Journal of

Oral Rehabilitation

Journal of Oral Rehabilitation 2010 37; 430451

Review Article

Management of TMD: evidence from systematic reviews and

meta-analyses
T. LIST* & S. AXELSSON

*Department of Stomatognathic Physiology, Faculty of Odontology, Malmo University, Malmo and

The Swedish Council on Technology Assessment in Health and Care, Stockholm, Sweden

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. Thirty-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 211).
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.
KEYWORDS: systematic review, randomised clinical
trial, evidence-based medicine, treatment, assessment

Background

read about 1720 original articles as a daily average

(7).
Systematic reviews (SRs) are a cornerstone in evidence-based medicine. An SR is a compilation of all
published research that addresses a carefully formulated
question. Research results are collected based upon predetermined inclusion and exclusion criteria; data are
critically analysed and synthesised so that evidencebased conclusions on the benefit or risks of different
methods can be drawn, with the final goal to improve
patient care. An SR may have a qualitative approach if
data from the primary studies are presented descriptively
or a quantitative approach if statistical analysis has
combined data in a meta-analysis. Of the over 24

SUMMARY

Population-based studies among adults report that

approximately 1015% have temporomandibular disorders (TMD) pain and 5% a perceived need for
treatment (1, 2). Several studies have pointed out that
persistent and recurrent pain has a potential impact on
daily life mainly in the areas of psychological
discomfort, physical disability, and functional limitations which leads to limitations in quality of life (36).
Keeping current on new developments in a medical
or dental field is often an imposing task for researchers
and clinicians. One researcher estimated that to keep
abreast of developments in his field, he would need to
2010 Blackwell Publishing Ltd

Accepted for publication 8 March 2010

doi: 10.1111/j.1365-2842.2010.02089.x

MANAGEMENT OF TMD
instruments that have been developed to assess SR
quality, one recent instrument deserves mention: assessment of multiple systematic reviews (AMSTAR) (8). This
tool comprises 11 items and has good face and content
validity for measuring methodological quality (9).
This systematic review of published SRs that survey
TMD management efficacy adds to these existing
reviews by (i) synthesising recent evidence and (ii)
assessing SR methodological quality.

Methods
Procedure
Both authors selected the articles based on inclusion
and exclusion criteria and independently read all titles
and abstracts that were found in multiple searches to
identify potentially eligible articles for inclusion. All
potentially eligible SRs were then retrieved, and fulltext articles were reviewed to determine whether they
met inclusion criteria. Disagreement was resolved by
discussion among the investigators. Authors were not
contacted for missing information. The reviewers were
experienced oro-facial pain specialist clinicians or
methodologists in evidence-based medicine.
The investigators independently evaluated the
methodological quality of each identified SR using
AMSTAR and level of research design (LRD) scoring.
The following data were extracted: study design, diagnosis, number of patients, types of intervention, outcome
measures, results, quality score, and authors conclusion.

Database search
The search encompassed all the articles that were (i)
indexed in PubMed, the Cochrane Library, and Bandolier, (ii) published in English, Swedish, or German, and
(iii) published between 1 January 1987 and 8 September
2009. The search strategy was designed to identify SRs
that focused on TMD management. The following search
terms were used for PubMed: Craniomandibular disorders drug therapy [MeSH] OR Craniomandibular disorders surgery
[MeSH]
OR
Craniomandibular
disorders surgery [MeSH] AND Review AND Metaanalysis [MeSH] AND Systematic review. For Cochrane Library, the search strategy included the terms
craniomandibular disorders and temporomandibular
joint (TMJ). References in original articles and SRs were
hand-searched to identify additional SRs.
2010 Blackwell Publishing Ltd

Inclusion criteria
Besides the database search criteria listed previously,
the selected articles must:
1 Be an SR
2 Focus on the management of TMD treatment
Systematic reviews that covered oro-facial pain or
TMD prevention besides TMD treatment effect were
included.

Exclusion criteria
1 Dual publication
2 Update of the SR by the same author in a later
publication
3 SR of orthodontic treatment focusing on development and not treatment of TMD
4 Systematic reviews of SRs

Quality assessment
Two instruments were used to assess the methodological quality of the SRs: (i) AMSTAR and (ii) LRD.
Shea et al. developed AMSTAR by evaluating the
importance of 37 items commonly used in SR assessment and reducing these items to an 11-item instrument that addresses key domains in methodological
qualities (8). Assessment of multiple systematic
reviews is reported to have good face and content
validity (9).
Assessment of multiple systematic reviews appraises
these key items:
1 Was an a priori design provided?
2 Was there duplicate study selection and data extraction?
3 Was a comprehensive literature search provided?
4 Was the status of publication (i.e. grey literature)
used as an inclusion criterion?
5 Was a list of studies (included and excluded)
provided?
6 Were the characteristics of the included studies
provided?
7 Was the scientific quality of the included studies
assessed and documented?
8 Was the scientific quality of the included studies
used appropriately in formulating conclusions?
9 Were the methods used to combine the findings of
studies appropriate?
10 Was the likelihood of publication bias assessed?

431

432

T. LIST & S. AXELSSON

11 Was the conflict of interest stated?
Each of these 11 items was scored as Yes, No,
Cant answer, or Not applicable.
The LRD assesses internal validity of the primary
studies based on design. The research design levels are
structured hierarchically according to evidence strength
(10):
1 Systematic review of randomised clinical trials (RCTs)
2 Randomised clinical trial
3 Study without randomisation, such as a cohort study,
casecontrol study
4 A non-controlled study, such as cross-sectional study,
case series, case reports
5 Narrative review or expert opinion

Computerised search of databases,

reference checking, abstracts:
PubMed: 602 references
Cochrane library: 19 references
Bandolier: 1 reference
Handsearch: 3 references
625 references

Abstracts excluded:
587 references

Screening of articles applying

inclusion criteria:
38 references

Abstracts excluded:
8 references
(1118)

Reliability of quality assessment

Both authors independently assessed SR quality to
determine inter-test reliability. The inter-reliability of
the two authors in assessing the quality of the SRs was
calculated with kappa-statistics. All articles were discussed to verify appraisal process until consensus was
reached. Disagreements on individual item scores were
resolved with discussion.

