The temporomandibular joint, masticatory muscles and associated structures are affected by musculoskeletal and neuromuscular conditions collectively grouped as temporomandibular disorders. Temporomandibular disorders (TMD) have been estimated to occur in 4-19% of the population and are often painful (Dental Elf – 3rd Feb 2021). A National Institute for Health and Care Excellence (NICE) Clinical Knowledge Summary summarises recommended treatment with psychological treatments considered likely to be helpful once pain has lasted longer than 3 months. Psychological therapies typically involve behavioural interventions with cognitive behaviour therapy (CBT) being used most often.
The aim of this Cochrane review was to assess the effects of psychological therapies in people (aged 12 years and over) with painful temporomandibular disorders lasting 3 months or longer.
Methods
Searches were conducted in the Cochrane Oral Health’s Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, PsycINFO, Tripdatabase, Web of Science Conference Proceedings, Proquest Dissertations and Theses Global, OpenGrey, ClinicalTrials.gov, and the WHO International Clinical Trials Registry platform. Randomised controlled trials (RCTs) of any psychological therapy (e.g. cognitive behaviour therapy (CBT), behaviour therapy (BT), acceptance and commitment therapy (ACT), mindfulness) compared with controls or alternative treatment (e.g. oral appliance, medication, physiotherapy) for the management of painful TMD were considered. Primary outcomes were pain intensity, disability caused by pain, adverse events. Standard Cochrane methodological procedures were followed.
Results
- 22 RCTs involving 2001 patients were included.
- All 22 RCTs had one of more domains at high risk of bias.
- 13 RCTs evaluated CBT, 2 evaluated relaxation and single studies evaluated mindfulness, hypnosis, mixed CBT and hypnosis, a habit reversal treatment, education and counselling, and a hope-based intervention.
- Follow-up times ranged from 3 – 12 months.
- 12 RCTs contributed to the meta-analyses.
For CBT v alternative treatment
| Outcome | No of studies (patients) | Standardised mean difference (95%CI) |
| Pain intensity at treatment completion | 5 (509) | 0.03 (-0.21 to 0.28) |
| Pain intensity at follow-up | 5 (475) | -0.29(-0.50 to -0.08) * |
| Disability outcomes (interference in activities caused by pain) at treatment completion | 3 (245) | 0.15 (-0.40 to 0.10) |
| Disability outcomes (interference in activities caused by pain) at follow-up | 3 (245) | -0.15 (-0.42 to 0.12) |
| Psychological distress at treatment completion | 6(553) | -0.32 (-0.50 to -0.15) * |
| Psychological distress at follow-up | 6(516) | -0.32 (-0.51 to -0.13) * |
- Small beneficial effect
For CBT v control/usual care
| Outcome | No of studies (patients) | Standardised mean difference (95%CI) |
| Pain intensity at treatment completion | 6 (577) | -0.09 (-0.30 to 0.12) |
| Pain intensity at follow-up | 6 (639) | -0.30 (-0.51 to -0.09) * |
| Disability outcomes (interference in activities caused by pain) | 3 (315) | 0.02 (-0.21 to 0.24) |
| Disability outcomes (interference in activities caused by pain) at follow-up | 2 (240) | 0.01 (-0.61 to 0.64) |
- Small beneficial effect
- For CBT versus control, only one study reported results for distress and did not find evidence of a difference between groups at treatment completion (mean difference (MD) 2.36, 95% CI -1.17 to 5.89; 101 participants) or follow-up (MD -1.02, 95% CI -4.02 to 1.98; 101 participants).
- There was little data on adverse effect those reported with psychological treatment tended to be minor and to occur less often than in alternative treatment groups.
- There were, however, insufficient data available to draw firm conclusions.
- The certainty of evidence was assessed as low of very low for all comparisons and outcomes.
- Apart from CBT the data was insufficient to draw any reliable conclusions.
Conclusions
The authors concluded: –
Overall, we found insufficient evidence on which to base a reliable judgement about the efficacy of psychological therapies for painful TMD. Further research is needed to determine whether or not psychological therapies are effective, the most effective type of therapy and delivery method, and how it can best be targeted. In particular, high-quality RCTs conducted in primary care and community settings are required, which evaluate a range of psychological approaches against alternative treatments or usual care, involve both adults and adolescents, and collect measures of pain intensity, pain disability and psychological distress until at least 12 months post-treatment.
Comments
The reviewers have undertaken an extensive database search and identified 22 RCTs of psychological therapies for TMDs. A majority of these relate to the use of CBT. None of the included studies were at low risk of bias across all domains. While it is acknowledged that blinding or patients and personnel is not possible only 8 studies provided clear details about the blinding of outcome assessment and only 11 gave clear details of the randomisation process. Some small beneficial effects were seen for CBT but the GRADE assessment for certainty of the evidence was low or very low meaning that there is a high likelihood that further research could change the effect size estimates reported in this review. Consequently, the reviewers recommend additional high-quality research of a range of psychological therapies against alternative treatments or usual care for both adolescents and adults with follow-up periods of at least 12 months that collect data on pain intensity, pain disability and psychological distress.
Links
Primary Paper
Penlington C, Bowes C, Taylor G, Otemade AA, Waterhouse P, Durham J, Ohrbach R. Psychological therapies for temporomandibular disorders (TMDs). Cochrane Database of Systematic Reviews 2022, Issue 8. Art. No.: CD013515.DOI: 10.1002/14651858.CD013515.pub2.
Other references
NICE Clinical Knowledge summary -TMDs
Dental Elf – 3rd Feb 202
Picture Credits
Photo by engin akyurt on Unsplash
