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New Report on Temporomandibular Disorders: Priorities for Research and Care

Over a year and half ago, the National Academy of Medicine (NAM) began the most comprehensive study ever undertaken on Temporomandibular Disorders (TMD). The study assessed the current state of TMD research, education and training, the safety and efficacy of clinical treatments, and associated burden and costs.

Statement by NIDCR Acting Director on the National Academies of Sciences, Engineering, and Medicine Report on Temporomandibular Joint Disorders

I am pleased to announce the release of the National Academies of Sciences, Engineering, and Medicine (NASEM) report, Temporomandibular Disorders: Priorities for Research and Care. As underscored by the comprehensive report, temporomandibular joint disorders (TMJDs) are a diverse and still poorly understood set of complex, painful conditions affecting the jaw muscles and tissues, temporomandibular joints, and associated nerves. Clearly, there is much more to be understood, and these conditions continue to confound medical and dental health care providers and researchers.

Have you seen the film Dark Waters?

The Film. Dark Waters is about attorney Robert Billott's real-life 20 year legal battle against DuPont chemical for releasing toxic waste - perfluorooctanoic acid, or PFOA - into Parkersburg, West Virginia's water supply, with devastating health effects on the townspeople and livestock. PFOA, also known as C8, is a man-made chemical. It is used in the process of making Teflon and similar chemicals known as fluorotelomers.

Online TMD Diet Diary Research Project

Online TMD Diet Diary Research Project The TMJ Association received the following request from Professor Justin Durham and his research team at Newcastle University. We encourage TMJ patients to participate in this project as it is an under researched

Drug Induced Bruxism

The authors of this article state that orofacial movement disorders (bruxism) are treated typically by dental professionals and not by those specialists (neurologists) researching and treating the other movement disorders (Parkinson's disease, Huntington's disease, tremors, etc.). Again, this is more evidence of the complexity of TMD and the need for multidisciplinary research and treatment in TMD.

TMD TREATMENTS

  • Dec 6, 2019

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 NIH, 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 TM disorders have become persistent, most patients still do not need aggressive types of treatment.

If your problems get worse with time, you should seek professional advice. However, first and foremost, educate yourself. Informed patients are better able to communicate with health care providers, ask questions, and make knowledgeable decisions.

The following are treaments often recommended to patients as well as helpful resources to provide guidance in making your health care decisions.

The Latest in Science on Various Therapeutic Interventions

  • Is nonsurgical management effective in temporomandibular joint disorders? - A systematic review and meta-analysis.
    Nandhini J, Ramasamy S, Ramya K, Kaul RN, Felix AJW, Austin RD.
    Dent Res J (Isfahan). 2018 Jul-Aug;15(4):231-241.
    BACKGROUND: Various nonsurgical interventions have been used for the management of patients with temporomandibular joint (TMJ) disorders, but their clinical effectiveness remains unclear. Hence, the purpose of this systematic review and meta-analyses was to assess the evidence of the effectiveness of nonsurgical interventions in the management of TMJ disorders. MATERIALS AND METHODS: A literature search on five databases such as PubMed, PubMed Central Cochrane, TRIP, NGCH databases and hand searching was conducted for a period from October 1995 to 2015. Randomized control trials (RCTs) on the nonsurgical management of TMJ disorders were included and reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The quality of the articles was assessed by JADAD scoring. Finally, out of 23 RCTs, 11 articles having any of the primary outcomes (pain pressure threshold [PPT], pain, maximal pain-free mouth opening, and level of dysfunction) were selected. The extracted data were analyzed using NCSS software. RESULTS: The results showed the evidence of pain reduction (P = 0.00), maximal pain-free mouth opening (P = 0.0138), and decrease in level of dysfunction (P = 0.0007) but no improvement in PPT to a significant level (P = 0.6600). CONCLUSION: Our results suggest that the simplest, cost-effective nonsurgical treatments have a positive therapeutic effect on the initial management of TMJ disorders. However, a consistent methodology recording both the objective and subjective outcomes would be a better choice for added reliability.
     
  • Outcomes of therapeutic TMD interventions on oral health related quality of life: A qualitative systematic review.
    Song YL, Yap AU. Quintessence Int. 2018;49(6):487-496. doi: 10.3290/j.qi.a40340.
    OBJECTIVES: This systematic review aims to determine the impact of temporomandibular disorder (TMD) therapeutic interventions on patients' oral health related quality of life (OHRQoL) and to recommend approaches that improve QoL. DATA SOURCES: A systematic search of the literature was performed between January 2007 and October 2017 to identify articles on TMD interventions and OHRQoL. Randomized controlled trials, and retrospective and prospective cohort studies that mentioned dedicated tools for measurement of OHRQoL changes in TMD patients after therapeutic interventions were included. Abstracts of studies that did not mention any form of measurement of OHRQoL in their treatment outcome were excluded. The initial screening yielded 171 articles. After evaluation of abstracts and full text articles, five articles fulfilled all selection criteria and were included. Most TMD treatment interventions seem to improve QoL to some extent, but no single treatment modality can be advocated as the sole approach to managing TMD. CONCLUSION: Psychotherapy, occlusal appliance therapy, arthrocentesis, and orthodontics/orthognathic surgery (in subjects with severe malocclusion) appear to improve OHRQoL of TMD patients. Recommendation on the best TMD intervention for improving QoL could not be made due to the diverse TMD subtypes and non-disease specific OHRQoL instruments employed. More studies incorporating TMD-specific OHRQoL measures and targeting explicit TMD subtypes based on internationally accepted diagnostic criteria are warranted in this area of research.
     