Results
Thirty-eight SRs were read in full text; 30 of these were
included in this SR: 23 were qualitative SRs and seven
were meta-analyses. Eight SRs were excluded after
reading because upon closer scrutiny, they did not fulfil
the inclusion criteria: three SRs had been updated in
more recent SRs by the same author (1113), one study
did not focus on TMD management (14), two SRs
focused on development of TMD following orthodontic
intervention (15, 16), and two SRs were SRs of SRs (17,
18) (Fig. 1).
Tables 15 list characteristics and assess quality of the
included SRs. Although the most common diagnosis in
the SRs was TMD, more specific TMD diagnoses such as
disc displacements and myofascial pain were sometimes
also reported. Two SRs focused on bruxism. Although it
is in the TMD domain, bruxism differs from other TMD
diagnoses: although it may be accompanied by pain,
bruxism is not related to pain in many cases. The
number of patients ranged from 0 to 7173 in the SRs.
Twenty-nine SRs had pain intensity or pain reduction
as primary outcome measures, 25 of the SRs reported
clinical outcome measures such as jaw movement and

Articles included for quality

assessment:
30 references
(1947, 65)
(23) reported two SRs

Fig. 1. Flow diagram of references included and excluded in the

systematic review.

tenderness pain on palpation, and 10 of the SRs

included measures of psychological status, daily activities, or quality of life. The median AMSTAR score was 6
(range 211). The LRD scores for the SRs are as follows:
Level
Level
Level
Level
Level
Level

III
I-III
II
IIIII
III
IIIV

2 SRs
1 SR
16 SRs
1 SR
1 SR
9 SRs

The SRs were divided into five treatment groups:

1 Occlusal appliances, occlusal adjustment, and bruxism
2 Physical treatment [acupuncture, transcutaneous
electrical nerve stimulation (TENS), exercise, and
mobilisation]
3 Pharmacologic treatment
4 TMJ and maxillofacial surgery
5 Behavioural therapy and multimodal treatment
Ten SRs evaluated occlusal appliances, occlusal
adjustment, or bruxism (Table 1). Eight of these concerned TMD treatment (12, 1926), one the effect of
2010 Blackwell Publishing Ltd

SR and
Meta-analysis of
6 RCTs
Disc displacement
with reduction
212 patients

Qualitative SR of
12 RCTs
Myofascial pain
496 patients

Qualitative
SR of 20 RCTs
TMD
1138 patients

Al-Ani MZ
2003 (19)

Forssell H
2004 (20)

Study design,
diagnosis, and
no. of patients

Santacatterina A
1998 (25)

Authors, year,
reference

AMSTAR 6
LRD II

AMSTAR 7
LRD II

I1 no better than C1
I1 somewhat better
than C2
I1 no better than C3

Contradictory
results for I1
compared with
C1C3
I2 no better than
C1 or C2

Pain reduction
Jaw motion

Pain reduction
Global
improvement
Clinical
examination
Depression scale

I1: Occlusal
appliance
I2: Occlusal
adjustment
C1: Other treatment
(biofeedback, jaw
exercises,
acupuncture)
C2: No treatment
C3: Placebo

A: A comparison between the two kinds of

treatment has demonstrated that the
repositioning splint is more effective both in the
resolution of the articular click and in the
resolution of the pain (P < 0001).
R: Methodological weaknesses of primary studies
such as heterogeneous patient material, outcome
measures not clearly defined, and three of the
studies were not RCTs.
A: There is insufficient evidence either for or
against the use of stabilisation splint therapy over
other active interventions for the treatment of
temporomandibular myofascial pain. However,
it appears that stabilisation splint therapy may be
beneficial for reducing pain severity at rest and on
palpation and depression when compared to no
treatment.
R: Included studies were small. Patient material
was heterogeneous. Outcome measures varied
between studies. Short-term follow-up.
Exclusion, inclusion, and diagnostic criteria
not clearly defined.
A: Occlusal splints yielded equivocal results. Even
for the most studied area, stabilisation splints for
myofascial pain, the results do not justify definite
conclusions about the efficacy of splint therapy.
Their clinical effectiveness to relieve pain also
seems modest when compared with treatment
methods in general. None of the occlusal
adjustment studies provided evidence supporting
the use of this treatment method.
R: Included studies small, often not blinded,
heterogeneity concerning outcome measures and
control treatment.

AMSTAR 2
LRD II-IV

I1: Occlusal
appliance
C1: Other treatment
(biofeedback, jaw
exercises,
acupuncture)
C2: No treatment
C3: Placebo

Authors (A) conclusions

Reviewers (R) comments

Quality
score

I2 better than I1
for pain reduction
and TMJ click.

Results

Pain reduction
TMJ click

Outcome
measures

I1: Occlusal
appliance
I2: repositioning
splint

Intervention (I)
and control (C)
groups

Table 1. Characteristics of systematic reviews (SRs) of occlusal appliances, occlusal adjustment, and orthodontic treatment

MANAGEMENT OF TMD

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Qualitative
SR of 9 RCTs
Myofascial pain
482 patients

Qualitative
SR of 39 RCTs
TMD
patients*

Qualitative
SR of 3 SRs and
3 RCTs
TMD
2299 patients

Fricton J
2006 (22)

SBU
2006 (23)

Study design,
diagnosis, and
no. of patients

Turp JC
2004 (21)

Authors, year,
reference

Table 1. (Continued)

AMSTAR 4
LRD II

AMSTAR 6
LRD III

No difference
between I1 and I2.
I1 and C2 have
similar effects
I2, I1, and C1 have
similar effects

I1 better than C3
I1 and C2 have
similar effect
Results of I1
compared with C1
are contradictory
I2 and C1 have
similar effect

Pain reduction

Pain reduction
Clinical
examination
Depression scale

I1: Stabilisation
splint
I2: Anterior
positioning and
soft splints
C1: Placebo
C2: Other treatment

I1: Stabilisation
splint
I2: Occlusal
adjustment
C1: Placebo
C2: Other
treatments
C3: No treatment

AMSTAR 6
LRD II

I1 better than C2
I1 no better than C1

Quality
score

Results

Pain reduction
Clinical
examination
Depression scale

Outcome
measures

I1: Intra-oral
appliance
C1: Other treatment
including placebo
C2: No treatment

Intervention (I)
and control (C)
groups

A: Based on the currently best available evidence,

it appears that most patients with masticatory
muscle pain are helped by incorporation of a
stabilisation splint. A stabilisation splint does not
appear to yield a better clinical outcome than a
soft splint, a non-occluding palatal splint, physical
therapy, or acupuncture.
R: Well-conducted SR. Limitations: small patient
studies, outcome measures vary between studies,
no long-term results.
A: Stabilisation splints can reduce TMD pain
compared to placebo splints. Stabilisation splints
are equally effective in reducing pain compared to
physical therapy, acupuncture and behavioural
therapy in the short term. The long-term effects of
behavioural therapy may be better than splints in
reducing symptoms in more severe patients with
psychosocial problems.
R: The article is an overview and separate articles
are under publishing with details regarding
methods and results.
A: Occlusal appliances gave better pain reduction
than no treatment. Treatment with occlusal
appliance had similar effect as other therapies
whereas the effect compared with placebo was
contradictory. No study found occlusal
adjustment to be effective compared to a control.
R: Reviewers and authors are identical persons

Authors (A) conclusions

Reviewers (R) comments

434
T. LIST & S. AXELSSON

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Qualitative
SR of 5 RCTs
TMD
Bruxism
Tension-type
headache (TTH)
Migraine
190 patients

SR and
meta-analysis
of 6 RCTs
TMD
392 patients

SR and
meta-analysis
of 5 RCTs
Bruxism
63 patients

Koh H
2009 (26)

Marcedo CR
2009 (27)

Study design,
diagnosis, and
no. of patients

Stapelman H
2008 (24)

Authors, year,
reference

Table 1. (Continued)

EMG activity
Polysomnographic
evaluation
Pain intensity
Jaw opening
Comfort
Analgesic
consumption

Global symptoms
Relief of headache
Quality of life

Sleep variables: e.g.

