and its treatment, in partnership with medical specialists and others in their network.

Second, individuals may believe that “self-management” means that they must triumph over or somehow conquer all aspects of their conditions. As a result, they may interpret their own inability to avoid certain negative consequences of a medical condition (e.g., flares in pain due to joint degeneration) as personal failures (i.e., that they are “poor self-managers”). Yet, a key element of self-management is educating individuals about their conditions so that they can better understand and prepare for outcomes that are part of the disease trajectory.

Learning self-management

A variety of ways are available to learn how to engage in the self-management of TMDs, including self-, peer-, and therapist-guided approaches. Many people with a TMD use self-guided approaches to learn some aspects of self-management on their own. For example, individuals with a TMD might find that the strategies they have found effective in dealing with other challenges in their lives (e.g., using

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

meditation or relaxation strategies, setting goals, staying involved in meaningful activities) are effective in managing a TMD. Alternatively, individuals might acquire strategies for managing a TMD from outside their own experiences, for example, by drawing on educational resources provided by a provider or on the Internet, reading self-help books on TMDs, or observing others who have coped with a TMD or other chronic medical conditions. Peer-guided self-management, on the other hand, is a more formal approach that uses a curriculum to educate patients about their conditions and teach self-management skills in group sessions. It features peer leaders who, because of their lived experience, have high credibility and can be powerful sources of support for helping individuals identify and cope with obstacles to self-management efforts. Peer training is often provided in a format that fits with participants’ language and cultural needs. Finally, therapist-guided self-management approaches combine a psychoeducational rationale with techniques drawn from cognitive-behavioral therapy (CBT) and biofeedback. These approaches are systematic (e.g., use standardized treatment protocols and manuals) and emphasize experiential learning (therapist modeling, guided practice, and supportive or corrective feedback) and the importance of home practice in mastering learned skills. Therapist-guided approaches have the advantage of being led by a trained health professional, often a psychologist. A professional is often in a better position to tailor training to the participants’ needs and past experiences, to provide knowledgeable feedback, and to recommend novel approaches that the participants might not have considered.

Evidence of efficacy

A number of meta-analyses and systematic reviews have examined the effectiveness of self-management approaches for chronic pain conditions in general (Hoffman et al., 2007; Williams et al., 2012; Morley et al., 2013; Pike et al., 2016) and chronic orofacial pain and TMDs more specifically (Aggarwal et al., 2011; Liu et al., 2012; Randhawa et al., 2016).

The most recent systematic review—by Aggarwal and colleagues (2019)—sought to examine whether formal training in self-management techniques (primarily CBT and biofeedback) is more effective than control conditions in improving long-term outcomes (>3 months) in terms of pain intensity and psychosocial well-being. The researchers’ search of the literature yielded a total of 14 randomized clinical trials that met their criteria for inclusion. All of these trials tested the effects of CBT, biofeedback, or both in patients with chronic orofacial pain or a TMD (12 of 14 studies focused on individuals with a TMD). Table 5-1 presents the CBT and biofeedback protocols used in several of these trials as well as a summary of the findings. The protocols shared several key features: (1) they were led by experienced and trained therapists (usually psychologists), (2) they provided participants

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

TABLE 5-1 Selected Randomized Clinical Trials of Cognitive-Behavioral Therapy (CBT) Interventions for TMD

Study Authors Key Treatment Components Treatment Format Findings
Turner et al., 2006
  • Rationale for CBT approach
  • Self-monitoring of use of learned skills
  • Progressive relaxation training
  • Checking and correcting jaw posture
  • Abdominal/diaphragmatic breathing
  • Goal setting to increase activity
  • Cognitive restructuring to identify and change overly negative thoughts
  • Home practice assignments
  • Problem solving around obstacles to practice of learned skills
  • Relapse-prevention training to promote maintenance and deal with setbacks
4 sessions
6 follow-up phone calls
Delivered by licensed clinical psychologists with experience in CBT
Compared to the control group, the group that received CBT skills training showed greater improvement at 3, 6, and 12 months on measures including use of relaxation techniques, activity interference, pain intensity, jaw function, and depression.
Litt et al., 2010
  • Rationale for CBT and using EMG biofeedback approach
  • Relaxation training
  • EMG biofeedback to reduce masseter muscle activity
  • Habit modification to reduce clenching and bruxing
  • Cognitive restructuring to identify and change overly negative thoughts
  • Stress management training
  • Home practice assignments
6 sessions
Delivered by master’s-level therapists with experience in CBT
Compared to the control group, the group that received CBT skills training showed steeper decreases in pain over time, particularly for those who were low in somatization or high in readiness or self-efficacy.
Ferrando et al., 2012
  • Rationale for combined CBT-hypnosis approach
  • Functional analysis to identify antecedents and consequences of problem behaviors/patterns
  • Hypnosis training to enhance relaxation, positive mood, and the use of imagery
  • Hypnosis to support self-suggestions for pain relief, reduction of pain and anxiety, reduction of tension in jaw
  • Activity planning
  • Assertiveness training
  • Relapse-prevention training
6 sessions
Delivered by master’s-level psychologist with experience in CBT
Compared to the control group, the group that received a CBT intervention that included hypnosis showed higher improvement in frequency in pain and emotional distress.
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Study Authors Key Treatment Components Treatment Format Findings
Shedden-Mora et al., 2013
  • Rationale for combined CBT-biofeedback approach
  • Lab-based EMG biofeedback to reduce muscle activity in masseter, temporalis, frontalis, and trapezius muscles
  • Home EMG biofeedback training to decrease daily and nocturnal jaw muscle tension
  • Lab-based biofeedback to lower autonomic arousal (i.e., feedback of skin conductance, finger temperature, and breathing)
  • Progressive relaxation training to assist biofeedback
  • Habit reversal training to reduce clenching/bruxing and promote jaw relaxation
  • Learning to challenge overly negative thoughts
  • Relapse-prevention training
  • Training in problem solving skills
8 sessions
Delivered by master’s-level psychologists with experience in CBT
Compared to the control group, the group that received biofeedback-based CBT showed larger improvements in pain coping skills and reported higher satisfaction with treatment and improvement.

NOTE: EMG = electromyography.

SOURCE: Adapted from Aggarwal et al., 2019.

with a psychoeducational rationale at the start of self-management training, and (3) they combined in-session experiential skills training with home-based practice assignments.

Several key findings emerged from that systematic review. First, at long-term follow-up, therapist-guided self-management was significantly more effective than control conditions in reducing pain intensity, depression, activity interference, and muscle palpation pain. Second, many of the studies included positive methodological features such as random assignment to one or more control conditions, well-described inclusion and exclusion criteria, a comprehensive set of well-validated outcome measures, and assessments of both short- and long-term outcomes. Third, as a group these studies were rated as having a low risk of bias, and the quality of evidence for the key outcomes was rated as high (Aggarwal et al., 2019). Taken together, these findings provided support for the efficacy of therapist-guided self-management (CBT and biofeedback) for TMDs.

The efficacy of peer-guided self-management has not been as widely studied in TMDs, though systematic reviews and meta-analyses conducted

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

on this approach in other chronically painful conditions (Jackson et al., 2014) and chronic diseases (Holden, 1991) have provided empirical support for its efficacy.

The future of self-management

Considered overall, it seems fair to conclude that there is growing recognition that self-management is important in care of TMDs. Persons with a TMD can learn self-management skills in a variety of ways. To date, evidence for the efficacy of self-management training has come primarily from randomized controlled studies of therapist-guided self-management training. Although the results are supportive, the total number of studies is relatively small, with most of them focused on CBT and biofeedback.

Much more needs to be done to advance the practice and science of self-management of TMDs. First, there is a need to involve patients, their families, health care professionals, and other key stakeholders in the review and evaluation of current TMD self-management materials and resources and peer-led and therapist-led self-management training protocols. Such a review could lead to the development of updated and tailored self-management materials. The availability of high-quality resources not only could heighten the impact of self-management approaches on patients and their families, but also could enhance health care providers’ awareness of self-management and knowledge about and skills in fostering self-management. Second, there is a need for programmatic research to develop and test novel self-management programs for individuals with a TMD. Novel psychosocial interventions (e.g., acceptance and commitment therapy, partner-assisted and couples-based training in self-management) and novel treatment delivery formats (e.g., eHealth approaches such as video over the Internet) could be more widely explored in TMD care. Third, although novel theoretical frameworks are available to guide the development of self-management interventions (e.g., the National Institutes of Health [NIH] stage model) that can be readily disseminated, these have not received much attention in the TMD area. These theoretical frameworks are important in guiding treatment development and in addressing the key limitations of the current TMD literature, including the need to involve patients and real-world providers in the development of training materials and methods, the need to link intervention components to theory, and the need to streamline treatments to make them easier to disseminate. Fourth, with the growing recognition that TMDs are a set of complex and multidimensional conditions has come heightened interest in the variance in how people respond to training in self-management. Finally, although there is evidence that formal training in self-management can be effective, much less is known about how it works. Research suggests that changes in measures of self-efficacy or in the perceived ability to control pain occurring

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

over the course of training are important in explaining improvements in pain and other outcomes (Lorig et al., 1989). Research is needed to identify other critical potential mediators of self-management training in TMD care. Among the potential key mediators are changes in biological responses (e.g., immune activity, changes in spinal cord responses to noxious stimuli, or activation of descending pain modulatory systems in the brain) and emotional responses (e.g., stress responding, emotional regulation). Box 5-1 lists a number of other important research priorities in this area.

Conclusion 5-2: Self-management and patient education can be important components of care of temporomandibular disorders (TMDs). People with TMDs need access to self-management resources, including formal training. Research is needed to test and refine self-management interventions in order to identify which techniques are most effective, to determine which patients are most likely to see benefits, and to understand the mechanisms of self-management for TMDs.

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

Physical Treatments

Occlusal Treatments

As described in Chapter 2, discrepancies between an individual’s dental occlusion (how teeth fit together) and the ideal occlusion, as defined by a range of attributes, have been a target for TMD treatment for more than 50 years. Occlusal treatments modify the teeth and bite. Intraoral appliances fit over the teeth and do not modify the teeth or bite (see section below on intraoral appliances). A 2017 protocol for evaluating the effectiveness of occlusal interventions for managing TMDs has been approved by Cochrane, but the review is not yet complete (Singh et al., 2017). Occlusal approaches, and available evidence-based status, include:

  • Occlusal adjustment: modifying the teeth through the addition of fixed crowns or removable devices in order to change the positioning of the lower jaw relative to the upper jaw. A 2003 Cochrane review found no difference between the group receiving occlusal adjustment and the control group (Koh and Robinson, 2003); the review was withdrawn in 2016 due to being out of date and not meeting Cochrane’s current methodological standards (Cochrane Library, 2016a).
  • Occlusal equilibration: adjusting the occlusion by removing enamel from the chewing surface of the tooth in order to modify the manner in which the teeth achieve full closure or the manner in which the teeth move past each other as the lower jaw is moved to the side or to the front. This approach has also been called selective grinding—when a dentist grinds one or a few biting surfaces of an individual’s teeth to improve the interaction of those teeth with the teeth on the opposing jaw. A 2018 assessment of the literature found no evidence to support its use (Manfredini, 2018).
  • Orthodontic treatments: the repositioning of some or all of the teeth with the goal of improving an individual’s bite. A Cochrane review (Luther et al., 2010) found that there were insufficient data available to inform clinical practice on the effectiveness of orthodontic treatments in reducing TMD symptoms. In 2016 the review was withdrawn due to being out of date and not meeting Cochrane’s current methodological standards (Cochrane Library, 2016b).

The time and cost for these different treatments vary. Full orthodontic treatment typically requires 2 to 3 years, and the cost depends on the geographic area. Adjusting the occlusion can require anywhere from a single treatment session to a series of recurring sessions over many years, which

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

are often stopped not because of therapeutic success but because of the tooth sensitivity that is inevitable with enough removal of enamel. Modifying the teeth through crowns or removable devices can require up to several years of treatment and cost thousands of dollars.

As discussed in Chapter 2, the current Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) considers the stability of the occlusion as a common symptom of degenerative joint disease but not as part of the diagnosis of a TMD. Over recent decades, research has not found sufficient evidence to support claims that dental occlusion is an important contributor toward TMDs (Clarke, 1982; Clark et al., 1999; Fricton, 2006; Klasser and Greene, 2009; Türp and Schindler, 2012). However, publications and position papers within the dental community often continue to promote the role of occlusion in diagnosing and treating individuals with TMDs (Dawson, 1996; Cooper, 2011; Racich, 2018).

Several studies have found that occlusion and a particular position of the TMJs (which includes freedom to move posteriorly relative to the fully closed occlusion) may actually be a protective factor for TMDs and an important adaptive response of the body (Levy, 1975; Pullinger et al., 1988). This research would suggest that treatment to correct the so-called “slide” in mandibular position (see Chapter 2) is misdirected as a treatment for TMD. The relationship between head posture and the closing position of the mandible and resultant stability of contact between lower and upper teeth reflects a complex interaction between cervical and masticatory systems (Mohl, 1984; Southard et al., 1990), highlighting the importance of understanding TMDs within broader frameworks (e.g., the role of the cervical system for both pain and mechanical jaw function). This contrasts with the common but unsupported belief that head or body posture problems are caused by TMDs (Manfredini et al., 2012), which is sometimes used to justify TMD treatments. Collectively, this type of information continues to not be typically incorporated into working clinical knowledge and research attention to these areas has waned over the years.

Intraoral Appliances (Splints)

Intraoral appliances, or laboratory-fabricated devices that fit over the teeth, are known by a wide variety of names such as splints, stabilization appliances, occlusal splints, occlusal appliances, interocclusal splints, fully balanced splints, repositioning splints, bruxism splints, nightguards, and several names denoting the commercial vendors of particular splint designs; the selected name usually relates to the perceived mechanism of action, for which evidence remains absent. Therefore, the theory-neutral term “intraoral appliance” is used. Intraoral appliance treatment is distinctly different than treatments that modify the occlusion (e.g., occlusal adjustment,

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

occlusal equilibration, and orthodontic treatments), which are described in the previous section.

The mechanism of action of intraoral appliances is unclear. When used during sleep, they were originally believed to stop sleep bruxism, but it became apparent that bruxism behavior decreased for some individuals, stayed the same for others, and increased for yet others, and this was independent of whether the symptoms improved (van der Zaag et al., 2005). Since then, the relationship between increased activity of the masticatory muscles during sleep and morning symptom reports has, if anything, become more uncertain, raising further questions regarding this treatment modality. As the real mechanism of action has still not been determined, the utility of one type of splint over another (e.g., a stabilization splint that separates the teeth but does not change the position of the jaw versus a repositioning splint that advances the mandible to a changed position) is similarly unclear. Data comparing several types of splint designs have not shown significant differences between them (Jokstad et al., 2005).