  • Effect of temporomandibular disorder therapy on otologic signs and symptoms: a systematic review.
    Stechman-Neto J, Porporatti AL, Porto de Toledo I, Costa YM, Conti PC, De Luca Canto G, Mezzomo LA.
    J Oral Rehabil. 2016 Jun;43(6):468-79. doi: 10.1111/joor.12380.
    The most common temporomandibular disorders (TMD) signs and symptoms are related to muscle sensitivity through palpation, restricted mouth opening, asymmetric mandibular movements, joint sounds, pain and otologic signs and symptoms. To date, counselling, occlusal splints, exercises, biofeedback and acupuncture are examples of conservative modalities proposed for TMD therapy. The aim of this systematic review was to investigate the effect of these conservative therapies for TMD on otologic signs and symptoms. The authors searched the following electronic databases published up to 1st May 2015: PubMed, LILACS, Scopus, Web of Science and Science Direct with no time or language limitations. Using a two-phase selection process, the authors identified 08 articles and used them to conduct a qualitative analysis. Methodological quality of each article was performed with the aid of 'Quality Assessment of a Cohort Study' and 'Quality Assessment of a Randomized Clinical Trial', developed by the Dutch Cochrane Centre, a centre of the Cochrane Collaboration. This systematic review showed in seven of the eight studies included that a total or partial resolution of otologic complains occurred after counselling, exercise therapies and occlusal splint therapy. Upon the limitations of the studies included in this systematic review, the present outcomes suggested that there is insufficient evidence in favour or against the conservative therapies for TMD on changes in otologic signs and symptoms. Thus, further studies with a higher level of evidence and more representative samples should be conducted to better understand the relationship of TMD therapy changes on otologic complains.
     
  • Management of TMD: Evidence from systematic reviews and meta-analyses.
    List T, Axelsson S. J Oral Rehabil. 2010 May;37(6):430-51. doi: 10.1111/j.1365-2842.2010.02089.x.
    This systematic review (SR) synthesises recent evidence and assesses the methodological quality of published SRs in the management of temporomandibular disorders (TMD). A systematic literature search was conducted in the PubMed, Cochrane Library, and Bandolier databases for 1987 to September 2009. Two investigators evaluated the methodological quality of each identified SR using two measurement tools: the assessment of multiple systematic reviews (AMSTAR) and level of research design scoring. Thirty0-eight SRs met inclusion criteria and 30 were analysed: 23 qualitative SRs and seven meta-analyses. Ten SRs were related to occlusal appliances, occlusal adjustment or bruxism; eight to physical therapy; seven to pharmacologic treatment; four to TMJ and maxillofacial surgery; and six to behavioural therapy and multimodal treatment. The median AMSTAR score was 6 (range 2-11). Eighteen of the SRs were based on randomised clinical trials (RCTs), three were based on case-control studies, and nine were a mix of RCTs and case series. Most SRs had pain and clinical measures as primary outcome variables, while few SRs reported psychological status, daily activities, or quality of life. There is some evidence that the following can be effective in alleviating TMD pain: occlusal appliances, acupuncture, behavioural therapy, jaw exercises, postural training, and some pharmacological treatments. Evidence for the effect of electrophysical modalities and surgery is insufficient, and occlusal adjustment seems to have no effect. One limitation of most of the reviewed SRs was that the considerable variation in methodology between the primary studies made definitive conclusions impossible.
     
  • Is there a superiority of multimodal as opposed to simple therapy in patients with temporomandibular disorders? A qualitative systematic review of the literature.
    Türp JC, Jokstad A, Motschall E, Schindler HJ, Windecker-Gétaz I, Ettlin DA.
    Clin Oral Implants Res. 2007 Jun;18 Suppl 3:138-50. Erratum in: Clin Oral Implants Res. 2008 Mar;19(3):326-8.
    BACKGROUND: Pain is the most common motivation for patients with temporomandibular disorders (TMDs) to seek care. Therapeutic options range from patient education to joint surgery. OBJECTIVES: To conduct a systematic review of articles reporting on simple and multimodal management strategies in TMD patients. 'Simple therapy' was defined as care provided by a dentist, without using technical dental interventions, whereas 'multimodal' refers to at least two different modalities. We followed the null hypothesis of no difference between these two approaches. MATERIAL AND METHODS: A systematic search was carried out in the following databases: Ovid Medline (1966-2006), Cochrane Library (Issue 3/2006), and Science Citation Index (1945-2006). Subsequently, the reference lists of the identified articles were searched to find additional pertinent publications. We divided the study reports according to the main presenting symptom: (1) disc displacement without reduction, with pain; (2) TMD pain, without major psychological symptoms; and (3) TMD pain, with major psychological symptoms. RESULTS: Eleven articles representing nine different clinical studies were identified. (1) In the disc displacement group with pain, multimodal therapy was not superior to explanation and advice. (2) A combination of occlusal appliance and biofeedback-assisted relaxation/stress management was not significantly superior to either of these therapies after 6 months. Furthermore, brief information alone or combined with relaxation training or occlusal appliance, respectively, were equally efficacious at the 6-month follow-up. There was no superiority of multimodal therapy including splints as compared with simple care. A slightly better outcome was reported for a combination of education and home physical therapy regimen than for patient education alone. (3) In temporomandibular pain patients with major psychological disturbances, patients benefited more from a combined therapeutic approach compared with simple care. CONCLUSION: Current research suggests that individuals without major psychological symptoms do not require more than simple therapy. In contrast, patients with major psychological involvement need multimodal, interdisciplinary therapeutic strategies. The clinician's acceptance of the importance of psychological factors in TMD pain forms the platform for convincingly educating patients about the need for multimodal management.

Recommended Resources


In Treating TMJ

To view or order a free booklet about TMJ Disorders, visit the National Institutes of Health website.

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES
National Institutes of Health
National Institute of Dental and Craniofacial Research
Office of Research on Women's Health