EMG activity,
arousal index
Report of bruxism
by partner
Tooth wear

I1: Occlusal
adjustment
C1: Placebo, no
treatment or
reassurance
I1: Occlusal splint
I2: Other appliances
I3: Other therapies
C1: No treatment

Outcome
measures

I1: NTI splint

C1: Flat occlusal
splint
C2: Bleaching tray

Intervention (I)
and control (C)
groups

2010 Blackwell Publishing Ltd

No difference
between I1 and I2
in the
meta-analysis of
arousal index.
No difference
between I1 and C1
for tooth wear
facets
No difference
between I1 and I3
for TMD pain

Reducing EMG
activity: I1 more
effective than C1
Improvement in
pain reduction:
results for I1
compared with C1
are contradictory
Treating TTH and
migraine: I1 more
effective than C2
Five reports of
complications or
side-effects
reported for I1
No difference
between I1 and C1

Results

AMSTAR 9
LRD II

A: There is an absence of evidence, from RCTs, that

occlusal adjustment treats or prevents TMD.
Occlusal adjustment cannot be recommended for
management or prevention of TMD.
R: Small studies, diagnostic criteria inaccurate.
Outcome measures poorly defined.
A: There is not sufficient evidence to state that the
occlusal splint is effective for treating sleep
bruxism. Indication of its use is questionable
concerning sleep outcomes, but it may be that
there are some benefits concerning tooth wear.
R: Small studies, methodological weaknesses in
primary studies

A: NTI-tss devices may be successfully used to

manage bruxism and TMDs. To avoid potential
unwanted effects, it should be chosen only if a
patient will be compliant with follow-up. Two of
five studies focused on treatment of TMD.
Overall, small groups, median of 14 participants
in each group. As adverse events were reported
for I1, and I1 was not more effective than C1,
only limited indication is warranted.
R: Well-conducted SR. Limitations are small
studies. Methodological weaknesses in primary
studies such as heterogeneity concerning
outcome measures and diagnostic criteria.

AMSTAR 7
LRD II

AMSTAR 10
LRD II

Authors (A) conclusions

Reviewers (R) comments

Quality
score

MANAGEMENT OF TMD
435

AMSTAR, assessment of multiple systematic reviews; LRD, level of research design; NTI, nociceptive trigeminal inhibition; RCT, randomised clinical trial; TMD,
temporomandibular disorders.
*Number of patients not reported.

A: One study was prospective and reported less

attrition in young children wearing bite plates
compared with subjects who did not wear
devices. In a case series of patients with severe
attrition, occlusal splints were found to slow
down the rate of tooth wear.
R: Small studies, methodological weaknesses in
primary studies. The results seem to confirm
clinical experience.
AMSTAR 6
LRD II-IV
I1 reduces attrition
compared with C1.
Attrition
I1: Occlusal
appliance
C1: no treatment
Qualitative
SR of 33 studies
2 studies related to
Intervention
because of
bruxism. 1 RCT
and 1 case series.
27 patients
vant Spijker A
2007 (28)

Authors, year,
reference

Study design,
diagnosis, and
no. of patients

Intervention (I)
and control (C)
groups

Outcome
measures

Results

Quality
score

Authors (A) conclusions

Reviewers (R) comments

T. LIST & S. AXELSSON

Table 1. (Continued)

436

occlusal appliances on sleep bruxism (27), and one the

effect of occlusal appliances on attrition (28). Six SRs
reported that occlusal appliances and other therapies
had similar effect, three that occlusal appliances were
better than no treatment, and four that there was no
difference between occlusal appliances and non-occluding splints (placebo). One SR reported stabilisation
splints and anterior positioning and soft splints to yield
similar results, while one SR reported anterior positioning splints to be more effective than stabilisation
splints. One SR reported contradictory results in a
comparison of nociceptive trigeminal inhibition (NTI)
splints and occlusal appliances. Several complications
and adverse events were documented for the NTI-tss
device. Three SRs reported no difference in outcome
between occlusal adjustments and control treatment.
Eight SRs evaluated various physical treatments in
patients with TMD (Table 2). Of these SRs, six assessed
acupuncture (23, 2932), three jaw exercises (23, 33,
34), two manual therapy (33, 34), and three various
forms of electrical therapy (30, 34). Three SRs reported
that acupuncture was better than no treatment, four
SRs that acupuncture and other therapies yielded
similar results, and one SR that acupuncture and
placebo treatment had similar results. Two SRs found
no support for acupuncture treatment.
As for the other types of physical treatment, three
SRs reported that jaw exercises were better than
controls, and two SRs found postural training to be
better than no treatment. No SR indicated that electrophysical modalities such as TENS, laser, and ultrasound
were effective in reducing pain.
Seven SRs evaluated various pharmacological treatments in patients with TMD, atypical facial pain,
trigeminal neuralgia, and burning mouth syndrome
(23, 3540) (Table 3). One SR reported anti-epileptic
drugs to be more effective than placebo in patients
with trigeminal neuralgia. In patients with TMD,
pharmacological treatment that was found to be more
effective than placebo was analgesics (two SRs),
clonazepam or diazepam (three SRs), antidepressants
(four SRs), and hyaluronate (one SR). This last SR also
reported hyaluronate and glycocorticoid to produce a
similar effect. Three SRs reported amitriptyline to have
a moderate effect in patients with atypical facial pain.
Two SRs reported the use of botulinum toxin in
patients with pain or masseter hypertrophy. One SR
reported positive outcome based upon one RCT,
whereas the other SR found no studies that met its
2010 Blackwell Publishing Ltd

 2010 Blackwell Publishing Ltd

Pain intensity
Daily activities
Global
improvement
Clinical
examination
Pain intensity
Daily activities
Clinical
examination

I1: Acupuncture
C1: Placebo
acupuncture
C2: Other treatment
C3: No treatment

Qualitative
SR of 15 RCTs
(7 RCTs on TMD)
Acute toothache
TMD
patients*
Qualitative
SR of 3
SRs and 1 RCT
TMD
575 patients

Rosted P
1998 (31)

SBU
2006 (23)

SBU
2006 (23)

I1: Jaw exercises

I2: Pulsed radio
frequency therapy
I3: Laser
I4: Pulsed
electromagnetic
fields
I5: Postural
correction
C1: Minimal
information
C2: Placebo
C3: No treatment

Self-reported
symptoms
Pain intensity
Clinical
examination
Pain intensity

I1: Biofeedback
I2: Acupuncture
I3: TENS
C1: No treatment
C2: Other treatment
I1: Acupuncture
C1: Other treatment

Qualitative
SR of 7 RCTs
TMD
379 patients

Jedel E
2003 (30)

