This systematic review aimed to estimate the comparative effectiveness of available therapies for chronic pain associated with temporomandibular disorders on pain.
Electronic databases were searched from their inception to January 2023. Randomised controlled trials enrolling adult participants with chronic pain associated with temporomandibular disorders were eligible. Any comparator (e.g. active treatment, placebo, or sham procedures) was eligible. Trials that included fewer than 10 participants per group were excluded. Risk of bias in each included trial was assessed using a modified Cochrane Risk of Bias tool.
Treatment effects were estimated as the risk difference for achieving the minimally important difference (1cm on the 10cm visual analogue scale for pain) and summarised as risk difference and its respective 95% confidence interval (CI). A frequentist network meta-analyses was used to summarise the evidence and the GRADE approach was used to rate the certainty of evidence and categorise interventions from most to least beneficial.
This review included 153 trials enrolling 8713 participants with chronic temporomandibular disorders. Eligible trials evaluated 23 conservative interventions, 15 pharmacological interventions, seven combinations of pharmacological and conservative interventions, 13 surgical interventions with or without adjunct treatments, and placebo/sham procedures. Most trials (133/153, 87%) were at high risk of bias. In total, 148 trials (7867 participants) evaluating 59 interventions had data on pain.
The three therapies probably most effective for pain relief were cognitive behavioural therapy augmented with biofeedback or relaxation therapy (risk difference for achieving the minimally important difference in pain relief: 36%, 95% CI 33 to 39), therapist-assisted jaw mobilisation (risk difference: 36%, 95% CI 31 to 40), and manual trigger point therapy (risk difference: 32% 95% CI 29 to 34).
Five interventions were less effective, yet more effective than placebo/sham procedures: cognitive behavioural therapy (risk difference: 30%, 95% CI 23 to 35), supervised postural exercise (risk difference: 26%, 95% CI 14 to 34), supervised jaw exercise with stretching (risk difference: 26%, 95% CI 20 to 31), usual care (e.g. home exercises, stretching, and education; risk difference: 25%, 95% CI 22 to 28), and supervised jaw exercise with stretching and manual trigger point therapy (risk difference: 23%, 95% CI 11 to 31). The certainty in effects for all other interventions was low or very low.
Interventions that promote coping and encourage movement and activity were most effective for reducing pain in people with chronic temporomandibular disorders. Several commonly used interventions for chronic temporomandibular disorders are supported by only low or very low certainty evidence.
Yao L, Sadeghirad B, Li M, Li J, Wang Q, Crandon HN, Martin G, Morgan R, Florez ID, Hunskaar BS, Wells J, Moradi S, Zhu Y, Ahmed MM, Gao Y, Cao L, Yang K, Tian J, Li J, Zhong L, Couban RJ, Guyatt GH, Agoritsas T, Busse JW. Management of chronic pain secondary to temporomandibular disorders: a systematic review and network meta-analysis of randomised trials. BMJ. 2023 Dec 15;383:e076226.