Data regarding the effectiveness of intraoral appliance therapy in the treatment of TMDs is generally of poor quality and yields mixed results (see Box 5-2). In one study of 51 participants with myofascial pain with or without limited jaw opening, those who received an intraoral appliance and received information about behavior changes reported earlier significant improvement in pain scores than those in a control group with no appliances (Conti et al., 2012). A study of 112 patients with painful TMDs who were randomly assigned to an anterior repositioning splint or biostimulation laser therapy found that the splint group had a greater decrease in pain intensity (Pihut et al., 2018). In a randomized trial of 81 patients with TMDs that were assigned to treatment groups including intraoral splint therapy, manual therapy, and counseling, all therapies were found to be effective in improving pain and quality of life, but no therapy was superior to another (de Resende et al., 2019). Many other studies have similarly shown intraoral appliance therapy to have minor or equivocal benefits for the improvement of pain in patients with TMDs.

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

While harms associated with TMJ surgery have been extensively investigated, the harms associated with intraoral appliances are less well understood. The committee was not aware of any specific literature that describes complications associated with intraoral appliances. Anecdotally, these harms include alteration in the occlusion or position of the teeth, aspiration of small appliances worn on the anterior teeth, dependence on a device and not acquiring self-management skills, and perpetuation of a belief that something is wrong with the masticatory system such that the appliance is necessary to “fix” it. Systematic research is needed to assess harms associated with occlusal appliances.

Several attempts have been made at meta-analyses and systematic reviews of the utility of intraoral splints in patients with TMDs. In 1999 a qualitative systematic review concluded that intraoral splints may be of some benefit in the treatment of TMDs but that the evidence to definitively support this conclusion was lacking (Forssell et al., 1999). In 2004 another qualitative systematic review indicated that most individuals with masticatory muscle pain are helped by intraoral appliances such as a stabilization splint but concluded that the evidence was uncertain as to whether the improvement in symptoms was caused by a specific effect of the appliance (Türp et al., 2004). A 2017 meta-analysis that included 30 randomized controlled trials found stabilization splints to have short-term benefits on pain reduction and pain intensity but no differences in long-term outcomes with other types of treatments (Kuzmanovic Pficer et al., 2017). In summary, intraoral splint therapy may confer a small benefit for the management of pain in individuals with TMDs, but the evidence for this is generally poor and mixed.

Physical Therapy

Physical therapists are fully integrated into the modern health system and work to meet the interdisciplinary and interprofessional management needs of individuals with chronic pain. Physical therapists are increasingly serving as primary care providers and may provide a gateway into the health care system for people with a TMD. Physical therapists use multiple approaches to the management of TMDs, including exercise, manual therapy, and education on self-management skills (see section on self-management above). Other therapies offered by physical therapists include electrotherapy and dry needling; these treatments need more evidence to support their use (see below).

Exercise

Exercise is considered a first-line treatment in the physical therapy management of TMDs. For other chronic pain conditions, like fibromyalgia and low back pain, clinical practice guidelines recommend

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

exercise as one of the first-line treatments (Kia and Choy, 2017; Oliveira et al., 2018). There are several types of exercise that may be effective in the management of TMDs. These include jaw strengthening, jaw stretching, and postural exercises.

  • Jaw strengthening exercises: Some studies support the effectiveness of exercises to build jaw strength and endurance, with or without stretching exercises, in improving pain, jaw opening, and TMJ sounds/clicking (Haggman-Henrikson et al., 2018; Wanman and Marklund, 2019). A study using supervised exercise training showed greater improvements than home exercises alone (Wanman and Marklund, 2019). Other publications, however, have not demonstrated as much benefit (Craane et al., 2012).
  • Jaw stretching exercises: Some clinical trials show that home exercise aimed at stretching the soft tissue around the jaw muscles increases jaw opening and may decrease pain. However, other studies do not show an effect of stretching exercises, whether applied by a physical therapist or by the patient in a home program (Armijo-Olivo et al., 2016). Meta-analyses, however, indicate overall benefit of stretching to regain normal jaw opening for both myalgia and clicking problems (Armijo Olivo et al., 2016).
  • Postural exercises: Individual studies and reviews have demonstrated some effectiveness of active and passive exercises that improve posture in reducing pain and improving the range of motion (McNeely et al., 2006; Medlicott and Harris, 2006). However, the methodological quality of the studies was found lacking (McNeely et al., 2006; Medlicott and Harris, 2006).

A recent systematic review and meta-analysis of exercise for TMDs (Armijo-Olivo et al., 2016) performed an extensive analysis of multiple types of exercise therapy. The review showed that jaw exercises were associated with a clinically significant increase in pain-free mouth opening and that postural exercises were associated with clinically significant increases in pain-free mouth opening as well as reductions in disturbances in daily living. It should be noted, however, that the researchers identified that no high-quality evidence was found and caution is warranted due to the low quality of the studies, large heterogeneity, and the small number of subjects per study.

One benefit of exercise in general (e.g., possibly more than jaw stretching or strengthening exercises) for patients with TMDs may be exercise-induced analgesia, the underlying mechanisms of which recent research has begun to uncover. In addition to improving function by increasing the range of motion, strength, and motor coordination of the joint and

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

muscles, exercise can also alter the immune system and the nervous systems in ways that promote healing and reduce pain (Brito et al., 2017; Lima et al., 2017a,b; Sluka et al., 2018). In addition, in chronic pain conditions, there are decreases in serotonin and increases in the serotonin transporter, both of which are normalized by regular exercise (Brito et al., 2017; Lima et al., 2017a,b; Sluka et al., 2018). In human subjects with chronic pain, researchers have found an interaction between the serotonin transporter gene and the mu-opioid gene that is associated with increased analgesia (Tour et al., 2017).

Understanding the underlying mechanisms by which exercise reduces pain and improves function may be important when designing exercise programs for individuals with TMDs. For example, if individuals with TMDs have a comorbid inflammatory condition or widespread pain with altered central nervous system processing, an aerobic conditioning program may be useful in both improving function and reducing pain. On the other hand, if there is significant weakness of the jaw muscles, more localized stretching and strengthening exercises are likely to improve function and may have a secondary effect of reducing pain.

Manual therapy

The aim of manual therapy is to increase motion by stretching the soft tissues and muscles surrounding a joint. Recent evidence suggests that manual therapy also directly affects nociceptor and central nervous system activity to reduce pain (Skyba et al., 2003; Bialosky et al., 2009; Martins et al., 2011, 2012, 2013a,b). Stretching of peripheral tissues can reduce inflammation, remodel fibroblast connective tissue structure, and increase the expression of muscle healing genes (Langevin et al., 2013; Berrueta et al., 2016). As stretching of peripheral tissues is an active component of manual therapy, these mechanisms may be particularly important in the resolution of a TMD with a peripheral inflammatory or connective tissue component. A recent systematic review found that manual therapy (soft tissue mobilization) can produce a clinically significant reduction in pain (Armijo-Olivo et al., 2016). Cervical mobilization in those with myofascial origin or craniofacial pain led to a clinically significant reduction in pain in one preliminary study (Armijo-Olivo et al., 2016). Unfortunately, the quality of the evidence in support of these treatments is poor, partially due to large heterogeneity between the studies and their small sample sizes.

Manual therapy and exercise are often combined; neither is frequently done as a stand-alone treatment. The review by Armijo-Olivo and colleagues (2016) examined data from seven studies and showed that manual therapy with exercise decreased symptoms of TMDs and increased the mouth opening and range of motion. These changes were of moderate effect sizes.

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

Conclusion 5-3: Some elements of physical therapy—including exercise and manual therapy—have been shown to improve pain and functional outcomes for individuals with temporomandibular disorders. However, many of the studies are of low quality and further research is needed to support the use of these treatment modalities.

Other Physical Therapy Interventions

In addition to exercise and manual therapy, there are a number of other physical therapy treatments for TMDs that are used clinically but which lack clinical evidence or have varying degrees of evidence. These include the use of heat and cold therapy, low-level laser therapy, and dry needling. Heat and cold therapy are often recommended as part of a self-management program and are inexpensive with minimal risk. However, there is no research to support or refute their effectiveness for TMDs. Systematic reviews have shown that low-level laser therapy was somewhat better than placebo in reducing pain from TMDs, and improving related outcomes (Maia et al., 2012; de Pedro et al., 2019). Dry needling is becoming increasingly accepted and used as a treatment for myofascial pain and TMDs. A recent systematic review considered 18 studies examining the effectiveness of dry needling and injection with different substances (Machado et al., 2018). The review concluded that while dry needling and local anesthetic injections seem promising, there is a need to conduct randomized clinical trials with larger sample sizes and longer follow-up times to truly evaluate the effectiveness of these techniques. A 2019 study in five women with chronic masticatory myofascial pain found that deep dry needling increased the individual’s pressure pain threshold (Tesch et al., 2019). Among the limitations noted by the authors was that increasing pressure pain thresholds is an isolated outcome that is not directly comparable with more general outcomes such as the intensity and severity of the pain experienced or a patient’s perception of the treatment’s efficacy and impact on quality of life.

Complementary Treatments

Acupuncture

Acupuncture is another treatment approach that has been used for TMD but for which evidence is limited. A 2017 meta-analysis found a significant one-point difference (out of 10) on the visual analog scale of pain between acupuncture and sham acupuncture for TMDs (Wu et al., 2017). Interestingly, the effect was only found when the comparison was with non-penetrating sham acupuncture; the difference between acupuncture

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

and penetrating sham acupuncture was not significant. The meta-analysis also found that acupuncture was more effective for patients with TMDs that were related to masticatory muscle disorders versus related to the TMJ itself.

Dietary Intake and Nutrition

Changing one’s diet is a type of behavioral modification some individuals with a TMD might undertake to relieve or avoid pain. Pursuing a soft diet and seeking pain-free chewing has been related to important nutritional challenges faced by individuals with a TMD. Given that TMDs can affect an individual’s ability to chew and swallow, serious nutritional challenges and deficiencies can occur. The TMJ Association advises a soft diet for individuals who are able to adequately open their mouths and have minimal pain and a pureed diet for those who cannot tolerate a soft diet (The TMJ Association, 2017). Because evidence-based dietary guidelines for patients with chronic orofacial pain do not exist, clinicians may provide customized advice for individuals based on the challenges they report (Durham et al., 2015; Nasri-Heir et al., 2016). While dietary interventions are commonly recommended for patients with a TMD, more research is needed on whether and how dietary changes have an impact.

Electrotherapy

Transcutaneous electrical nerve stimulation (TENS) is a form of neuromodulation that applies electrical current through the skin for pain control. The mechanisms of TENS analgesia have been extensively studied and involve the activation of endogenous opioid, serotonin, and GABAergic pathways in a frequency-dependent manner which can reduce central excitability and central sensitization (Vance et al., 2014). High-frequency TENS has been shown to reduce pain and decrease electromyography (EMG) activity of the masticatory muscles in people with TMDs (Rodrigues et al., 2004). Low-frequency TENS reduces EMG activity (Kamyszek et al., 2001). A single treatment of either sensory-stimulation or motor-stimulation low-frequency TENS reduces the EMG activity of the masticatory muscles similarly and improves mouth opening (Monaco et al., 2013). Additionally, two 30-minute TENS treatments in combination with pharmaceutical treatment provide additional pain relief when compared with pharmaceutical treatment alone (Shanavas et al., 2014). However, it should be noted that these studies were small with short-duration TENS treatments.

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

Pharmacological Treatments

Oral Medication

A variety of pharmacological treatments have been suggested for the management of the pain and symptoms associated with TMDs. Most studies on pharmacological treatments have focused on evaluating the efficacy of various drugs in relieving pain, which is the primary reason for which individuals with a TMD seek medical care. However, there are no drugs specifically approved by FDA for this disorder, and the evidence for the efficacy of many of the recommended treatments is weak. Pharmacotherapies recommended for patients with a TMD have generally been based on drugs that have been shown to be efficacious for other musculoskeletal conditions or neuropathic pain states. Commonly recommended pharmacological agents for TMDs, based on expert opinion, include acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, antidepressants, anticonvulsants, benzodiazepines, muscle relaxants, opioid analgesics, tricyclic antidepressants, and topical lidocaine patches.

To assess the effectiveness of pharmacological interventions in individuals with a TMD, a Cochrane Collaboration literature review was conducted and found that most trials had few participants and there was insufficient evidence to support or refute the effectiveness of the reported drugs (Mujakperuo et al., 2010). Large-scale efficacy and effectiveness trials of pharmacological agents in the treatment of TMDs are needed.

A brief summary of select pharmacological approaches to TMD pain relief and relevant studies is presented below.

Non-steroidal anti-inflammatory drugs (NSAIDs)

NSAIDs are used to relieve the pain and inflammation in the TMJ and muscles of the jaw, face, and neck in individuals with a TMD. Patients with suspected early disc displacement, synovitis, and arthritis have been suggested as appropriate candidates for early treatment with NSAIDs (Gauer and Semidey, 2015). However, placebo-controlled randomized trials reported mixed results (Mujakperuo et al., 2010; Ouanounou et al., 2017). A randomized comparative trial suggested that dual COX-1 and COX-2 inhibition with naproxen was more effective for the treatment of painful TMDs than celecoxib and placebo, as judged by the degree of improvement in the clinical signs and symptoms of TMJ disc disorder (Ta and Dionne, 2004). Based on these mixed results, there is a need for more rigorous examination of NSAID use for TMD-related pain. NSAIDs need to be used with caution because of their possible adverse effects, including exacerbation of hypertension, gastritis, ulcers and gastrointestinal bleeding, and nephrotoxicity.

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Opioids

The inconsistent efficacy of NSAIDs in relieving chronic pain associated with severe TMDs has led to exploration of alternatives, including the use of opioid analgesics (Ouanounou et al., 2017). One randomized trial with 80 subjects provided moderate evidence that a combination analgesic product (NSAID and low-dose codeine) delivered relief from pain associated with TMDs (Shaheed et al., 2019). A recent review identified placebo-controlled studies that reported improved outcomes with morphine and fentanyl for TMJ arthrocentesis (Gopalakrishnan et al., 2018). Evidence supporting the use of opioids to manage chronic pain is lacking (NASEM, 2017). Given the high rates of opioid use disorder and opioid-related deaths, the use of opioid analgesics for TMDs should not be a first-line pharmaceutical treatment. The guidelines by the Centers for Disease Control and Prevention emphasize the improvements needed in prescribing opioids for chronic pain (CDC, 2019).