Qualitative
SR of 6 RCTs
TMD
279 patients

Pain Intensity
Daily activity
Global
improvement
Clinical
examination

I1: Acupuncture
C1: Occlusal
appliance
C2: No treatment

Qualitative
SR of 6 RCTs
TMD
205 patients

Ernst E
1999 (29)

Outcome
measures

Intervention (I)
and control (C)
groups

Authors, year,
reference

Study design,
diagnosis, and
no. of patients

AMSTAR 3
LRD II

AMSTRAR 4
LRD II-IV

AMSTAR 6
LRD III

No evidence of an
effect for any
treatment mode

No difference
between I1 and C1

I1 better than C3
I1 and C2 have
similar effect
I1 and C1 have
contradictory
results
I1 better than C1
I1I4 no different
from C2
I5 better than C3

A: The evidence to draw any conclusions regarding

physical treatment for TMD is insufficient because
the studies are heterogeneous regarding diagnosis
and treatment method.
R: Some of the studies showed a difference compared
with controls. Because these findings were not
supported by more studies, there is lack of evidence.
Reviewers and authors are identical persons

A: Although all studies agree with the notion that

acupuncture is effective for TMD, this hypothesis
requires confirmation through more rigorous
investigations.
R: Short follow-up time in two studies. One study
reports a 1-year follow-up. No reported side-effects.
SR based on three studies with low quality.
A: The studies were heterogeneous with low quality,
and therefore it is not possible to draw any
conclusions.
R: Limitations in the SR methodology and therefore
difficult to draw any conclusions
A: Acupuncture and conventional treatment were
found to have similar effect. The effect in treating
TMD and facial pain seems real, and acupuncture
could be an alternative to conventional treatment.
R: Non-RCTs were included in the evaluation.
Methodology and results not clearly described.
A: Acupuncture was found to show better pain
reduction than no treatment and similar effect
compared to other treatments. Compared to placebo,
the results are contradictory.
R: Reviewers and authors are identical persons

AMSTAR 5
LRD II

I1 better than C2
No difference
between I1 and C1

AMSTAR 6
LRD III

Authors (A) conclusions

Reviewers (R) comments

Quality
score

Results

Table 2. Characteristics of systematic reviews (SRs) of physical therapy: acupuncture, TENS, exercise, and mobilisation

MANAGEMENT OF TMD
437

Qualitative
SR of 12 RCTs
TMD
480 patients

Qualitative
SR of 24 RCTs
and 6 uncontrolled
studies
TMD
1071 patients

McNeely M
2006 (33)

Medlicott MS
2006 (34)

Pain intensity
Global
improvement
Clinical
examination
Jaw mobility
Pressure pain
threshold

I1: Exercise
I2: Manual therapy
I3: Electrotherapy
(ultrasound, TENS,
laser, PRFE)
I4: Relaxation
training and
education
C1: Occlusal splint
C2: Placebo
C3: Waiting-list

I1: Exercise and

manual therapy
I2: Acupuncture
I3: Electrophysical
modalities (PRFE,
TENS, biofeedback,
laser)
C1: Other therapies
C2: Placebo

Pain intensity
Global
improvement
Daily activities
Clinical
examination
Pain thresholds
Pain reduction
Jaw mobility

Outcome
measures

I1: Acupuncture
C1: Sham
acupuncture
C2: Other treatment
C3: No treatment

Intervention (I)
and control (C)
groups
Authors (A) conclusions
Reviewers (R) comments

A: The analysed studies on acupuncture in the

treatment of TMD confirm acupuncture to be as
effective as conservative treatment.
R: Short follow-up time in three studies. One study
reports a 1-year follow-up. No reported side-effects.
SR based on three studies with low and one with
high quality.
A: The results support use of active and passive oral
exercises and exercises to improve posture as
effective interventions to reduce symptoms
associated with TMD. There is inadequate
information to either support or refute use of
acupuncture in TMD treatment. There is no evidence
to support use of electrophysical modalities to reduce
TMD pain.
R: Methodological weaknesses of primary studies such
as diagnostic criteria of TMD, outcome measures and
chosen controls limit conclusions in the study.
A: Active exercise and manual mobilisation may be
effective. Postural training may be used in
combination with other interventions, as
independent effects of postural training are
unknown. Mid-laser therapy may be more effective
than other electrotherapy modalities. Programmes
involving relaxation techniques and biofeedback,
electromyographic training, and proprioceptive
re-education may be more effective than placebo
treatment or occlusal splints. Combinations of active
exercise, manual therapy, postural correction, and
relaxation techniques may be effective.
R: Because of the heterogeneous population and to
differences in diagnosis and outcome measures, it not
possible to draw any clear conclusions from this SR.

Quality
score
AMSTAR 7
LRD II

AMSTAR 7
LRD II

AMSTAR 5
LRD II-IV

I1 and C2 have
similar effects
No difference
between I1 and C1

No synthesis of
results

No synthesis of
results

Results

TENS, transcutaneous electric nerve stimulation; PRFE, pulsed radio frequency energy; AMSTAR, assessment of multiple systematic reviews; LRD, level of research design; RCT,
randomised clinical trials; TMD, temporomandibular disorders.

Qualitative
SR of 6 RCTs
TMD
223 patients

Study design,
diagnosis, and
no. of patients

Fink M
2006 (32)

Authors, year,
reference

Table 2. (Continued)

438
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Qualitative
SR of 27 RCTs
TMD, trigeminal
neuralgia, atypical
facial pain
931 patients

Qualitative
SR of 11 RCTs
TMD, atypical
facial pain,
burning mouth
syndrome
368 patients

Qualitative
SR of 1 SR and
13 RCTs
TMD, atypical
facial pain,
burning mouth
syndrome
968 patients

List T
2003 (36)

SBU
2006 (23)

Study design,
diagnosis, and
no. of patients

Sommer C
2002 (35)

Authors, year,
reference

2010 Blackwell Publishing Ltd

Pain reduction
Global
improvement
Depression scale

I1: Analgesics
I2: Antidepressants
I3: Benzodiazepines
I4: Miscellaneous
(corticosteroids,
sodium
hyaluronate,
sumatriptan,
cocaine)
C1: Placebo
I1: Analgesics
I2: Antidepressants
I3: Benzodiazepines
I4: Miscellaneous
(corticosteroids,
sodium
hyaluronate,
sumatriptan,
capsaicin,
botulinum toxin)
C1: Placebo
Pain reduction

Pain reduction
>50%

Outcome
measures

I1: Carbamazepin,
baclofen,
lamotrigine
I2: Clonazepam,
Diazepam
I3: Amitriptyline
C1: Placebo

Intervention (I)
and control (C)
groups

Table 3. Characteristics of systematic reviews (SRs) of pharmacologic treatment

TMD and atypical

facial pain: few
studies found better
effect of I1I4
compared with C1
For burning mouth,
I = C1

Trigeminal neuralgia:
I1 significantly better
than C1
TMD: moderate
evidence that I2 and
I3 are better than C1
Atypical facial pain: a
moderate effect of I3
compared with C1
TMD and atypical
facial pain: few
studies found better
effect of I1-I4
compared with C1
Burning mouth:
I2 = C1

Results

A: The common use of analgesics in TMD, AFP,

and BMS is not supported by scientific
evidence.
R: The studies are too heterogeneous to draw
any conclusions from.

AMSTAR 7
LRD II

A: Studies on pharmacological treatment of

TMD, atypical facial pain, and burning mouth
syndrome report contradictory results.
No conclusions can be drawn as the studies are
heterogeneous regarding diagnosis and
treatment method.
R: Reviewers and authors are identical persons

A: Apart from studies on trigeminal neuralgia,

there is little evidence for pharmacotherapy in
oro-facial pain.
R: Some of the studies showed a difference
compared with controls. Limitations in the
primary studies were small groups,
heterogeneous outcome measures, and no
long-term follow-up.

AMSTAR 4
LRD II

AMSTAR 6
LRD III

Authors (A) conclusions

Reviewers (R) comments

Quality
score

MANAGEMENT OF TMD
439

SR and
meta-analysis of
RCTs
No studies
included
Masseter
hypertrophy
0 patients
Qualitative
SR of 1 SR,
1 RCT and 1
casecontrol study
TMD
patients*
Qualitative
SR of 1 RCT and
10 case series
TMD
Bruxism
Masseter
hypertrophy
Oro-mandibular
dystonia
402 patients

Al-Muharraqi MA
2009 (38)

Pain

I1: Antidepressants
C1: Placebo

Pain reduction
Jaw opening
Functional
improvement
Aesthetic result

Self-reported
facial
appearance
Pain and
discomfort

I1: Botulinum toxin

C1: Placebo

I1: Botulinum toxin

C1 Placebo

Symptoms
(e.g. pain,
Clinical
examination
Adverse events

Outcome
measures

I1: Hyaluronate
I2: Hyaluronate +
Arthroscopy lavage
C1: Placebo
C2: Glycocorticoid
C3: Arthroscopy lavage

Intervention (I)
and control (C)
groups

I1 better than C1 for

reducing pain based
on one RCT.
No synthesis of
results.

I1 better than C1

Long-term effects
favour I1 compared
to C1
I1 had the same
long-term effects on
symptoms and clinical
signs compared to C2
Comparing I1 to C3,
results were
inconsistent
167 references were
retrieved, but none
matched the
inclusion criteria.

Results

A: No randomised trial on the efficacy of

intra-muscular injections of botulinum toxin
with bilateral benign masseter hypertrophy
was identified.
R: No trend of the effect can be drawn because
all studies were excluded.

AMSTAR 7
LRD II

AMSTAR 3
LRD II-IV

A: The use of tricyclic antidepressants for the

treatment of TMD is recommended.
R: Synthesis of results from primary studies are
missing, and therefore, because of limitations
in the SR, it is difficult to draw any
conclusions.
A: Botulinum toxin appears relative safe and
effective in treating chronic facial pain
associated with masticatory hyperactivity.
R: Methodological limitations in the SR.
Results only relate to one RCT study.
Synthesis of results missing so a conclusion of
the effect of Botulinum toxin is difficult to
determine

A: There is insufficient consistent evidence to

support or refute the use of hyaluronate for
treating patients with TMD.
R: Methodological weaknesses of primary
studies such as diagnostic criteria of TMD and
outcome measures in the study.

AMSTAR 11
LRD II

AMSTAR 4
LRD IIII

Authors (A) conclusions

Reviewers (R) comments

Quality
score

AMSTAR, assessment of multiple systematic reviews; LRD, level of research design; RCT, randomised clinical trials; TMD, temporomandibular disorders.
*Number of patients not reported.

Ihde S 2007 (40)

Cascos-Romero J
2009 (39)

SR and
meta-analysis
of 7 RCTs
TMD, rheumatoid
arthritis
364 patients

Study design,
diagnosis, and
no. of patients

Shi ZC
2009 (37)

Authors, year,
reference

Table 3. (Continued)

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 2010 Blackwell Publishing Ltd

Abrahamsson C
2007 (44)

Kropmans TJ
1999 (42)

Reston JT
2003 (41)

Authors, year,
reference

Qualitative
SR of 3
casecontrol
studies
280 patients

SR and
meta-analysis of
30 studies (3 RCTs
and 27
uncontrolled
studies)
Disc displacement
with reduction,
Disc displacement
without reduction
1463 patients
Qualitative SR of 24
studies (6 RCTs
and 6 casecontrol
and 12
uncontrolled
studies)
Disc displacement
without reduction
4916 patients

Study design,
diagnosis, and
no. of patients

AMSTAR 8
LRD III
Contradictory
results in signs
and symptoms

Self-report of
symptoms
Clinical
examination

I1: Bilateral sagittal

split and or Le Fort
I osteotomy
C1: No treatment

A: No distinguishing effects on jaw mobility, jaw

function, or pain intensity was seen between
arthroscopic surgery, arthrocentesis, and physical
therapy in patients with permanent
temporomandibular joint disc displacement.
R: Methodological weaknesses of primary studies
such as diagnostic criteria of TMD and outcome
measures in the study. A majority of the studies
are LRD level IV, and therefore, it not possible to
draw any clear conclusions from this SR.
A: Because of few studies with unambiguous
results and heterogeneity in study design, the
scientific evidence was insufficient to evaluate the
effects that orthognathic surgery had on TMD.
R: Well-designed SR. Methodological weaknesses
of primary studies such as diagnostic criteria of
TMD and outcome measures in the study.

AMSTAR 2
LRD IIIV

No synthesis of
results presented

Pain intensity
Jaw function
Jaw mobility

I1: Arthroscopy
I2: Arthrocentesis
I3: Physical therapy
(e.g. exercise,
massage, TENS)
C1: Placebo
C2: No treatment

A: Surgical treatment appears to provide some

benefit to patients refractory to non-surgical
therapies. The most reliable evidence supports the
effectiveness of arthrocentesis and arthroscopy for
patients with disc displacement with reduction.
R: Methodological weaknesses of primary studies
such as heterogeneous patient material, outcome
measures not clearly defined, and majority of the
studies were not RCTs.

AMSTAR 4
LRD IIIV
(most studies,
level IV)

Disc displacement
with reduction:
I2 and I3
comparable results
Disc displacement
without reduction:
Similar results for
I1, I2, and I3

Pain reduction
Global
improvement
Jaw mobility

I1: Arthrocentesis
I2: Arthroscopy
I3: Disc
repair repositioning
I4: Discectomy

Authors (A) conclusions

Reviewers (R) comments

Results

Quality
score

Outcome
measures

Intervention (I) and

control (C) groups

Table 4. Characteristics of systematic reviews (SRs) of the TMJ and maxillofacial surgery

MANAGEMENT OF TMD
441

Qualitative
SR of 19 Studies
(2 RCTs and 6
casecontrol and
11 uncontrolled
studies)
Anchored disc
phenomenon,
Disc displacement
with or without
reduction,
capsulitis
synovitis.
571 patients

Study design,
diagnosis, and
no. of patients
Outcome
measures
Pain intensity
Jaw mobility
Clinical
examination

Intervention (I) and

control (C) groups
I1: Arthrocentesis
C1: Not specified

Overall success
varied between
60% -100%.
No comparison
between I1
and C1.