Antidepressants

Antidepressants are used as adjuvant treatment for chronic TMD pain, based on both known efficacy in neuropathic and musculoskeletal pains, including fibromyalgia, and their beneficial effects on comorbid depression and sleep disturbance. The tricyclic antidepressant amitriptyline was shown to decrease pain and discomfort in a small controlled study in patients with chronic TMD (Rizzatti-Barbosa et al., 2003). In a small study of 29 patients, a selective serotonin and norepinephrine reuptake inhibitor, duloxetine, was effective at relieving chronic pain in the orofacial region compared to baseline (Nagashima et al., 2012). Although there is anecdotal evidence of individual patients experiencing pain relief from paroxetine, a selective serotonin reuptake inhibitor (SSRI) (Inagaki et al., 2007), SSRIs have the potential to cause increased bruxism and exacerbate pain (Rajan and Sun, 2017). Additional well-controlled clinical trials are needed to assess the potential benefits of tricyclic antidepressants in TMD patients.

Anticonvulsants

Anticonvulsant medications, such as gabapentin and pregabalin, are commonly used to treat neuropathic pain; however, their mechanism of action is unclear (Ouanounou et al., 2017). In one randomized controlled trial, gabapentin was found to be clinically and statistically superior to placebo in reducing pain and masticatory muscle hyperalgesia, and in improving daily functioning in patients with chronic pain in the masticatory muscles (Kimos et al., 2007). However, a recent systematic review on the efficacy of anticonvulsants on orofacial pain found limited to moderate evidence supporting the use of anticonvulsants for treatment of patients with orofacial pain disorders (Martin and Forouzanfar, 2011).

Benzodiazepines

Benzodiazepines have been suggested as treatment options for chronic orofacial pain associated with TMDs despite weak

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

evidence for their efficacy in controlled trials. One randomized trial found diazepam to be efficacious in the short-term management of chronic orofacial muscle pain (Singer and Dionne, 1997). Other muscle relaxants (e.g., cyclobenzaprine) are also recommended for treating patients with orofacial muscle spasms, though the quality of the evidence for the efficacy of these drugs is weak. A 2009 Cochrane review cited two randomized controlled trials reporting the use of cyclobenzaprine for the treatment of myofascial pain. The two studies included in the review examined a total of 79 participants; however, there was insufficient evidence to support the use of cyclobenzaprine for the treatment of myofascial pain (Leite et al., 2009).

Cannabis

Medical cannabis has been proposed to reduce pain and potentiate the effects of other pain control regimens for several painful conditions (Hill et al., 2017). Most cannabis research is outside of the arena of TMDs. One study, however, investigated the utility of cannabinoids, the active components of cannabis, for TMJ-related nociception in rats; it found that the cannabinoids potentiated the effects of other medications in decreasing inflammatory pain of the TMJ (Lee et al., 2008).

Glucosamine

Two studies cited by a systematic literature review found that glucosamine supplements were as effective at reducing pain and improving mouth opening as ibuprofen taken two to three times daily over 12 weeks (Melo et al., 2018). A third study cited in the same review did not find significant differences in pain reduction or maximum mouth opening between a group receiving glucosamine and a group receiving a placebo over 6 weeks of medication administration. Melo and colleagues (2018) cautioned that the results of the studies were at risk of bias and should be interpreted carefully.

Topical Medication

Capsaicin (topical)

Capsaicin is a chemical agent derived from chili peppers that has been shown to have analgesic properties due to its interactions with the TRP vanilloid subfamily member 1 (TRPV1) ion channel. A small study (n=15 individuals with a TMD) showed some pain relief after a 1-week period following a single topical application of 8 percent capsaicin cream (Campbell et al., 2017), but further studies with additional patients are needed to confirm this finding.

Intramuscular Medication

Botulinum toxin

Intramuscular injections are primarily used for the management of musculoskeletal pain. The injection of botulinum toxin Type A

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

into the muscles of mastication has been proposed to decrease muscle spasm and pain. Botulinum toxin is a neurotoxic protein that prevents the release of the neurotransmitter acetylcholine, thereby impairing muscle contraction. Some studies have reported improvement in facial pain in some patients with TMDs from botulinum toxin Type A injection into the muscles of mastication (Chaurand et al., 2017; Khawaja et al., 2017), but others have reported equivocal results (Chen et al., 2015; Keenan, 2015); the data are limited and often of poor quality. A Cochrane review (233 subjects in 4 trials) found inconclusive evidence concerning the effectiveness of botulinum toxin for myofascial pain in the neck and head muscles (Soares et al., 2014).

Navarrete and colleagues (2013) reported a study in which rabbits were injected with either botulinum toxin Type A or saline solution into the masseter muscle. The result was a dramatic loss of bite force, after 3 weeks, in the rabbits receiving botulinum toxin Type A injections. While this study, and others, indicated success in using botulinum toxin Type A to unload, or temporarily paralyze, the muscle and relieve the jaw joint, The TMJ Association issued caution to individuals with TMD pursuing treatment with botulinum toxin Type A due to the loss of bone strength resulting from the treatment in rabbits. There is concern for the health of the TMJ in humans using botulinum toxin Type A in the long term given the osteoporotic condition of the TMJ in rabbits (The TMJ Association, 2016).

Prolotherapy

Other intra-articular injection agents have been proposed for specific subdiagnoses of TMDs. In the case of chronic dislocation and hypermobility of the TMJ, for example, prolotherapy (injection of an irritant solution to promote a reparative immune response) has shown promise (Zhou et al., 2014; Cezairli et al., 2017; Refai, 2017). Two studies demonstrated a success rate of 80 percent in reducing or eliminating dislocations by 1 year after injection of autologous blood to the superior TMJ space and the joint capsule (Machon et al., 2009; Daif, 2010).

Interventional Treatments

Arthrocentesis and Arthroscopy

In patients who have not achieved relief from or who are not candidates for noninvasive treatment, minimally invasive surgical treatment may be indicated. The simplest of these minimally invasive operations is arthrocentesis. The indications for arthrocentesis include an identification of an intra-articular pathology such as disc dislocation in combination with

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

pain or joint dysfunction. Musculoskeletal pain may not be improved by arthrocentesis, and this treatment is typically used as only one component of a comprehensive management strategy.

Arthrocentesis involves the insertion of a needle into the superior TMJ space, followed by joint lavage. This can be accomplished with either a single needle for both the inflow and outflow of lavage fluid or by using two separate puncture sites to allow the inflow and outflow ports to be separated. The idea behind this intervention is to flush viscous synovium and inflammatory mediators from the joint and to release joint adhesions via hydraulic pressure. Arthrocentesis has been shown to be effective in relieving pain and improving mouth opening in patients with temporomandibular disc displacements (Dimitroulis et al., 1995; Nitzan and Price, 2001; Nitzan et al., 2017), though its benefits may decrease after 6 months (Bjørnland et al., 2007).

Arthroscopy, which involves the insertion of a small video endoscope into the superior TMJ space, is similar to arthrocentesis but with the added benefit of indirect visualization of the joint. The ability to visualize the joint space provides confirmation of joint access, enhances diagnosis, and allows additional therapy such as the laser resection of adhesions and disc repositioning (McCain and Hossameldin, 2011). The short-term outcomes of arthroscopy with regard to pain and function have been found to be similar to those for arthrocentesis (Fridrich et al., 1996), with both showing moderate effectiveness.

Both arthrocentesis and arthroscopy are often, but not always, combined with an injection of medication into the superior joint compartment. The most frequently injected medications are corticosteroid and hyaluronic acid. The reported results of these injections are mixed, with some studies demonstrating superior outcomes for pain relief with corticosteroid and hyaluronate (Liu et al., 2018), others purporting better outcomes with hyaluronic acid (Bjørnland et al., 2007), and several showing no significant difference among corticosteroid, hyaluronic acid, and saline alone (de Souza et al., 2012; Bouloux et al., 2017a,b; Davoudi et al., 2018).

Operations with Direct Access to the TMJ

“Open operations,” or surgical procedures that provide direct access to the joint, are reserved for individuals with severe and irreversible destruction of the TMJ and those who have persistent debilitating symptoms or dysfunction of the joint despite other treatment. Less than 3 percent of 2,104 individuals who completed treatment for a TMD received an open surgical procedure in a multi-site analysis (Brown and Gaudet, 2002).

The selection of an operation is based on the severity of the symptoms and the health of the joint components. Several classification systems exist

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

to guide treatment decisions (see Chapter 2), but there is no universally accepted protocol for operative management of a TMD. Imaging, particularly magnetic resonance imaging, plays a major role in the staging of the disease and the determination of the appropriate surgical treatment approach. Surgical treatment is sometimes graded, beginning with minimally invasive procedures and progressing to more aggressive operations as needed. Evidence has emerged, however, that shows that patients who have had fewer total TMJ operations have superior surgical outcomes than those who have had many smaller operations (Mercuri, 1999). This indicates the need to make an accurate diagnosis and choose the appropriate surgical intervention, when indicated, carefully.

Open operations are used when irreversible joint destruction has occurred and associated symptoms and dysfunction are present. Open operations require direct access to the TMJ via an incision adjacent to the ear. The diagnosis then dictates the procedure. When the TMJ disc is displaced from its normal position, it can be repositioned; when the disc is damaged, it can either be repaired or be removed (discectomy), with or without replacement. When the mandibular condyle or glenoid fossa has been eroded or free pieces of bone (osteophytes) are within the joint, a modification of the bony components of the joint, including the mandibular condyle, glenoid fossa, or articular eminence, may be indicated. Many other similar procedures can be performed within the joint once direct access has been obtained, depending on the objective of the operation.

When multiple components of the joint are severely damaged, reconstruction may be required. This can be accomplished with autologous tissues such as costochondral (rib) grafts or alloplastic materials (TMJ implants). TMJ implants will be discussed further in the next section.

Several subdiagnoses that may mimic TMDs but are not considered to be TMDs in this report require variations of the surgical considerations described above, each with corresponding evidence within the applicable subspecialty. In patients with a TMJ pathology such as a cyst or a tumor, an open operation may be required as the primary treatment. In patients with progressive condylar resorption disorders, including idiopathic condylar resorption and juvenile idiopathic arthritis affecting the TMJ, open operations for replacement of the degenerated joint components using autogenous or alloplastic implants may be required. Similarly, in patients with congenital anomalies of the TMJ, such as hemifacial microsomia, bilateral craniofacial microsomia, and Treacher Collins syndrome, construction of the joint with autogenous or alloplastic materials may be indicated as the first-line treatment. In patients with TMJ ankylosis, most commonly a result of trauma or infection, aggressive joint debridement and reconstruction is necessary. Patients with hypermobility syndromes such as Ehlers-Danlos and recurrent dislocation may require strategies to induce fibrosis of the

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

peri-articular tissues, such as autologous blood injection (Daif, 2010), and to eliminate anatomic factors that lead to dislocation, which may include resection of the articular eminence (eminectomy) (Tocaciu et al., 2019).

TMJ Implants

Patients with bony ankylosis, condylar injuries, developmental abnormalities, functional deformity, severe inflammatory conditions, and/or painful or dysfunctional internal derangements after failed conservative and surgical treatment, all of whom have not responded to less invasive treatments, may be candidates for a TMJ replacement with alloplastic implants (Sidebottom et al., 2008; NICE, 2014). Commensurate with improvements in biomaterials and long-term data demonstrating favorable outcomes in pain reduction, improved function (Wolford et al., 2015), and improved quality of life (Kunjur et al., 2016), the use of total alloplastic TMJ replacements has recently increased (Onoriobe et al., 2016). Several total alloplastic TMJ implants are currently available in the United States and are generally categorized as either stock implants (those that come in standard sizes and are then modified to fit the patient’s anatomy) or custom implants (those that are produced prior to implantation in a customized patient-specific shape and size based on preoperative imaging).

The TMJ implants that are currently on the market have been subjected to testing by manufacturers in compliance with FDA requirements for Class III devices. A follow-up study of 56 patients with implants found positive outcomes and stability at least 20 years after insertion, but only 50 percent of the initial cohort of 111 patients could be contacted and met study criteria (Wolford et al., 2015). However, earlier implants, which have since been removed from the market (discussed below), were associated with severe complications, which often went unrecognized until years after surgery. Unfortunately, this led to significant harm for some patients and clouded the field of TMJ surgery. The committee heard from individuals with TMDs and TMD patient representatives who reported significant challenges in the implant recall process. Not all patients who received the recalled device were properly notified by their oral surgeon. Even though the device was recalled by FDA in 1990, TMD patient representatives told the committee that some patients are just being notified now that they received the faulty device.

As introduced above, the use of Proplast/Teflon-based TMJ implants in the 1970s and 1980s resulted in severe adverse events and the need for corrective surgery in some patients (AAOMS, 1993; Lypka and Yamashita, 2007). In especially severe cases, implant recipients required multiple follow-up operations to fix the damage (Henry and Wolford, 1993). Many affected patients continue to suffer from irreversible iatrogenic damage and

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

TABLE 5-2 TMJ Implants with FDA Approval (as of October 14, 2019)

Device Name Manufacturer PMA Number Decision Date*
TMJ Concepts Patient-Fitted TMJ Reconstruction Prosthesis TMJ Concepts (Ventura, CA, USA) P980052 July 2, 1999
TMJ Fossa-Eminence Prosthesis™ Nexus CMF, LLC (Golden, CO, USA) P000035 February 27, 2001
Walter Lorenz Total Temporomandibular Joint Replacement System Biomet Microfixation, Inc. (Jacksonville, FL, USA) P020016 September 21, 2005

NOTE: PMA = premarket approval application.

*Indicates the date of approval of the original PMA. PMA supplements are not included in this table.

SOURCES: FDA, 2019a,b,c.

require lifelong care. In 1991 an FDA bulletin recommended the removal of all previous Proplast/Teflon TMJ implants based on evidence of mechanical failures resulting in significant adverse health outcomes (Ferreira et al., 2008). Shortly thereafter, the American Association of Oral and Maxillofacial Surgeons issued a similar mandate recommending the discontinuation of Proplast/Teflon-based implants (AAOMS, 1993). In 1998 FDA issued regulations that required TMJ implant sponsors to submit premarket approval applications (GAO, 2007). Table 5-2 lists the TMJ implants that currently have premarket approval from FDA.

There is evidence that newer TMJ implants can improve function and quality of life in properly selected patients (Gruber et al., 2015). However, the National Institute of Dental and Craniofacial Research (NIDCR) still cautions patients about surgical approaches to treating TMDs, stating that the treatments are “controversial, often irreversible, and should be avoided where possible” (NIDCR, 2018). While there are outcome studies demonstrating some measurable benefits of TMJ reconstruction for select patients, there is a need for longer-term studies examining the safety and efficacy of TMJ implants (see section below on patient registries). The TMJ Patient-Led RoundTable—which involves patients, NIDCR, FDA, clinicians, and researchers—has a goal of defining the natural history and assessing biomarkers associated with outcomes in TMJ implant patients to better target therapies to patients most likely to benefit from them (Kusiak et al., 2018).