Results

Authors (A) conclusions

Reviewers (R) comments
A: The majority of the reviewed publications were
prospective case series with flawed methodology
and, despite the impression that arthrocentesis
may be beneficial for patients with TMJ closed
lock, there have been no good prospective
randomised clinical trial confirm the efficacy
of the procedure.
R: The overall success rate was high from the
primary studies. The results are difficult to
interpret because of methodological weaknesses
of primary studies such as diagnostic criteria of
TMD, outcome measures, missing analysis
between Intervention and control treatment in
the studies. In addition, a majority of the studies
patients received complementary pharmacologic
or conservative treatment besides lavage. The
majority of the studies are LRD level IV, and
therefore, it not possible to draw any clear
conclusions from this SR.

Quality
score
AMSTAR 2
LRD II-IV

AMSTAR, assessment of multiple systematic reviews; LRD, level of research design; RCT, randomised clinical trials; TMD, temporomandibular disorders.

Al-Belasy FA
2007 (43)

Authors, year,
reference

Table 4. (Continued)

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 2010 Blackwell Publishing Ltd

Qualitative
SR of 6 RCTs
TMD
449 patients

Qualitative
SR of 2 SRs
and 6 RCTs
TMD
XX patients

Crider AB
2005 (46)

SBU (23)

Jedel E
2003 (30)

SR and
meta-analysis of
13 RCTs and
un-controlled
studies
TMD
patients*
Qualitative
SR of 7 RCTs
TMD
379 patients

Study design,
diagnosis, and no.
of patients

Crider AB
1999 (45)

Authors, year,
reference

Pan intensity
Daily activities
Depression
Sleep quality

A: Behavioural treatment such as biofeedback

and CBT have better effect than no treatment.
R: Reviewers and authors are identical persons

AMSTAR 3
LRD II

AMSTAR 3
LRD IIIII

AMSTAR 6
LRD III

No evidence of an
effect for any
treatment mode

I1 was superior to
C1 in one of two
RCTs
I2 was significantly
better than
C2 and I4
I3 was better
than C2
I3 was better than
I4 in one of two
RCTs
I1 was better than
C1 and C3
I2 was better
than C2
I3 was similar to I4

Self-reported
symptoms
Pain intensity
Clinical
examination
Pain intensity
Global
improvement
Limitation in jaw
function
Depression
Clinical
examination

I1: Biofeedback
I2: Acupuncture
I3: TENS
C1: No treatment
C2: Other treatment
I1: Biofeedback
training
I2: Biofeedback
training + CBT
I3: Biofeedbackassisted relaxation
training
I4: Alternative
treatment
C1: Sham treatment
C2: No treatment
I1: CBT
I2: Biofeedback
I3: Education
I4: Education + home
instruction
C1: Brief information
C2. No treatment
C3: Conventional
treatment

A: Although limited in extent, the available

data support the efficacy of EMG biofeedback
treatments for TMD.
R: Methodological weaknesses of primary
studies such as heterogeneous patient
material, outcome measures not clearly
defined, and several studies were not RCTs.
A: The studies were heterogeneous with low
quality, and therefore, it is not possible to
draw any conclusions.
R: Limitations in the SR methodology and
therefore difficult to draw any conclusions
A: Biofeedback training with adjunctive CBT
was reported to be an efficacious treatment for
TMD; both biofeedback training as the sole
intervention and biofeedback-assisted
relaxation training are probably efficacious
treatments.
R: Small studies, no long-term follow-up.
Methodological limitations in SR.

AMSTAR 4
LRD II-IV

Pain reduction and

clinical signs: I1
better than
C1 and C2

Pain reduction
Clinical signs of
dysfunction
Global assessment

I1: Electromyographic
biofeedback
C1: Active control
C2: No treatment or
placebo

Authors (A) conclusions

Reviewers (R) comments

Quality
score

Results

Outcome
measures

Intervention (I) and

control (C) groups

Table 5. Characteristics of systematic reviews (SRs) of behavioural therapy and multimodal treatments

MANAGEMENT OF TMD
443

Qualitative
SR of 11 RCTs
TMD:
Disc displacement
without reduction,
with pain
TMD pain, without
major
psychological
symptoms
TMD pain, with
major
psychological
symptoms
895 patients

Turp J
2007 (47)

Outcome
measures
Pain reduction
Jaw mobility

Pain intensity
Graded Chronic
Pain Scale
Analgesic
consumption
Psychologic status
Pain threshold

Intervention (I) and

control (C) groups
I1: CBT
I2: Biofeedback
I3: Relaxation
C1: Occlusal splint
C2: No treatment

I1: Simple treatment

I2: Multimodal
treatment

Authors (A) conclusions

Reviewers (R) comments
A: Programmes involving relaxation techniques
and biofeedback, electromyographic training,
and proprioceptive re-education may be more
effective than placebo treatment or occlusal
splints.
R: Studies had small numbers of participants
and outcome measures were poorly defined,
so it is difficult to draw any conclusions.
A: 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.
R: Methodological weaknesses of primary
studies such as diagnostic criteria of TMD,
poor description of how the treatment was
conducted, and outcome measures in the
study

Quality
score
AMSTAR 7
LRD II

AMSTAR 4
LRD II

Pain reduction: I1
better than C2
I2 similar effect
to C1
I2 and I3 similar
effect

Disc displacement
without reduction
with pain: I1 = I2.
TMD pain, without
major
psychological
symptoms: I1 = I2
TMD pain, with
major
psychological
symptoms:
I2 better than I1.

Results

AMSTAR, assessment of multiple systematic reviews; CBT, cognitive behavioural therapy; LRD, level of research design; RCT, randomised clinical trials; TMD, temporomandibular
disorders.
*Number of patients not reported.

Qualitative
SR of 4 RCTs
TMD
207 patients

Study design,
diagnosis, and no.
of patients

McNeely M
2006 (33)

Authors, year,
reference

Table 5. (Continued)

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MANAGEMENT OF TMD
inclusion criteria because of limitations in the quality
of the studies.
Three SRs evaluated surgical treatment of the TMJ in
patients with disc displacements (4143) and one SR
orthognathic surgery in patients with TMD (44)
(Table 4). In patients with disc displacements with
reduction, one SR reported similar treatment effects for
arthrocentesis, arthroscopy, and discectomy. In patients
with disc displacement without reduction, one SR
reported similar effect for arthrocentesis, arthroscopy,
and physical therapy. One SR reported overall high
success rate for arthrocentesis but made no comparison
of arthrocentesis with other interventions. In patients
with TMD pain, one SR reported contradictory results
following orthognathic surgery. But all SRs included in
these SRs had low levels of evidence.
Five SRs evaluated the treatment of various behavioural therapies in patients with TMD (23, 30, 33, 45, 46),
and one SR analysed the effect of multimodal and
simple treatment in TMD (47) (Table 5). Biofeedback
was reported to be (i) better than active control or no

Occlusal appliance
6 SR, 55 studies

treatment (two SRs), (ii) better than no treatment

when administered in combination with cognitive
behavioural therapy (CBT) or relaxation (two SRs),
and (iii) similar in effect compared with relaxation
training (one SR). Cognitive behavioural therapy was
reported to be (i) better than conventional treatment
(two SRs) and (ii) better than no treatment (one SR).
Education at the clinic and education at the clinic
combined with home exercises produced similar results.
In patients with disc displacement without reduction
and pain and in patients with TMD pain without major
psychological symptoms, no difference in outcome was
found between simple treatment and multimodal
treatment (one SR). But in patients with TMD pain
and major psychological symptoms, multimodal treatment was found to be better than simple treatment.
The overall inter-reliability agreement of the two
authors in assessing the quality of the SRs was 070 and
free-marginal kappa 067. Figure 2 presents percentage
of primary studies cited in one or more of the different
SRs for each treatment area.