Conclusion 5-4: Although considerable research has been conducted in occlusal adjustment and equilibration for temporomandibular

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

disorders (TMDs), these treatments have not been found to be effective. Evidence-based findings need to be widely disseminated to dentists and other clinicians to ensure that the treatment approaches individuals with a TMD receive are consistently based on the best available evidence and focused on starting with conservative approaches.

Conclusion 5-5: Data are inadequate and are of poor quality for most treatments for temporomandibular disorders (TMDs). Research is needed to determine safe and effective treatments for TMDs. Systematic reviews and methodologically rigorous new studies are needed.

IMPROVING AND DISSEMINATING EVIDENCE

As discussed above, the evidence base for many TMD treatments is poor. Clinicians tend “to see what they treat and treat what they see,” based on the theory of TMDs in which they are educated and trained. To improve care and outcomes for people with TMDs, it is critical that researchers gather and disseminate high-quality evidence about these treatments. Three approaches for doing so are discussed here: conducting clinical trials, building a patient registry, and developing and implementing clinical practice guidelines.

Conducting Clinical Trials

Randomized controlled trials (RCTs) are considered the gold standard for assessing the effectiveness of a particular medication or treatment approach (Bothwell et al., 2016). RCTs in general can be challenging to carry out for several reasons, including difficulty with endpoint selection, inadequate randomization or blinding, and other logistical problems (Nichol et al., 2010). Although some RCTs for TMD treatments have demonstrated small to moderate reductions in pain intensity (as described earlier in this chapter), the quality of evidence is limited, and some of the studies have been plagued by methodological shortcomings (e.g., insufficient blinding, small sample sizes, a range of outcome measures and control treatments, and short follow-up times). Furthermore, many RCTs for TMD treatments are carried out in tertiary care centers (centers that focus on specialized care), and few, if any, take place in a primary dental care setting, which is often where patients go first if they begin experiencing orofacial pain (Velly et al., 2013). As of October 2019, 191 clinical trials were listed on clinicaltrials.gov for a variety of interventions for TMDs. Of those 191 trials, 29 were actively recruiting, and 4 were taking place in the United States. Given the currently inadequate research base for TMD treatments, more

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

well-designed clinical trials are needed in the future to inform evidence-based care for individuals with a TMD.

Ideal Characteristics of Clinical Trials for TMD Treatments

Ideally, clinical trials for TMD treatments would focus on outcomes that are meaningful to patients, such as improvements in health and quality of life, reduction in pain, restoration of function, and physical, social, and psychological well-being, and they would examine TMDs in the context of the real world in which patients live. The incorporation of patient preference data and real-world evidence and experiences is one of the key objectives of the TMJ Patient-Led RoundTable. Clinical trials for TMDs could be improved through the adoption of a universal TMD case classification system, such as DC/TMD, across all trials and could incorporate broad eligibility criteria as a way to reach a large, diverse patient population and increase the generalizability of the trial results. Detecting, measuring, and taking into account the comorbidities often seen in TMD patients is an important step toward improving the quality of clinical studies in this area.

Conducting pragmatic trials that incorporate real-world evidence may represent an opportunity to gather better information about the effectiveness of TMD treatments. Pragmatic clinical trials test an intervention in a real-world clinical setting (e.g., hospitals, clinics, primary care providers) and differ from traditional RCTs, which take place in a highly controlled setting (Weinfurt et al., 2017). One type of pragmatic trial that has been proposed for TMD clinical research involves cluster-randomized stepped-wedge blinded controlled trials. This type of trial attempts to alleviate flaws such as information, inferential, and selection bias and to improve reporting quality (Chiappelli et al., 2015).

Opportunity for a National TMD Clinical Trials Consortium

Bringing together researchers through a national TMD clinical trials consortium could provide opportunities to improve the quality of clinical studies of TMD treatments. The committee identified the following groups that could be beneficial to include in a national TMD clinical trial consortium:

  • NIH Health Care Systems Research Collaboratory. It aims to improve the conduct of clinical trials through the development of a new infrastructure for clinical research with health care systems. The collaboratory supports the design and execution of pragmatic clinical trial demonstration projects.
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
  • The Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT). The initiative develops consensus guidelines regarding how to improve the design, execution, and interpretation of clinical trials for the treatment of pain (IMMPACT, 2019). The IMMPACT recommendations for routine clinical measures (Dworkin et al., 2005) have been incorporated into Axis 2 of the DC/TMD (Schiffman et al., 2014). Ongoing IMMPACT developments will continue to provide guidance for the best approaches to measuring and assessing pain in clinical trials for TMD treatments.
  • The Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION). A public–private partnership with FDA, ACTTION’s mission is to “identify, prioritize, sponsor, coordinate, and promote innovative activities—with a special interest in optimizing clinical trials—that will expedite the discovery and development of improved analgesic, anesthetic, addiction, and peripheral neuropathy treatments for the benefit of the public health” (ACTTION, 2020).
  • Dental Practice-Based Research Networks (PBRNs). The major PBRN in the dental field is the National Dental Practice-Based Research Network with participation by more than 6,500 general dentists and practitioners who engage in clinical research (National Dental PBRN, 2019). Additionally, a number of other PBRNs are actively engaged in many areas of clinical research.
  • National Patient-Centered Clinical Research Network (PCORnet). This network aims to use a patient-centered approach to increase the efficiency of clinical research. PCORnet consists of nine large clinical research networks, two health plan research networks, a coordinating center, and a central office (PCORnet, 2019). Clinical research carried out through PCORnet incorporates data from electronic health records, claims databases, and patient registries.

Building a Patient Registry

A patient registry offers a way to collect real-world data about clinical practices, patient outcomes, safety, and the effectiveness of treatments (Gliklich et al., 2014). Patient registries have been developed for a number of health conditions and take different forms depending on the specific condition and population. Patient registries can collect a wide variety of information, such as symptoms, pain levels, day-to-day functioning, treatments, and patient perceptions and goals. Developing common data elements is one way of improving the efficiency of the registries as is being done through the Core Outcome Measures in Effectiveness Trials (COMET) Initiative (COMET Initiative, 2020). There are platforms that are designed

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

to facilitate the creation and connection of condition-specific registries. One example is PEER, which is operated by Genetic Alliance (see Box 5-3).

One common use for a patient registry is the monitoring of medical devices that are on the market. After devices receive clearance from FDA, companies may be required to collect information about patient outcomes and how the device performs over time. There have been several patient registries in the TMD space—existing and planned—all of which are designed to collect information about implants.

National TMJ Implant Registry and Repository at the University of Minnesota

Alloplastic TMJ implants are Class III devices, the most complex and highest risk devices regulated by the Center for Devices and Radiological Health (CDRH) at FDA. FDA ordered device manufacturers to conduct Section 522 postmarket surveillance studies on TMJ implants as a way to gather additional data on the natural life cycle of the devices (FDA, 2011). A brief description of the 522 studies of Class III TMJ prostheses is provided

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

in Table 5-3. However, these studies do not provide enough evidence about the performance and clinical outcomes associated with TMJ implants, and there is a need to redesign and strengthen studies of FDA-approved TMJ implants. In 2002, NIDCR recognized the need for further examination of TMJ implants and the reasons for their failures and awarded funding to the University of Minnesota School of Dentistry to develop a national TMJ implant registry and repository (Myers et al., 2006). This registry allowed researchers to access and study explanted TMJ prostheses and other biological specimens in conjunction with clinical outcomes. The effort involved two parallel tracks: a registry that recruited clinicians, surgeons, and patients to collect patient data over time and a repository that housed biological specimens and explanted prostheses. A potentially important

TABLE 5-3 Current or Recent 522 Surveillance Studies of FDA-Approved TMJ Implants

Device Name Manufacturer Study Details Study Status (as of January 2020)
Patient-Fitted TMJ Reconstruction Prosthesis System
(FDA, 2019e)
TMJ Concepts Prospective cohort study to determine the rate and reasons for revision or removal for 3 years after placement. Explant analysis was performed to determine the modes and causes of device failure. Progress Adequate
TMJ Fossa Eminence/Condylar Prosthesis System
(FDA, 2019d)
Nexus CMF Prospective postmarket surveillance study and explant analysis. Further study details are not available on the 522 Postmarket Surveillance Studies Webpage (FDA). Progress Inadequate (prospective postmarket surveillance study)

Progress Adequate (explant study)
Walter Lorenz Total Temporomandibular Joint Replacement System
(FDA, 2019f)
Biomet Microfixation Prospective, observational study to collect follow-up data on all subjects who received a joint replacement system, and a retrospective review to collect data on demographics, clinical history, and diagnosis for subjects treated with the joint replacement system. Completed
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

distinction is that this registry did not include samples from patients who received total joint implants, but rather only samples from those patients who had disc replacements. Funding for the registry ended in 2010, but the biospecimens remain available at the University of Minnesota and represent a potentially valuable research tool.

FDA is also working toward increasing the quality of data on the safety and effectiveness of TMJ implants through the Medical Device Epidemiology Network (MDEpiNet), a global public–private partnership initiated in 2010 (MDEpiNet, 2019a). MDEpiNet aims to advance the collection and use of real-world data from routine patient care in order to improve outcomes. In 2014, MDEpiNet convened a Medical Device Registries Task Force with the goal of strengthening the medical device postmarket surveillance system as a way to support better regulatory decisions and patient care (Krucoff et al., 2015). The Medical Device Registries Task Force proposed strategically coordinated registry networks (CRNs) as a way to link existing complementary registries and provide interoperability solutions to data-related challenges including disparate and potentially incomplete data sources. In 2017 the Department of Health and Human Services’ Office of the Assistant Secretary for Planning and Evaluation awarded FDA/CDRH funds to develop a CRN community of practice, which is comprised of 14 CRNs operating or in development, one of which is focused on TMDs (MDEpiNet, 2019b). One key stakeholder involved in developing the TMD CRN is the TMJ Patient-Led RoundTable. The TMD CRN aims to do the following:

  • Create a standardized data infrastructure,
  • Develop new and more effective ways to incorporate patient and real-world evidence data in clinical trials,
  • Support the design of predictive analytics algorithms,
  • Foster evidence-based protocols and best practices for inclusion into health care, and
  • Promote collaborative multidisciplinary research (MDEpiNet, 2019c).

Efforts to build the TMD CRN also include coordinating with other registries and databases that collect information on the comorbidities present in TMD patients. Care is being taken to align the minimum core datasets to the greatest extent possible. The TMD CRN is also enlisting help from patients via The TMJ Association, which has amassed a great deal of information directly from individuals who are affected by a TMD (The TMJ Association, 2019a). The involvement of public and private payers will be key to the success of the TMD CRN because they can provide valuable input on TMD claims data and how best to standardize the collection of that information.

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

Need for a Patient Registry

Despite these important existing efforts, the committee believes that it would be beneficial to explore the development of a comprehensive national registry that would collect a wide variety of data from all types of TMD patients and would incorporate a core set of data elements. Ideally, this registry would be easily accessible for individuals with a TMD and their care providers in order to facilitate data collection. An important first step would be to gather information about best practices and lessons learned from other and ongoing patient registry efforts, including, but not limited to, the University of Minnesota implant registry, the TMD CRN, and the PEER platform. (See recommendations in Chapter 8.)

Developing and Implementing Clinical Practice Guidelines

There are currently no formal clinical practice guidelines that provide evidence about effective TMD treatments, for whom or for what specific types of TMDs particular treatments may be effective, and criteria for when to escalate treatment beyond the initial conservative approaches. Given the historical misunderstanding of TMDs and misguided treatment approaches that have led to iatrogenic harm for some, and as current diagnosis and treatment remains disparate and heterogeneous, TMD clinical practice guidelines are greatly needed.

Some professional associations, federal research agencies, and patient advocacy organizations have developed general guidance for treating TMDs. However, this guidance is largely focused on self-care, is not firmly grounded in evidence, and is in some cases inaccurate or contradictory (see Table 5-4). The American Dental Association (ADA), as part of the Choosing Wisely campaign, released guidance in 2016 on TMDs. The Choosing Wisely campaign is aimed at improving communication between providers and patients and encouraging patients to choose treatments that are evidence based, free from harm, and truly necessary. ADA’s guidance on TMDs encourages patients to avoid irreversible procedures as a first-line treatment and notes that many TMDs resolve spontaneously without treatment (see Table 5-4).

The American Academy of Orofacial Pain has published six editions of guidelines for assessing, diagnosing, and managing orofacial pain (de Leeuw and Klasser, 2018). The guidelines are geared toward a professional audience and have increasingly focused on rigorous incorporation of sound evidence.

The publication of these types of guidelines for diagnosing and treating individuals with a TMD has elicited controversy. For example, in 2010 the American Association for Dental Research (AADR) approved a new guideline for the care of patients with TMDs (Greene, 2010). The

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

TABLE 5-4 TMD General Guidance from Various Associations and Federal Agencies

Organization TMD Treatment Guidelines
National Institute of Dental and Craniofacial Research (NIDCR, 2013)
  • Individuals with a temporomandibular disorder (TMD) should first try simple self-care practices (e.g., eating soft foods, using ice packs, over-the-counter pain medications).
  • Individuals with a TMD should avoid, where possible, treatments that cause permanent changes in the bite or jaw or surgical treatments on the jaw joint.
American Dental Association (ADA, 2016)
  • Avoid routinely using irreversible surgical procedures such as braces, occlusal equilibration, and restorations as the first treatment of choice in the management of temporomandibular joint disorders.
  • There is a lack of evidence that temporomandibular joint disorders (defined as musculoskeletal disorders, not the lesion of traumatic occlusion) are always progressive, and evidence exists that in many instances patients with TMD have spontaneous remissions without treatment.
  • Therefore, management is generally conservative and includes reversible strategies such as patient education, medications, physical therapy, and the use of occlusal appliances that do not alter the shape or position of the teeth or the alignment of the jaws.
The TMJ Association (2019b)
  • Individuals who suspect they have a TMD should see a medical doctor to rule out some of the conditions that mimic TMDs (e.g., sinus or ear infections, decayed or abscessed teeth, etc.).
  • Most people with TMD have relatively mild or periodic symptoms which may improve on their own within weeks or months with simple home therapy. Self-care practices, such as eating soft foods, applying ice or moist heat, and avoiding extreme jaw movements (such as wide yawning, loud singing, and gum chewing) are helpful in easing symptoms. According to the National Institutes of Health, because more studies are needed on the safety and effectiveness of most treatments for jaw joint and muscle disorders, experts strongly recommend using the most conservative, reversible treatments possible. Conservative treatments do not invade the tissues of the face, jaw, or joint, or involve surgery. Reversible treatments do not cause permanent changes in the structure or position of the jaw or teeth. Even when TMDs have become persistent, most patients still do not need aggressive types of treatment.
American Academy of Family Physicians (AAFP, 2019)
  • There is a lack of evidence that TMDs are always progressive, and many patients experience spontaneous remissions without treatment.
  • Therefore, management is generally conservative treatment and includes reversible strategies such as patient education, medications, physical therapy, and the use of occlusal appliances that do not alter the shape or position of the teeth or alignment of the jaws.
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Organization TMD Treatment Guidelines
American Association for Dental Research (AADR, 2015)
  • Unless there are specific and justifiable indications to the contrary, the treatment of individuals with a TMD should initially be based on the use of conservative, reversible, and evidence-based therapeutic modalities.
  • While no specific therapies for TMDs have proven to be uniformly effective, many of the conservative modalities have proven to be at least as effective in providing symptomatic relief as most forms of invasive treatment.
American Academy of Orofacial Pain (AAOP, 2014)
  • Because there are many possible causes of TMD, there is no “quick fix.”
  • Focus on conservative, reversible therapies first.
  • Self-management and conservative treatments are the most successful.
  • For about 5 out of 100 TMD patients, conservative therapy is not enough and these individuals may benefit from surgery.
American Association of Oral and Maxillofacial Surgeons (AAOMS, 2017)
  • TMJ surgery is indicated for the treatment of a wide range of pathological conditions, including developmental and acquired deformities, internal derangements, arthritis, functional abnormalities, ankylosis, and infection.
  • Separate parameters of care are available for the surgical management of TMJ tumors as well as fractures due to trauma.

guideline encouraged clinicians to (1) diagnose TMDs using information on the patient’s history, clinical examination, and, when indicated, TMJ radiology and other imaging modalities, as opposed to adjunctive diagnostic tools, and (2) initially treat patients with conservative, reversible, and evidence-based modalities unless specific indications suggest a different initial treatment. In response to AADR’s new guideline, the Journal of the American Dental Association received an unprecedented 228 letters, the vast majority in opposition to the guideline (JADA, 2010). The published letters opposing the guideline mostly came from dentists following the neuromuscular approach to TMDs, who cited a number of issues including disagreement that a biopsychosocial model is best for treating individuals with TMD, disagreement about the effect of dental appliances for treating TMDs, and disagreement that most cases of TMD resolve on their own (JADA, 2010). The published letters in support of the guideline were from orofacial pain dental providers and indicated that the clinical data point to the majority of patients with TMDs benefiting from “reversible, nonsurgical, non-orthodontic treatment, for a fraction of the cost” (JADA, 2010, p. 1415).

This debate highlights the deep divide between different approaches to TMDs, and how the lack of clear evidence creates confusion about how to

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

treat TMDs. At present, even the principle regarding what constitutes strong evidence remains disputed. Absence of training in research methods and statistics or in the skills needed to critically evaluate published literature pervade much of the dental field. Without such critical skills to evaluate evidence and incorporate it into the behavioral repertoire of the clinician, the deep divide between those who adhere to belief-based models versus those who work flexibly and adaptively according to current evidence will continue.

Related Clinical Practice Guidelines

Clinical practice guidelines in related areas may serve as guides to the formal development of clinical practice guidelines for TMDs. The ADA Center for Evidence-Based Dentistry publishes clinical practice guidelines for a number of conditions, for example, although it has not done so for TMDs (ADA Center for Evidence-Based Dentistry, 2019). Clinical practice guidelines are available for pain conditions similar to TMDs, such as low back pain and fibromyalgia. For example, the American College of Physicians released clinical practice guidelines in 2017 for the treatment of low back pain (Qaseem et al., 2017). The recommendations encourage patients and providers to first select non-pharmacological treatment (such as massage, acupuncture, exercise, yoga, mindfulness therapies, and CBT). For chronic back pain that does not respond to these therapies, clinicians and patients can consider pharmacological treatment with NSAIDs, tramadol, or duloxetine. Similarly, the American Physical Therapy Association’s clinical practice guidelines for low back pain emphasize the importance of physical activity and active pain coping strategies (see Box 5-4).

While the development of clinical practice guidelines is often led by associations of health professionals, patient-focused organizations may be able to fill this role as well. For example, the Alzheimer’s Association convened a group of experts to develop consensus clinical practice guidelines (see Box 5-5).

Need for TMD Clinical Practice Guidelines

There is a clear need for formal clinical practice guidelines to reduce confusion among providers and patients about TMD management. In contrast to the general guidelines discussed above, clinical practice guidelines are “statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options” (IOM, 2011, p. 4). Trustworthy clinical practice guidelines:

  • Are based on a systematic review of existing evidence;
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
  • Are developed by a knowledgeable, multidisciplinary panel of experts that includes representatives from key affected groups;
  • Acknowledge important patient subgroups and patient preferences, as appropriate;
  • Are developed using an explicit and transparent process that minimizes distortions, biases, and conflicts of interest;
  • Provide a clear explanation of the logical relationships between alternative care options and health outcomes and provide ratings of both the quality of evidence and the strength of the recommendations; and
  • Are reconsidered and revised as appropriate when important new evidence warrants modifications of recommendations (IOM, 2011).

Currently, there is minimal robust, high-quality evidence on which to draw in developing clinical practice guidelines. However, conducting basic and translational research (see Chapter 4), conducting clinical trials (this chapter), and creating a patient registry (this chapter) would greatly improve the evidence base and facilitate the creation of clinical practice

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

guidelines. Clinical practice guidelines for TMDs need to be developed with a strict eye toward balancing biases and avoiding conflicts of interest.

Conclusion 5-6: Evidence-based clinical practice guidelines from a trusted source are needed to effectively manage care for individuals with a temporomandibular disorder. New research should be tightly linked to the goal of producing evidence for developing clinical practice guidelines.

CONCLUSIONS

Conclusion 5-1: Clinical assessment using the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) allows for the identification of patients with temporomandibular disorders ranging from simple to complex presentations, and the DC/TMD is appropriate for use in a range of clinical settings. Ideally, the DC/TMD would be used during the first patient visit and selectively thereafter for monitoring treatment progress.

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

Conclusion 5-2: Self-management and patient education can be important components of care of temporomandibular disorders (TMDs). People with TMDs need access to self-management resources, including formal training. Research is needed to test and refine self-management interventions in order to identify which techniques are most effective, to determine which patients are most likely to see benefits, and to understand the mechanisms of self-management for TMDs.

Conclusion 5-3: Some elements of physical therapy—including exercise and manual therapy—have been shown to improve pain and functional outcomes for individuals with temporomandibular disorders. However, many of the studies are of low quality and further research is needed to support the use of these treatment modalities.

Conclusion 5-4: Although considerable research has been conducted in occlusal adjustment and equilibration for temporomandibular disorders (TMDs), these treatments have not been found to be effective. Evidence-based findings need to be widely disseminated to dentists and other clinicians to ensure that the treatment approaches individuals with a TMD receive are consistently based on the best available evidence and focused on starting with conservative approaches.

Conclusion 5-5: Data are inadequate and are of poor quality for most treatments for temporomandibular disorders (TMDs). Research is needed to determine safe and effective treatments for TMDs. Systematic reviews and methodologically rigorous new studies are needed.

Conclusion 5-6: Evidence-based clinical practice guidelines from a trusted source are needed to effectively manage care for individuals with a temporomandibular disorder. New research should be tightly linked to the goal of producing evidence for developing clinical practice guidelines.

REFERENCES

AADR (American Association for Dental Research). 2015. Temporomandibular disorders (TMDs). http://www.iadr.org/AADR/About-Us/Policy-Statements/Science-Policy/Temporomandibular-Disorders-TMD (accessed August 30, 2019).

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

AAFP (American Academy of Family Physicians). 2019. Choosing wisely: Avoid routinely using irreversible surgical procedures such as braces, occlusal equilibration, and restorations as the first treatment of choice in the management of temporomandibular join disorders. https://www.aafp.org/afp/recommendations/viewRecommendation.htm?recommendationId=313# (accessed August 30, 2019).

AAOMS (American Association of Oral and Maxillofacial Surgeons). 1993. Recommendations for management of patients with temporomandibular joint implants. Temporomandibular Joint Implant Surgery Workshop. Journal of Oral and Maxillofacial Surgery 51(10):1164–1172.

AAOMS. 2017. Parameters of care: Clinical practice guidelines for oral and maxillofacial surgery. Temporomandibular joint surgery. https://www.aaoms.org/docs/member-center/parcare/parcare_8_temporomandibular.pdf (accessed August 30, 2019).

AAOP (American Academy of Orofacial Pain). 2014. Temporomandibular joint disorders (patient brochure). https://aaop.clubexpress.com/content.aspx?page_id=22&club_id=508439&module_id=108085 (accessed February 2, 2020).

ACTTION (Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks). 2020. ACTTION. http://www.acttion.org (accessed February 2, 2020).

ADA (American Dental Association). 2016. Five things dentists and patients should question. http://www.choosingwisely.org/societies/american-dental-association (accessed December 30, 2019).

ADA Center for Evidence-Based Dentistry. 2019. Clinical practice guidelines. https://ebd.ada.org/en/evidence/guidelines (accessed December 30, 2019).

Adams, R. J. 2010. Improving health outcomes with better patient understanding and education. Risk Management and Healthcare Policy 3:61–72.

Aggarwal, V. R., K. Lovell, S. Peters, H. Javidi, A. Joughin, and J. Goldthorpe. 2011. Psychosocial interventions for the management of chronic orofacial pain. Cochrane Database of Systematic Reviews 11:CD008456.

Aggarwal, V. R., Y. Fu, C. J. Main, and J. Wu. 2019. The effectiveness of self-management interventions in adults with chronic orofacial pain: A systematic review, meta-analysis, and meta-regression. European Journal of Pain 23(5):849–865.

Ahmad, M., L. Hollender, Q. Anderson, K. Kartha, R. Ohrbach, E. L. Truelove, M. T. John, and E. L. Schiffman. 2009. Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD): Development of image analysis criteria and examiner reliability for image analysis. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics 107:844–860.

Alzheimer’s Association. 2018. Alzheimer’s Association workgroup reports recommendations to improve timely and accurate diagnosis and disclosure. https://www.alz.org/aaic/releases_2018/AAIC18-Sun-clinical-practice-guidelines.asp (accessed October 4, 2019).

Armijo-Olivo, S., L. Potance, V. Singh, F. Neto, N. Thie, and A. Michelotti. 2016. Effectiveness of manual therapy and therapeutic exercise for temporomandibular disorders: Systematic review and meta-analysis. Physical Therapy 96(1):9–25.

Berrueta, L., I. Muskaj, S. Olenich, T. Butler, G. J. Badger, R. A. Colas, M. Spite, C. N. Serhan, and H. M. Langevin. 2016. Stretching impacts inflammation resolution in connective tissue. Cell Physiology 231(7):1621–1627.

Bialosky, J. E., M. D. Bishop, D. D. Price, M. E. Robinson, and S. Z. George. 2009. The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model. Manual Therapy 14(5):531–538.

Bjørnland, T., A. Gjaerum, and A. Møystad. 2007. Osteoarthritis of the temporomandibular joint: An evaluation of the effects and complications of corticosteroid injection compared with injection with sodium hyaluronate. Journal of Oral Rehabilitation 34(8):583–589.

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

Blau, J. N. 1982. How to take a history of head or facial pain. British Medical Journal 285:1249–1251.

Bothwell, L. E., J. A. Greene, S. H. Podolsky, and D. S. Jones. 2016. Assessing the gold standard: Lessons from the history of RCTS. New England Journal of Medicine 374(22):2175–2181.

Bouloux, G. F., J. Chou, D. Krishnan, T. Aghaloo, N. Kahenasa, J. A. Smith, and H. Giannakopoulos. 2017a. Is hyaluronic acid or corticosteroid superior to lactated Ringer solution in the short-term reduction of temporomandibular joint pain after arthrocentesis? Part 1. Journal of Oral and Maxillofacial Surgery 75(1):52–62.

Bouloux, G. F., J. Chou, D. Krishnan, T. Aghaloo, N. Kahenasa, J. A. Smith, and H. Giannakopoulos. 2017b. Is hyaluronic acid or corticosteroid superior to lactated Ringer solution in the short term for improving function and quality of life after arthrocentesis? Part 2. Journal of Oral and Maxillofacial Surgery 75(1):63–72.

Breckons, M., S. M. Bissett, C. Exley, V. Arauio-Soares, and J. Durham. 2017. Care pathways in persistent orofacial pain: Qualitative evidence from the DEEP study. Journal of Dental Researach—Clinical and Translational Research 2(1):48–57.

Brito, R. G., L. A. Rasmussen, and K. A. Sluka. 2017. Regular physical activity prevents development of chronic muscle pain through modulation of supraspinal opioid and serotonergic mechanisms. Pain Reports 2(5):e618.

Brown, D. T., and E. L. Gaudet, Jr. 2002. Temporomandibular disorder treatment outcomes: Second report of a large-scale prospective clinical study. Cranio 20:244–253.

Campbell, B. K., R. B. Fillingim, S. Lee, R. Brao, D. D. Price, and J. K. Neubert. 2017. Effects of high-dose capsaicin on TMD subjects: A randomized clinical study. Journal of Dental Research, Clinical and Translational Research 2(1):58–65.

CDC (Centers for Disease Control and Prevention). 2019. Guideline for prescribing opioids for chronic pain. https://www.cdc.gov/drugoverdose/prescribing/guideline.html (accessed January 24, 2020).

Cezairli, B., E. C. Sivrikaya, M. M. Omezli, F. Ayranci, and N. S. Cezairli. 2017. Results of combined, single-session arthrocentesis and dextrose prolotherapy for symptomatic temporomandibular joint syndrome: A case series. Journal of Alternative and Complementary Medicine 23:771–777.

Chaurand, J., L. Pacheco-Ruíz, H. Orozco-Saldívar, and J. López-Valdés. 2017. Efficacy of botulinum toxin therapy in treatment of myofascial pain. Journal of Oral Science 59:351–356.

Chen, Y-W., Y-W. Chiu, C-Y. Chen, and S-K. Chuang. 2015. Botulinum toxin therapy for temporomandibular joint disorders: A systematic review of randomized controlled trials. International Journal of Oral and Maxillofacial Surgery 44:1018–1026.

Chiappelli, F., A. Barkhordarian, G. Demerjian, Q. Bach, and V. Kasar. 2015. Cluster randomized stepped wedge blinded controlled trials (CRSWBCT) in comparative effectiveness research (CER). Part II: Implications for temporomandibular joint disorders (TMD) research. Translational Medicine 5:e131.

Clark, G. T., Y. Tsukiyama, K. Baba, and T. Watanabe. 1999. Sixty-eight years of experimental occlusal interference studies: What have we learned? Journal of Prosthetic Dentistry 82:704–713.

Clarke, N. G. 1982. Occlusion and myofascial pain dysfunction: Is there a relationship? Journal of the American Dental Association 104:443–446.