Occlusal adjustment
4 SR, 12 studies

5
4
5%
9%

3
17%

1
43%

3
18%

Bruxism
2 SR, 6 studies

4
8%

2
33%

1
58%

2
17%

1
67%

2
25%

Acupuncture
6 SR, 10 studies

Physical treatment
4 SR, 26 studies

Pharmacologic treatment
7 SR, 60 studies

4
3 8%
8%

1
40%

5
40%

2
12%

2
20%
1
72%

2
4
3
10% 0% 10%

TMJ and maxillofacial surgery

4 SR, 54 studies

2
15%

Fig. 2. Percentage of same primary

study cited in one or more of the
different systematic reviews, for each
treatment area.
2010 Blackwell Publishing Ltd

4
3 13%
5%

Behavioral therapy and

Multimodadal treatment
6 SR, 30 studies
5
4
7%
7%

3
4%

1
36%

3
17%

1
2
3
4

1
81%

1
62%

5
2
33%

Reference cited number of times

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T. LIST & S. AXELSSON

Discussion
Systematic reviews are a synthesis and critical assessment of primary studies, or even other SRs, and they
play an important role in evidence-based decision
making. The SR has the benefit that it provides a
systematic overview of what has been published on a
specific issue and what current trends are, such as the
effect of various treatment modes in the management
of TMD. Because the conclusions in our study are based
on several SRs published by independent researchers,
findings are well supported.
Because many researchers and practitioners may not
have time to read SRs much less all the primary
studies on which these SRs are based a systematic
review of these SRs may (i) give a valuable, time-saving
overview of a specific issue, (ii) provide a pool of
references of SRs and of primary studies that have been
quality assessed, and (iii) serve as a useful tool for
giving undergraduate students an understanding of
how to conduct systematic literature searches and
quality assessments of a topic.
Studies have indicated that it is difficult to change
competences and knowledge that a dentist learned in
undergraduate dental education (48). It is therefore
important to implement SRs in undergraduate teaching
so that students understand evidence-based medicine
(49).
The results of the SRs are impacted by the quality of
the primary studies included in the review. However, the
methodological quality of the SR should not be affected
by flaws in the primary studies, as long as these flaws are
reported, commented on and sufficiently regarded in the
conclusions. One SR resulted in no included studies but
it was included because it reflected our second aim, to
assess the methodological quality of SRs (38).
In AMSTAR, one key item is whether the scientific
quality of the included SRs was assessed and documented The most commonly used quality assessment
tool used in the SRs was the Jadad score (50). Grades of
Recommendation Assessment, Development and Evaluation (GRADE) is a recently developed tool for
assessing the synthesised evidence for specified outcome measures. As one of the aims of this study was to
detect trends in the evidence base regarding the overall
effect of different methods for treating TMD, we
decided that introducing GRADE in this context would
give too detailed information for this purpose (51).
A concern in this SR was that 30% of the SRs included

case series, that is, no control group, which limits the

conclusions of the SR. Several leading scientific journals
have made a united effort to provide guidelines for how
a clinical trial should be conducted in the CONSORT
statement (52). These guidelines can be used as a
checklist for avoiding pitfalls in conducting clinical
trials.
Our SR found inconsistencies in several SRs concerning diagnosis. Temporomandibular disorders were
inconsistently defined in the primary studies but, more
importantly, also in the SRs reviewed here. Similar
results were reported for radiographic findings in TMD
(53). The classification that has been found to provide
acceptable reliability and validity and is commonly used
in TMD research is the research diagnostic criteria for
temporomandibular disorders (RDC TMD) (54, 55).
The future challenge is to convince researchers to use
the diagnostic system with the best evidence acceptable sensitivity and specificity (56).
In this SR, a large variety of outcome measures were
used, and instrument reliability and validity were often
not described. It is essential that evidence be based on
measures that are important indicators of patient health
and that are not surrogate endpoints. For example, pain
reduction and daily functioning are more important
aspects in an evaluation than clicking sounds, deviation
in mm, or tenderness on palpation. Clinical trials and
SRs must begin meeting international standards, and
clinical scientists must begin designing and reporting
such trials. To create a core of common outcome
measures in the field of pain, Dworkin et al. and a
consensus group undertook to put together the
Initiative on Methods, Measurements, and Pain Assessment in Clinical Trials (IMMPACT) (57). IMMPACT
recommendations include the following domains:
pain, physical functioning, emotional functioning,
participant rating of improvement and satisfaction
with treatment, symptoms and adverse events, and
participant disposition.
It is also important that (i) these measures are
expressed in clinically relevant terms such as numbers
of responders and non-responders to treatment, for
example, number of patients with >30% pain reduction
and (ii) data are presented in a transparent manner, so
that mathematical syntheses or meta-analyses of the
results may be conducted. In this review, only a few of
the SRs had conducted a meta-analysis because of
heterogeneity of the original data or methodological
differences such as variability of measures. In future,
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MANAGEMENT OF TMD
the ability to synthesise the results of several primary
studies would allow more accurate assessment of
treatment efficacy and treatment effectiveness. This
approach would allow the continuous update of RCTs
in meta-analyses, which would (i) limit the number of
qualitative SRs and (ii) allow more accurate, overall
assessment of treatment result.

Quality assessment
In this SR, AMSTAR scores ranged from 2 to 11. But it is
important to point out that item scores are not equal in
weight; for example, characteristics of included SRs and
conflict of interest statement have different weights.
With its focus on study design, the LRD was used to
supplement AMSTAR in SR quality assessment. Use of
both instruments was essential to gain perspective on
SR quality.
The number of SRs evaluated in the various treatment
groups ranged from 10 for occlusal splint, occlusal
adjustment, and bruxism to 4 for TMJ and maxillofacial
surgery. In each treatment area, a small number of welldesigned primary studies overlapped and were cited in
several of the SRs that covered that area. But 4080% of
the primary studies did not overlap between different
SRs and were only cited once (Fig. 2). Variations
between the SRs in aims, inclusion criteria, and time of
data collection may explain this lack of overlap. Despite
these differences, conclusions drawn in several of the
SRs for a specific treatment form had similar evidence.
Thus, synthesising evidence from several SRs can also be
a tool for validation of this kind of meta-research.
A general impression from this study was that
strength of evidence of an SR was weak if the SR (i)
had a low AMSTAR score (e.g. <5) and (ii) was based
upon non-randomised studies. In SRs where AMSTAR
scores ranged between 5 and 10, the results were
similar, regardless of quality. It has been emphasised
that a clinical trial should follow strict rules; likewise an
SR should be conducted in a standardised manner.