Cochrane Library. 2016a. Occlusal adjustment for treating and preventing temporomandibular joint disorders—reason for withdrawal from publication. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003812.pub2/full (accessed December 11, 2019).

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

Cochrane Library. 2016b. Orthodontics for treating temporomandibular joint (TMJ) disorders—reason for withdrawal from publication. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006541.pub3/full/es (accessed December 11, 2019).

COMET (Core Outcome Measures in Effectiveness Trials) Initiative. 2020. Core Outcome Measures in Effectiveness Trials. http://www.comet-initiative.org (accessed February 14, 2020).

Conti, P. C. R., E. N. De Alencar, A. S. Da Mota Correa, J. R. P. Lauris, A. L. Porporatti, and Y. M. Costa. 2012. Behavioural changes and occlusal splints are effective in the management of masticatory myofascial pain: A short-term evaluation. Journal of Oral Rehabilitation 39(10):754–760.

Cooper, B. C. 2011. Temporomandibular disorders: A position paper of the International College of Cranio-Mandibular Orthopedics (ICCMO). Cranio 29:237–244.

Craane, B., P. U. Dijkstra, K. Stappaerts, and A. De Laat. 2012. One-year evaluation of the effect of physical therapy for masticatory muscle pain: A randomized controlled trial. European Journal of Pain 16(5):737–747.

Daif, E. T. 2010. Autologous blood injection as a new treatment modality for chronic recurrent temporomandibular joint dislocation. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology 109(1):31–36.

Davoudi, A., H. Khaki, I. Mohammadi, M. Daneshmand, A. Tamizifar, M. Bigdelou, and F. Ansaripoor. 2018. Is arthrocentesis of temporomandibular joint with corticosteroids beneficial? A systematic review. Medicina Oral, Patologia Oral y Cirugia Bucal 23:e367–e375.

Dawson, P. E. 1996. A classification system for occlusions that relates maximal intercuspation to the position and condition of the temporomandibular joints. Journal of Prosthetic Dentistry 75:60–66.

de Leeuw, R and G. Klasser. 2018. Orofacial pain: guidelines for assessment, diagnosis, and management, sixth edition. Hanover Park, IL: Quintessence Publishing.

de Pedro, M., R. M. López-Pintor, J. L. de la Hoz-Aizpurua, E. Casañas, and G. Hernández. 2019. Efficacy of low-level laser therapy for the therapeutic management of neuropathic orofacial pain: A systematic review. Journal of Oral & Facial Pain & Headache 34(1):13–30.

de Resende, C. M. B. M., F. G. L. De Oliveira Medeiros, C. R. De Figueiredo Rego, A. De Sousa Leite Bispo, G. A. S. Barbosa, and E. O. De Almeida. 2019. Short-term effectiveness of conservative therapies in pain, quality of life, and sleep in patients with temporomandibular disorders: A randomized clinical trial. Journal of Craniomandibular & Sleep Practice June 15. [Epub ahead of print].

de Souza, R. F., C. H. L. da Silva, M. Nasser, Z. Fedorowicz, and M. A. Al-Muharraqi. 2012. Interventions for managing temporomandibular joint osteoarthritis. Cochrane Database of Systematic Reviews CD007261.

Delitto, A., S. Z. George, L. Van Dillen, J. M. Whitman, G. Sowa, P. Shekelle, T. R. Denninger, J. J. Godges, and Orthopaedic Section of the American Physical Therapy Association. 2012. Low back pain: Clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic and Sports Physical Therapy 42(4):A1–A57.

Deyo, R. A., S. F. Dworkin, D. Amtmann, G. Andersoon, D. Borenstein, E. Carragee, J. Carrino, R. Chou, K. Cook, A. Delittlo, C. Goertz, P. Khalsa, J. Loeser, S. Mackey, J. Panagis, J. Rainville, T. Tosteson, D. Turk, M. Von Korff, and D. K. Weiner. 2014. Report of the NIH Task Force on Research Standards for Chronic Low Back Pain. Spine 39:1128–1143.

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

Dimitroulis, G., M. Dolwick, and A. Martinez. 1995. Temporomandibular joint arthrocentesis and lavage for the treatment of closed lock: A follow-up study. British Journal of Oral and Maxillofacial Surgery 33:23–27.

Durham, J., R. Touger-Decker, D. R. Nixdorf, D. Rigassio-Radler, and P. Moynihan. 2015. Oro-facial pain and nutrition: A forgotten relationship. Journal of Oral Rehabilitation 42(1):75–80.

Dworkin, R. H., D. C. Turk, J. T. Farrar, J. A. Haythornthwaite, M. P. Jensen, N. P. Katz, R. D. Kerns, G. Stucki, R. R. Allen, N. Bellamy, D. B. Carr, J. Chandler, P. Cowan, R. Dionne, B. S. Galer, S. Hertz, A. R. Jadad, L. D. Kramer, D. C. Manning, S. Martin, C. G. McCormick, M. P. McDermott, P. McGrath, S. Quessy, B. A. Rappaport, W. Robbins, J. P. Robinson, M. Rothman, M. A. Royal, L. Simon, J. W. Stauffer, W. Stein, J. Tollett, J. Wernicke, J. Witter, and IMMPACT. 2005. Core outcome measures for chronic pain clinical trials: IMMPACT recommendations. Pain 113(1–2):9–19.

Dworkin, S. F., K. H. Huggins, L. Wilson, L. Manci, J. Turner, D. Massoth, L. LeResche, and E. Truelove. 2002. A randomized clinical trial using research diagnostic criteria for temporomandibular disorders-axis II to target clinic cases for a tailored self-care TMD treatment program. Journal of Orofacial Pain 16:48–63.

FDA (Food and Drug Administration). 2011. FDA orders postmarket surveillance of certain TMJ implants. https://wayback.archive-it.org/7993/20170114063520/http:/www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm242421.htm (accessed June 12, 2019).

FDA. 2019a. Premarket approval P980052. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=P980052 (accessed November 20, 2019).

FDA. 2019b. Premarket approval P000035. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=P000035 (accessed November 20, 2019).

FDA. 2019c. Premarket approval P020016. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=P020016 (accessed November 20, 2019).

FDA. 2019d. 522 postmarket surveillance studies. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMA/pss.cfm (accessed November 20, 2019).

FDA. 2019e. 522 postmarket surveillance studies: PS110003/PSS001. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMA/pss.cfm?t_id=40&c_id=393 (accessed January 2, 2020).

FDA. 2019f. 522 postmarket surveillance studies: PS110004/PSS001. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMA/pss.cfm?t_id=41&c_id=394 (accessed January 2, 2020).

Ferrando, M., M. J. Galdon, E. Dura, Y. Andreu, Y. Jiminez, and R. Poveda. 2012. Enhancing the efficacy of treatment for temporomandibular patients with muscle diagnosis through cognitive-behavioral intervention, including hypnosis: A randomized study. Oral Medicine 113:81–89.

Ferreira, J. N., C. C. Ko, S. Myers, J. Swift, and J. R. Fricton. 2008. Evaluation of surgically retrieved temporomandibular joint alloplastic implants: Pilot study. Journal of Oral and Maxillofacial Surgery 66(6):1112–1124.

Forssell, H., E. Kalso, P. Koskela, R. Vehmanen, P. Puukka, and P. Alanen. 1999. Occlusal treatments in temporomandibular disorders: A qualitative systematic review of randomized controlled trials. Pain 83(3):549–560.

Fricton, J. 2006. Current evidence providing clarity in management of temporomandibular disorders: Summary of a systematic review of randomized clinical trials for intra-oral appliances and occlusal therapies. Journal of Evidence Based Dental Practice 6:48–52.

Fridrich, K. L., J. M. Wise, and D. L. Zeitler. 1996. Prospective comparison of arthroscopy and arthrocentesis for temporomandibular joint disorders. Journal of Oral and Maxillofacial Surgery 54(7):816–820.

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

GAO (Government Accountability Office). 2007. Medical devices: FDA’s approval of four temporomandibular joint implants. GAO-0-996. https://www.gao.gov/assets/270/266885.pdf (accessed December 12, 2019).

Gauer, R. L., and M. J. Semidey. 2015. Diagnosis and treatment of temporomandibular disorders. American Family Physician 91(6):378–386.

Genetic Alliance. 2019. PEER: Platform for Engaging Everyone Responsibly. http://www.geneticalliance.org/programs/biotrust/peer (accessed October 14, 2019).

Gewandter, J. S., S. M. Smith, A. McKeown, K. Edwards, A. Narula, J. R. Pawlowski, D. Rothstein, P. J. Desjardins, S. F. Dworkin, R. A. Gross, R. Ohrbach, B. A. Rappaport, B. J. Sessle, D. C. Turk, and R. H. Dworkin. 2015. Reporting of adverse events and statistical details of efficacy estimates in randomized clinical trials of pain in temporomandibular disorders: Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks systematic review. Journal of the American Dental Association 146(4):246–254.

Gliklich, R. E., N. A. Dreyer, and M. B. Leavy, eds. 2014. Registries for evaluating patient outcomes: A user’s guide, 3rd edition. https://effectivehealthcare.ahrq.gov/products/registries-guide-3rd-edition/research (accessed December 12, 2019).

Gopalakrishnan, V., S. A. Nagori, S. K. Roy Chowdhury, and V. Saxena. 2018. The use of intra-articular analgesics to improve outcomes after temporomandibular joint arthrocentesis: A review. Oral and Maxillofacial Surgery 22(4):357–364.

Greene, C. S. 2010. Managing the care of patients with temporomandibular disorders: A new guideline for care. Journal of the American Dental Association 141:1086–1088.

Gruber, E. A., J. McCullough, and A. J. Sidebottom. 2015. Medium-term outcomes and complications after total replacement of the temporomandibular joint. Prospective outcome analysis after 3 and 5 years. British Journal of Oral and Maxillofacial Surgery 53(5):412–415.

Haggman-Henrikson, B., B. Wiesinger, and A. Wanman. 2018. The effect of supervised exercise on localized TMD pain and TMD pain associated with generalized pain. Acta Odontologica Scandinavica 76(1):6–12.

Henry, C. H., and L. M. Wolford. 1993. Treatment outcomes for temporomandibular joint reconstruction after Proplast-Teflon implant failure. Journal of Oral and Maxillofacial Surgery 51(4):352–360.

Hill, K. P., M. D. Palastro, B. Johnson, and J. W. Ditre. 2017. Cannabis and pain: A clinical review. Cannabis and Cannabinoid Research 2(1):96–104.

Hoffman, B. M., R. K. Papas, D. K. Chatkoff, and R. D. Kerns. 2007. Meta-analysis of psychological interventions for chronic low back pain. Health Psychology 26(1):1–9.

Holden, G. 1991. The relationship of self-efficacy appraisals to subsequent health related outcomes: A meta-analysis. Social Work in Health Care 16(1):53–93.

IMMPACT (Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials). 2019. IMMPACT. http://www.immpact.org (accessed October 4, 2019).

Inagaki, T., T. Miyaoka, H. Shinno, J. Horiguchi, S. Matsuda, and H. Yoshikawa. 2007. Treatment of temporomandibular pain with the selective serotonin reuptake inhibitor paroxetine. Primary Care Companion to the Journal of Clinical Psychiatry 9(1):69–70.

IOM (Institute of Medicine). 2011. Clinical practice guidelines we can trust. Washington, DC: The National Academies Press.

Jackson, T., Y. Wang, Y. Wang, and H. Fan. 2014. Self-efficacy and chronic pain outcomes: A meta-analytic review. Journal of Pain 15(8):800–814.

JADA (Journal of the American Dental Association). 2010. Letters. Journal of the American Dental Association 141(12):1407–1417.

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

Jokstad, A., A. Mo, and B. S. Krogstad. 2005. Clinical comparison between two different splint designs for temporomandibular disorder therapy. Acta Odontologica Scandinavica 63(4):218–226.

Kamyszek, G., R. Ketcham, R. Garcia, Jr., and J. Radke. 2001. Electromyographic evidence of reduced muscle activity when ULF-TENS is applied to the Vth and VIIth crian nerves. Cranio 19(3):162–168.

Kassirer, J. P., and R. I. Kopelman. 1991. Learning clinical reasoning. Baltimore, MD: Williams and Wilkins.

Keenan, J. R. 2015. Unclear results for the use of botulinum toxin therapy for TMD pain. Evidence-Based Dentistry 16:122.

Khawaja, S. N., S. J. Scrivani, N. Holland, and D. A. Keith. 2017. Effectiveness, safety, and predictors of response to botulinum toxin type A in refractory masticatory myalgia: A retrospective study. Journal of Oral and Maxillofacial Surgery 75:2307–2315.

Kia, S., and E. Choy. 2017. Update on treatment guideline in fibromyalgia syndrome with focus on pharmacology. Biomedicines 5(2):20.

Kimos, P., C. Biggs, J. Mah, G. Heo, S. Rashiq, N. M. Thie, and P. W. Major. 2007. Analgesic action of gabapentin on chronic pain in the masticatory muscles: A randomized controlled trial. Pain 127(1–2):151–160.

Klasser, G. D., and C. S. Greene. 2009. The changing field of temporomandibular disorders: What dentists need to know. Journal of the Canadian Dental Association 75:49–53.

Koh, H., and P. G. Robinson. 2003. Occlusal adjustment for treating and preventing temporomandibular joint disorders. Cochrane Database of Systematic Reviews CD003812.

Kotiranta, U., T. Suvinen, and H. Forssell. 2014. Tailored treatments in temporomandibular disorders: Where are we now? A systematic qualitative literature review. Journal of Oral & Facial Pain and Headache 28(1):28–37.

Krucoff, M. W., A. Sedrakyan, and S. T. Normand. 2015. Bridging unmet medical device ecosystem needs with strategically coordinated registries networks. JAMA 314(16):1691–1692.

Kunjur, J., R. Niziol, and N. S. Matthews. 2016. Quality of life: Patient-reported outcomes after total replacement of the temporomandibular joint. British Journal of Oral and Maxillofacial Surgery 54(7):762–766.

Kusiak, J. W., C. Veasley, W. Maixner, R. B. Fillingim, J. S. Mogil, L. Diatchenko, C. B. Meloto, I. Belfer, M. Kaseta, T. Kalinowski, J. Gagnier, N. Hu, C. Alvarez-Garriga, M. Bayona, B. Eloff, M. Reardon, C. Greene, A. Bertagna, T. Cowley, J. Wilentz, and D. Clare. 2018. The TMJ Patient-Led RoundTable: A History and Summary of Work. http://mdepinet.org/wp-content/uploads/TMJ-Patient-RoundTable-Briefing-Report_9_25_18.pdf (accessed January 31, 2020).

Kuzmanovic Pficer, J., S. Dodic, V. Lazic, G. Trajkovic, N. Milic, and B. Milic. 2017. Occlusal stabilization splint for patients with temporomandibular disorders: Meta-analysis of short and long term effects. PLoS One 12(2):e0171296.

Langevin, H. M., T. Fujita, N. A. Bouffard, T. Takano, C. Koptiuch, G. J. Badger, and M. Nedergaard. 2013. Fibroblast cytoskeletal remodeling induced by tissue stretch involves ATP signaling. Cell Physiology 228(9):1922–1926.

Lee, M. K., B. Y. Choi, and D. K. Ahn. 2008. Low doses of cannabinoids enhance the anti-nociceptive effects of intracisternally administered mGluRs groups II and III agonists in formalin-induced TMJ nociception in rats. Pain 139(2):367–375.

Leite, F. M. G., Á. Atallah, R. El Dib, E. Grossmann, E. Januzzi, R. B. Andriolo, and E. M. K. da Silva. 2009. Cyclobenzaprine for the treatment of myofascial pain in adults. Cochrane Database of Systematic Reviews CD006830.

Levy, P. H. 1975. Clinical implications of mandibular repositioning and the concept of an alterable centric relation. Dental Clinics of North America 19:543–570.

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

Li, C., N. Su, X. Yang, X. Yang, Z. Shi, and L. Li. 2012. Ultrasonography for detection of disc displacement of temporomandibular joint: A systematic review and meta-analysis. Journal of Oral and Maxillofacial Surgery 70:1300–1309.

Lima, L. V., T. S. S. Abner, and K. A. Sluka. 2017a. Does exercise increase or decrease pain? Central mechanisms underlying these two phenomena. Journal of Physiology 595(13):4141–4150.

Lima, L. V., J. M. DeSantana, L. A. Rasmussen, and K. A. Sluka. 2017b. Short-duration physical activity prevents the development of activity-induced hyperalgesia through opioid and serotoninergic mechanisms. Pain 158(9):1697–1710.

Litt, M. D., D. M. Shafer, and D. L. Kreutzer. 2010. Brief cognitive-behavioral treatment for TMD pain: Long-term outcomes and moderators of treatment. Pain 151(1):110–116.

Liu, H., Q. Liang, P. Xiao, H. Jiao, Y. Gao, and C. Ahmetjiang. 2012. The effectiveness of cognitive–behavioral therapy for temporomandibular disorders: A systematic review. Journal of Oral Rehabilitation 39(1):55–62.

Liu, Y., J. Wu, W. Fei, X. Cen, Y. Xiong, S. Wang, Y. Tang, and X. Liang. 2018. Is there a difference in intra-articular injections of corticosteroids, hyaluronate, or placebo for temporomandibular osteoarthritis? Journal of Oral and Maxillofacial Surgery 76(3):504–514.

Lorig, K., R. L. Chastain, E. Ung, S. Shoor, and H. R. Holman. 1989. Development and evaluation of a scale to measure perceived self efficacy in people with arthritis. Arthritis and Rheumatism 32(1):37–44.

Luther, F., S. Layton, and F. McDonald. 2010. Orthodontics for treating temporomandibular joint (TMJ) disorders. Cochrane Database of Systematic Reviews CD006541.

Lypka, M., and D. D. Yamashita. 2007. Exuberant foreign body giant cell reaction to a Teflon/Proplast temporomandibular joint implant: Report of a case. Journal of Oral and Maxillofacial Surgery 65(9):1680–1684.

Machado, E., P. Machado, V. F. Wandscher, A. M. E. Marchionatti, F. B. Zanatta, and O. B. Kaiser. 2018. A systematic review of different substance injection and dry needling for treatment of temporomandibular myofascial pain. International Journal of Oral and Maxillofacial Surgery 47(11):1420–1432.

Machon, V., S. Abramowicz, J. Paska, and M. F. Dolwick. 2009. Autologous blood injection for the treatment of chronic recurrent temporomandibular joint dislocation. Journal of Oral and Maxillofacial Surgery 67(1):114–119.

Maia, M. L., L. R. Bonjardim, J. Quintans, M. Ribeiro, L. Maia, and P. C. Conti. 2012. Effects of low-level laser therapy on pain levels in patients with temporomandibular disorders: A systematic review. Journal of Applied Oral Science 20(6):594–602.

Manfredini, D. 2018. Occlusal equilibration for the management of temporomandibular disorders. Oral and Maxillofacial Surgery Clinics of North America 30(3):257–264.

Manfredini, D., T. Castroflorio, G. Perinetti, and L. Guarda-Nardini. 2012. Dental occlusion, body posture and temporomandibular disorders: Where we are now and where we are heading for. Journal of Oral Rehabilitation 39:463–471.

Martin, W. J., and T. Forouzanfar. 2011. The efficacy of anticonvulsants on orofacial pain: A systematic review. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology 111(5):627–633.

Martins, D. F., L. Mazzardo-Martins, V. M. Gadotti, F. P. Nascimento, D. A. Lima, B. Speckhann, G. A. Favretto, E. Cargnin-Ferreira, E. Bressan, R. C. Dutra, J. B. Calixto, and A. R. Santos. 2011. Ankle joint mobilization reduces axonotmesis-induced neuropathic pain and glial activation in the spinal cord and enhances nerve regeneration in rats. Pain 152(11):2653–2661.

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

Martins, D. F., F. Bobinski, L. Mazzardo-Martins, F. J. Cidral-Filho, F. P. Nascimento, V. M. Gadotti, and A. R. Santos. 2012. Ankle joint mobilization decreases hypersensitivity by activation of peripheral opioid receptors in a mouse model of postoperative pain. Pain Medicine 13(8):1049–1058.

Martins, D. F., L. Mazzardo-Martins, F. J. Cidral-Filho, J. Stramosk, and A. R. Santos. 2013a. Ankle joint mobilization affects postoperative pain through peripheral and central adenosine A1 receptors. Physical Therapy 93:401–412.

Martins, D. F., L. Mazzardo-Martins, F. J. Cidral-Filho, V. M. Gadotti, and A. R. Santos. 2013b. Peripheral and spinal activation of cannabinoid receptors by joint mobilization alleviates postoperative pain in mice. Neuroscience 255:110–121.

McCain, J. P., and R. H. Hossameldin. 2011. Advanced arthroscopy of the temporomandibular joint. Atlas of the Oral and Maxillofacial Surgery Clinics of North America 19(2):145–167.

McNamara, J. A. 1997. Orthodontic treatment and temporomandibular disorders. Oral Surgery Oral Medicine Oral Pathology Oral Radiology & Endodontics 83:107–117.

McNeely, M. L., O. S. Armijo, and D. J. Magee. 2006. A systematic review of the effectiveness of physical therapy interventions for temporomandibular disorders. Physical Therapy 86:710–725.

MDEpiNet (Medical Device Epidemiology Network). 2019a. The medical device epidemiology network. http://mdepinet.org (accessed December 30, 2019).

MDEpiNet. 2019b. CRN community of practice. http://mdepinet.org/crn-community-practice (accessed December 30, 2019).

MDEpiNet. 2019c. TMJ CRN. mdepinet.org/TMJ-crn (accessed December 30, 2019).

Medlicott, M. S., and S. R. Harris. 2006. A systematic review of the effectiveness of exercise, manual therapy, electrotherapy, relaxation training, and biofeedback in the management of temporomandibular disorder. Physical Therapy 86(7):955–973.

Melo, G., E. Casett, J. Stuginski-Barbosa, E. N. S. Guerra, D. A. Fernandes, A. L. Porporatti, C. Flores-Mir, and G. De Luca Canto. 2018. Effects of glucosamine supplements on painful temporomandibular joint osteoarthritis: A systematic review. Journal of Oral Rehabilitation 45(5):414–422.

Mercuri, L. G. 1999. Subjective and objective outcomes in patients reconstructed with a custom-fitted alloplastic temporomandibular joint prosthesis. Journal of Oral and Maxillofacial Surgery 57:1427–1430.

Mohl, N. D. 1984. The role of head posture in mandibular function. In W. K. Solberg and G. T. Clark, eds. Abnormal jaw mechanics: Diagnosis and treatment. Chicago, IL: Quintessence. Pp. 97–116.

Monaco, A., F. Sgolastra, D. Pietropaoli, M. Giannoni, and R. Cattaneo. 2013. Comparison between sensory and motor transcutaneous electrical nervous stimulation on electromyographic and kinesiographic activity of patients with temporomandibular disorder: A controlled clinical trial. BMC Musculoskeletal Disorders 14:168.

Morley, S., A. C. Williams, and C. Eccleston. 2013. Examining the evidence of psychological treatments for chronic pain: Time for a paradigm shift? Pain 154(10):1929–1931.

Mujakperuo, H. R., M. Watson, R. Morrison, and T. V. Macfarlane. 2010. Pharmacological interventions for pain in patients with temporomandibular disorders. Cochrane Database Systematic Reviews 10:CD004715.

Myers, S., S. Kaimal, J. Springsteen, J. Ferreira, C. C. Ko, and J. Fricton. 2006. Development of a National TMJ Implant Registry and Repository: NIDCR’s TIRR. Northwest Dentistry 86(6):13–18.

Nagashima, W., H. Kimura, M. Ito, T. Tokura, M. Arao, B. Aleksic, K. Yoshida, K. Kurita, and N. Ozaki. 2012. Effectiveness of duloxetine for the treatment of chronic nonorganic orofacial pain. Clinical Neuropharmacology 35(6):273–277.

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

NASEM (National Academies of Sciences, Engineering, and Medicine). 2017. Pain management and the opioid epidemic: Balancing societal and individual benefits and risks of prescription opioid use. Washington, DC: The National Academies Press.

Nasri-Heir, C., J. B. Epstein, R. Touger-Decker, and R. Benoliel. 2016. What should we tell patients with painful temporomandibular painful temporomandibular disorders about what to eat? Journal of the American Dental Association 47(8):667–671.

National Dental PBRN (Practice-Based Research Network). 2019. National Dental Practice-Based Research Network. http://nationaldentalpbrn.org (accessed January 24, 2020).

Navarrete, A. L., K. L. Rafferty, Z. J. Liu, W. Ye, G. M. Greenlee, and S. W. Herring. 2013. Botulinum neurotoxin type A in the masseter muscle: Effects on incisor eruption in rabbits. American Journal of Orthodontics and Dentofacial Orthopedics 143(4):499–506.

NICE (National Institute for Health and Care Excellence). 2014. Overview: Total prosthetic replacement of the temporomandibular joint: Guidance. www.nice.org.uk/guidance/ipg500 (accessed October 3, 2019).

Nichol, A. D., M. Bailey, D. J. Cooper, POLAR, and EPO Investigators. 2010. Challenging issues in randomized controlled trials. Injury 41(Suppl 1):S20–S23.

NIDCR (National Institute of Dental and Craniofacial Research). 2013. Less is often best in treating TMJ disorders. https://www.nidcr.nih.gov/sites/default/files/2017-09/less-is-best-tmj.pdf (accessed August 30, 2019).

NIDCR. 2018. TMJ (Temporomandibular Joint & Muscle Disorders). https://www.nidcr.nih.gov/health-info/tmj/more-info (accessed November 18, 2019).

Nitzan, D. W., and A. Price. 2001. The use of arthrocentesis for the treatment of osteoarthritic temporomandibular joints. Journal of Oral and Maxillofacial Surgery 59:1154–1159.

Nitzan, D. W., J. Svidovsky, A. Zini, and Y. Zadik. 2017. Effect of arthrocentesis on symptomatic osteoarthritis of the temporomandibular joint and analysis of the effect of preoperative clinical and radiologic features. Journal of Oral and Maxillofacial Surgery 75:260–267.

Ohrbach, R., G. Slade, E. Bair, N. Rathnayaka, L. Diatchenko, J. D. Greenspan, W. Maixner, and R. B. Fillingim. 2020. Premorbid and concurrent predictors of TMD onset and persistence. European Journal of Pain 24(1):145–158.

Oliveira, C. B., C. G. Maher, R. Z. Pinto, A. C. Traeger, C. C. Lin, J. F. Chenot, M. van Tulder, and B. W. Koes. 2018. Clinical practice guidelines for the management of nonspecific low back pain in primary care: An updated overview. European Spine Journal 27(11):2791–2803.

Onoriobe, U., M. Miloro, C. Sukotjo, L. G. Mercuri, A. Lotesto, and R. Eke. 2016. How many temporomandibular joint total joint alloplastic implants will be placed in the United States in 2030? Journal of Oral and Maxillofacial Surgery 74(8):1531–1538.

Ouanounou, A., M. Goldberg, and D. A. Haas. 2017. Pharmacotherapy in temporomandibular disorders: A review. Journal of the Canadian Dental Association 83:h7.

PCORNet (National Patient-Centered Clinical Research Network). 2019. PCORnet. https://pcornet.org/clinical-research-network (accessed October 4, 2019).

Peck, C. C., J-P. Goulet, F. Lobbezoo, E. L. Schiffman, P. Alstergren, G. C. Anderson, R. de Leeuw, R. Jensen, A. Michelotti, R. Ohrbach, A. Petersson, and T. List. 2014. Expanding the taxonomy of the diagnostic criteria for temporomandibular disorders. Journal of Oral Rehabilitation 41:2–23.

Pihut, M., M. Gorecka, P. Ceranowicz, and M. Wieckiewicz. 2018. The efficiency of anterior repositioning splints in the management of pain related to temporomandibular joint disc displacement with reduction. Pain Research and Management 9089286.

Pike, A., L. Hearn, and A. C. Williams. 2016. Effectiveness of psychological interventions for chronic pain on health care use and work absence: Systematic review and meta-analysis. Pain 157(4):777–785.

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

Pullinger, A. G., D. A. Seligman, and W. K. Solberg. 1988. Temporomandibular disorders. Part II: Occlusal factors associated with temporomandibular joint tenderness and dysfunction. Journal of Prosthetic Dentistry 59:363–367.

Qaseem, A., T. J. Wilt, R. M. McLean, M. A. Forciea, and Clinical Guidelines Committee of the American College of Physicians. 2017. Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine 166(7):514–530.

Racich, M. J. 2018. Occlusion, temporomandibular disorders, and orofacial pain: An evidence-based overview and update with recommendations. Journal of Prosthetic Dentistry 120:678–685.

Rajan, R., and Y. M. Sun. 2017. Reevaluating antidepressant selection in patients with bruxism and temporomandibular joint disorder. Journal of Psychiatric Practice 23(3):173–179.

Randhawa, K., R. Bohay, P. Cote, G. van der Velde, D. Sutton, J. J. Wong, H. Yu, D. Southerst, S. Varatharajan, S. Mior, M. Stupar, H. M. Shearer, C. Jacobs, and A. Taylor-Vaisey. 2016. The effectiveness of noninvasive interventions for temporomandibular disorders: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Clinical Journal of Pain 32(3):260–278.

Refai, H. 2017. Long-term therapeutic effects of dextrose prolotherapy in patients with hypermobility of the temporomandibular joint: A single-arm study with 1–4 years’ follow up. British Journal of Oral and Maxillofacial Surgery 55:465–470.

Resnick, C. M., P. M. Vakliain, M. Breen, D. Zurakowski, P. Caruso, L. Henderson, P. A. Nigrovic, L. B. Kaban, and Z. S. Peacock. 2016. Quantifying temporomandibular joint synovitis in children with juvenile idiopathic arthritis. Arthritis Care Research 68(12):1795–1802.

Resnick, C. M., R. Dang, L. A. Henderson, D. A. Zander, K. M. Daniels, P. A. Nigrovic, and L. B. Kaban. 2017. Frequency and morbidity of temporomandibular joint involvement in adult patients with a history of juvenile idiopathic arthritis. Journal of Oral and Maxillofacial Surgery 75(6):1191–1200.

Rizzatti-Barbosa, C. M., M. T. Nogueira, E. D. de Andrade, G. M. Ambrosano, and J. R. de Barbosa. 2003. Clinical evaluation of amitriptyline for the control of chronic pain caused by temporomandibular joint disorders. Cranio 21(3):221–225.

Rodrigues, D., A. O. Siriani, and F. Bérzin. 2004. Effect of conventional TENS on pain and electromyographic activity of masticatory muscles in TMD patients. Brazilian Oral Research 18(4):290–295.

Rugh, J. D., G. S. Graham, J. C. Smith, and R. K. Ohrbach. 1989. Effects of canine versus molar occlusal splint guidance on nocturnal bruxism and craniomandibular symptomatology. Journal of Craniomandibular Disorders 3(4):203–210.

Schiffman, E., R. Ohrbach, E. Truelove, J. Look, G. Anderson, J-P. Goulet, T. List, P. Svensson, F. Lobbezoo, A. Michelotti, S. L. Brooks, W. Ceusters, M. Drangsholt, D. Ettlin, C. Gaul, L. J. Goldberg, J. A. Haythornthwaite, L. Hollender, R. Jensen, M. T. John, A. De Laat, R. de Leeuw, W. Maixner, M. vaqn der Meulen, G. M. Murray, D. R. Nixdorf, S. Palla, A. Petersson, P. Pionchon, B. Smith, C. M. Visscher, J. Zakrzewska, S. F. Dworkin, International RDC/TMD Consortium Network, International Association for Dental Research, Orofacial Pain Special Interest Group, and International Association for the Study of Pain. 2014. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: Recommendations of the International RDC/TMD Consortium Network and Orofacial Pain Special Interest Group. Journal of Oral and Facial Pain and Headache 28(1):6–27.

Shaheed, C. A., C. G. Maher, and A. J. McLachlan. 2019. Efficacy and safety of low-dose codeine-containing combination analgesics for pain: Systematic review and meta-analysis. Clinical Journal of Pain 35(10):836–843.

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

Shanavas, M., L. Chatra, P. Shenai, P. K. Rao, V. Jagathisth, S. P. Kumar, and B. Naduvakkattu. 2014. Transcutaneous electrical nerve stimulation therapy: An adjuvant pain controlling modality in TMD patients—a clinical study. Dental Research Journal (Isfahan) 11(6):676–679.

Sharma, S., M. Breckons, B. Bronnimann-Lambelet, J. W. Chung, T. List, F. Lobbezoo, D. R. Nixdorf, J. F. Oyarzo, C. Peck, Y. Tsukiyama, and R. Ohrbach. 2019. Challenges in the clinical implementation of a biopsychosocial model for assessment and management of orofacial pain. Journal of Oral Rehabilitation 47(1):87–100.

Shedden-Mora, M. C., D. Weber, A. Neff, and W. Rief. 2013. Biofeedback-based cognitive-behavioral treatment compared with occlusal splint for temporomandibular disorder: A randomized controlled trial. Clinical Journal of Pain 29(12):1057–1065.

Sidebottom, A. J., UK TMJ Replacement Surgeons, and British Association of Oral and Maxillofacial Surgeons. 2008. Guidelines for the replacement of temporomandibular joints in the United Kingdom. British Journal of Oral and Maxillofacial Surgery 46(2):146–147.

Singer, E., and R. Dionne. 1997. A controlled evaluation of ibuprofen and diazepam for chronic orofacial muscle pain. Journal of Orofacial Pain 11(2):139–146.

Singh, B. P., S. Jayaraman, R. Kirubakaran, S. Joseph, M. S. Muthu, H. Jivnani, F. Hua, and N. Singh. 2017. Occlusal interventions for managing temporomandibular disorders (protocol). Cochrane Database of Systematic Reviews 11:CD012850.

Skyba, D. A., R. Radhakrishnan, J. J. Rohlwing, A. Wright, and K. A. Sluka. 2003. Joint manipulation reduces hyperalgesia by activation of monoamine receptors but not opioid or GABA receptors in the spinal cord. Pain 106(1–2):159–168.

Slade, G. D., R. Ohrbach, J. D. Greenspan, R. B. Fillingim, E. Bair, A. E. Sanders, R. Dubner, L. Diatchenko, C. B. Meloto, S. Smith, and W. Maixner. 2016. Painful temporomandibular disorder: Decade of discovery from OPPERA studies. Journal of Dental Research 95(10):1084–1092.

Sluka, K. A., L. Frey-Law, and M. Hoeger Bement. 2018. Exercise-induced pain and analgesia? Underlying mechanisms and clinical translation. Pain 159(Suppl 1):S91–S97.

Soares, A., R. B. Andriolo, A. N. Atallah, and E. M. da Silva. 2014. Botulinum toxin for myofascial pain syndromes in adults. Cochrane Database Systematic Reviews 7:CD007533.

Southard, T. E., K. A. Southard, and E. A. Tolley. 1990. Variation of approximal tooth contact tightness with postural change. Journal of Dental Research 69:1776–1779.

Ta, L. E., and R. A. Dionne. 2004. Treatment of painful temporomandibular joints with a cyclooxygenase-2 inhibitor: A randomized placebo-controlled comparison of celecoxib to naproxen. Pain 111(1):13–21.

Tesch, R. S., L. C. D. S. P. Macedo, F. S. Fernandes, G. S. Goffredo Filho, and C. P. Q. F. Goes. 2019. Effectiveness of dry needling on the local pressure pain threshold in patients with masticatory myofascial pain. Systematic review and preliminary clinical trial. Cranio 27:1–9.

The TMJ Association. 2016. Botox’s effect on the jaw joint. http://www.tmj.org/site/page?pageId=218 (accessed February 3, 2020).

The TMJ Association. 2017. TMD nutrition and you. http://www.tmj.org/site/page?pageId=318 (accessed October 3, 2019).

The TMJ Association. 2019a. TMJ Patient RoundTable Project: Status update. http://www.tmj.org/site/page?pageId=408 (accessed December 30, 2019).

The TMJ Association. 2019b. TMD treatments. http://www.tmj.org/Page/52/20 (accessed December 30, 2019).

Tocaciu, S., M. J. McCullough, and G. Dimitroulis. 2019. Surgical management of recurrent TMJ dislocation: A systematic review. Oral and Maxillofacial Surgery 23(1):35–45.

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

Tour, J., M. Lofgren, K. Mannerkorpi, B. Gerdle, A. Larsson, A. Palstam, I. Bilevicite-Ljungar, J. Bjersing, I. Martin, M. Ernberg, M. Schalling, and E. Kosek. 2017. Gene-to-gene interactions regulate endogenous pain modulation in fibromyalgia patients and healthy controls-antagonistic effects between opioid and serotonin-related genes. Pain 158(7):1194–1203.

Truelove, E., K. H. Huggins, L. Mancl, and S. F. Dworkin. 2006. The efficacy of traditional, low-cost and nonsplint therapies for temporomandibular disorder: A randomized controlled trial. Journal of the American Dental Association 137:1099–1107.

Turner, J. A., L. Mancl, and L. A. Aaron. 2006. Short- and long-term efficacy of brief cognitive-behavioral therapy for patients with chronic temporomandibular disorder pain: A randomized controlled trial. Pain 121(3):181–194.

Türp, J., and H. Schindler. 2012. The dental occlusion as a suspected cause for TMDs: Epidemiological and etiological considerations. Journal of Oral Rehabilitation 39:502–512.

Türp J. C., F. Komine, and A. Hugger. 2004. Efficacy of stabilization splints for the management of patients with masticatory muscle pain: A qualitative systematic review. Clinical Oral Investigations 8(4):179–195.

Türp, J. C., A. Jokstad, E. Motschall, H. J. Schindler, I. Windecker-Getaz, and D. A. Ettlin. 2007. Is there a superiority of multimodal as opposed to simple therapy in patients with temporomandibular disorders? A qualitative systematic review of the literature. Clinical Oral Implants Research 18(Suppl 3):138–150.

van der Zaag, J., F. Lobbezoo, D. J. Wicks, C. M. Visscher, H. L. Hamburger, and M. Naeije. 2005. Controlled assessment of the efficacy of occlusal stabilization splints on sleep bruxism. Journal of Orofacial Pain 19(2):151–158.

Vance, C. G., D. L. Dailey, B. A. Rakel, and K. A. Sluka. 2014. Using TENS for pain control: The state of the evidence. Pain Management 4:197–209.

Velly, A. M., E. L. Schiffman, D. B. Rindal, J. Cunha-Cruz, G. H. Gilbert, M. Lehmann, A. Horowitz, and J. Fricton. 2013. The feasibility of a clinical trial of pain related to temporomandibular muscle and joint disorders: The results of a survey from the collaboration on networked dental and oral research dental practice-based research networks. Journal of the American Dental Association 144(1):e1–e10.

Wanman, A., and S. Marklund. 2019. Treatment outcome of supervised exercise, home exercise and bite splint therapy, respectively, in patients with symptomatic disc displacement with reduction: A randomised clinical trial. Journal of Oral Rehabilitation 47(2):143–149.

Weinfurt, K. P., A. F. Hernandez, G. D. Coronado, L. L. DeBar, L. M. Dember, B. B. Green, P. J. Heagerty, S. S. Huang, K. T. James, J. G. Jarvik, E. B. Larson, V. Mor, R. Platt, G. E. Rosenthal, E. J. Septimus, G. E. Simon, K. L. Staman, J. Sugarman, M. Vazquez, D. Zatzick, and L. H. Curtis. 2017. Pragmatic clinical trials embedded in healthcare systems: Generalizable lessons from the NIH Collaboratory. BMC Medical Research Methodology 17(1):144.

Williams, A. C., C. Eccleston, and S. Morley. 2012. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database of Systematic Reviews 11:D007407.

Wolford, L. M., L. G. Mercuri, E. D. Schneiderman, R. Movahed, and W. Allen. 2015. Twenty-year follow-up study on a patient-fitted temporomandibular joint prosthesis: The Techmedica/TMJ Concepts device. Journal of Oral and Maxillofacial Surgery 73(5):952–960.

Wu, J. Y., C. Zhang, Y. P. Xu, Y. Y. Yu, L. Peng, W. D. Leng, Y. M. Niu, and M. H. Deng. 2017. Acupuncture therapy in the management of the clinical outcomes for temporomandibular disorders: A PRISMA-compliant meta-analysis. Medicine (Baltimore) 96(9):e6064.

Zhou, H., K. Hu, and Y. Ding. 2014. Modified dextrose prolotherapy for recurrent temporomandibular joint dislocation. British Journal of Oral and Maxillofacial Surgery 52:63–66.

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

This page intentionally left blank.

Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 197
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 198
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 199
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 200
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 201
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 202
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 203
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 204
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 205
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 206
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 207
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 208
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 209
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 210
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 211
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 212
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 213
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 214
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 215
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 216
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 217
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 218
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 219
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 220
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 221
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 222
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 223
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 224
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 225
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 226
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 227
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 228
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 229
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 230
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 231
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 232
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 233
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 234
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 235
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 236
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 237
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 238
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 239
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 240
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 241
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 242
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 243
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 244
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 245
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 246
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 247
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 248
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 249
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 250
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 251
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 252
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 253
Suggested Citation:"5 Caring for Individuals with a TMD." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
Page 254
Next: 6 Improving TMD Health Care: Practice, Education, Access, and Coverage »
Temporomandibular Disorders: Priorities for Research and Care Get This Book
×
Buy Paperback | $80.00 Buy Ebook | $64.99
MyNAP members save 10% online.
Login or Register to save!
Download Free PDF

Temporomandibular disorders (TMDs), are a set of more than 30 health disorders associated with both the temporomandibular joints and the muscles and tissues of the jaw. TMDs have a range of causes and often co-occur with a number of overlapping medical conditions, including headaches, fibromyalgia, back pain and irritable bowel syndrome. TMDs can be transient or long-lasting and may be associated with problems that range from an occasional click of the jaw to severe chronic pain involving the entire orofacial region. Everyday activities, including eating and talking, are often difficult for people with TMDs, and many of them suffer with severe chronic pain due to this condition. Common social activities that most people take for granted, such as smiling, laughing, and kissing, can become unbearable. This dysfunction and pain, and its associated suffering, take a terrible toll on affected individuals, their families, and their friends. Individuals with TMDs often feel stigmatized and invalidated in their experiences by their family, friends, and, often, the health care community. Misjudgments and a failure to understand the nature and depths of TMDs can have severe consequences - more pain and more suffering - for individuals, their families and our society.

Temporomandibular Disorders: Priorities for Research and Care calls on a number of stakeholders - across medicine, dentistry, and other fields - to improve the health and well-being of individuals with a TMD. This report addresses the current state of knowledge regarding TMD research, education and training, safety and efficacy of clinical treatments of TMDs, and burden and costs associated with TMDs. The recommendations of Temporomandibular Disorders focus on the actions that many organizations and agencies should take to improve TMD research and care and improve the overall health and well-being of individuals with a TMD.

  1. ×

    Welcome to OpenBook!

    You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

    Do you want to take a quick tour of the OpenBook's features?

    No Thanks Take a Tour »
  2. ×

    Show this book's table of contents, where you can jump to any chapter by name.

    « Back Next »
  3. ×

    ...or use these buttons to go back to the previous chapter or skip to the next one.

    « Back Next »
  4. ×

    Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

    « Back Next »
  5. ×

    Switch between the Original Pages, where you can read the report as it appeared in print, and Text Pages for the web version, where you can highlight and search the text.

    « Back Next »
  6. ×

    To search the entire text of this book, type in your search term here and press Enter.

    « Back Next »
  7. ×

    Share a link to this book page on your preferred social network or via email.

    « Back Next »
  8. ×

    View our suggested citation for this chapter.

    « Back Next »
  9. ×

    Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

    « Back Next »
Stay Connected!