Occlusal appliances, occlusal adjustment, and bruxism

Several of the SRs concluded that management of TMD
with a stabilisation splint worn at night is likely to lead
to short-term improvement when compared with no
treatment, but is inconclusive compared with placebo
(non-occluding palatinal splint). In the short term,
stabilisation splints were equally effective in reducing
2010 Blackwell Publishing Ltd

TMD pain compared to other treatment modalities such

as physical medicine, behavioural medicine, and acupuncture treatment. Overall, documentation on the
long-term pain-relieving effect of occlusal appliances is
limited, as it is for patient compliance in occlusal
appliance treatment. Few SRs reported data on adverse
events related to the use of occlusal appliances. The
major concern with adverse events has been related to
partial non-occluding splints such as the NTI, where the
design of the splint may contribute to tooth pain and
occlusal changes (24).
One SR evaluated the use of splints in bruxism,
which was assessed as number of bruxism episodes per
hour [electromyographic (EMG) activity] and episodes
with grinding noises. The SR found no significant
differences between occlusal splints, no treatment, and
palatinal splints. Small sample size was one explanation
for the lack of significance between outcomes which
the authors of the SR emphasised (27). It should also be
emphasised that some primary studies, particularly
those that use polysomnographic registration, are
technically very difficult to conduct on large patient
samples. One SR examined tooth attrition related to
bruxism, and based on two small studies, found that
occlusal appliances retarded wear.
No SR found evidence that occlusal adjustments are
more or less effective than placebo in the treatment of
TMD pain. All SRs were restrictive in recommending
the use of occlusal adjustments for treatment for TMD
pain, especially because this therapy is non-reversible.

Physical therapy (acupuncture, TENS, exercise, and

mobilisation)
Most SRs found evidence that acupuncture is better
than no treatment and comparable to other forms of
conservative treatment. But because of methodological
shortcomings, MacPherson et al. recommended specific
guidelines to improve the quality of intervention
primary studies; before effectiveness of acupuncture
can be determined more primary studies are needed
(58). Few SRs reported any adverse events or sideeffects from acupuncture treatment. In treatment of
patients with TMD, side-effects seem to be rare or
complications only minor (59). MacPherson et al. came
to similar conclusions concerning use of acupuncture in
general for pain treatment in a large population group
(60). Major adverse events are very rare, but because
some have occurred following acupuncture treatment,

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T. LIST & S. AXELSSON

it is strongly recommended that those practicing acupuncture have good theoretical knowledge and training
in the therapy (61).
Next to information, patient education, and occlusal
appliance, jaw exercises are a common form of TMD
treatment (62). One SR found active exercise and
postural training to be effective in treatment of TMD
pain but no evidence for the effectiveness of various
electrical modalities. Overall, few primary studies have
been published and more research is needed to establish the efficacy of the various physical treatment
modalities, including acupuncture.

Pharmacologic treatment
Several SRs indicated that analgesics, antidepressants,
diazepam, hyaluronate, and glycocorticoid may be
effective in TMD pain. Few primary studies were well
designed with a relevant follow-up time, so the main
conclusion in the SR was that results were heterogeneous, and no conclusions could be drawn. But it is
important to differentiate between lack of evidence and
evidence for lack of effect. Because of current limitations in
knowledge of pharmacologic effects on TMD pain, only
comparisons between similar pain conditions such as
backache or tension-type headache can be made. In
several chronic pain conditions, drugs such as analgesics, opioids, antidepressants, and anti-epileptics have
been found to be effective in relieving pain (63); these
drugs would probably be effective in TMD pain.
Important endpoints such as numbers needed to treat
(NNT) and numbers needed to harm (NNH) were rare
in these primary studies, despite being recommended
for use in pharmacologic treatment studies because
they are easy to understand and provide a clinically
relevant measure of the success rate and rate of harm of
an intervention (63).
The SR on pharmacologic treatment reported minor
adverse events. Because there is currently no criterion
standard in the pharmacological treatment of chronic
oro-facial pain, the positive effects of drugs must be
weighed against possible adverse and toxic effects, and
risk of dependency.

TMJ and maxillofacial surgery

The SRs of surgical treatment of TMD concluded that
arthroscopic surgery, arthrocentesis, and physical therapy affected mandibular movement, reduction in pain

intensity, and mandibular functioning to the same

degree. Success rates were often high, independent of
treatment mode. The effect of maxillofacial surgery on
TMD pain is unclear. Many of the RCTs included in the
SRs had low quality scores, and outcome measures were
often coarse, which made data difficult to interpret.
One important aspect in the evaluation of invasive
TMJ interventions versus conservative treatment is the
patient groups. In most TMJ surgery primary studies,
the inclusion criterion for entering the study was
that the patient had been refractory to conservative treatment for 6 months, while the inclusion
criterion for conservative treatment was pain duration
of 6 months. So a comparison between the groups is
inconclusive.
More well-designed primary studies with proper
evidence-based standards are needed to identify the
patients who are most suited for surgical interventions.

Behavioural therapy and multimodal treatment

All SRs of behavioural therapy concluded that this type
of treatment was effective in treating TMD pain. The
treatment modalities included education, biofeedback,
relaxation training, stress management, and CBT.
Treatment modes were often combined, for example,
biofeedback and relaxation could be compared with
biofeedback and CBT, making it difficult to determine
which part of the treatment was most important.
Several primary studies indicated that behavioural
therapy was as effective as other forms of conservative
TMD treatment.
One SR reported that most patients with TMD
without psychological involvement benefited from
simple treatments. Patients with TMD pain and major
psychological disturbances were in need of a combined
therapeutic approach. This emphasises the need for
combining the clinical examination with a behavioural
assessment to be able to direct the patient to the proper
mode of treatment. The RDC TMD is a classification
system that uses a clinical (axis I) and a psychosocial
assessment (axis II) to gain a more complete picture of
the patient; Garofalo and Wesley recommended this
approach use of a dual axis in chronic pain
assessment (64).
Evidence-based medicine is defined as the integration
of best research evidence with clinical expertise and
patient values. In future, we need to expand our
understanding of how to:
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MANAGEMENT OF TMD
1 Tailor treatment for the individual patient, so they
benefit from the best treatment for them.
2 Transfer research findings to the practicing dentist,
because they are the main caregiver of patients with
TMD.
3 Balance our judgment of best research evidence with
clinical expertise in the choice of treatment.
4 Gain more information about patient preferences
and values and what impact this has on treatment
outcome.

Conclusions
There is some evidence that occlusal appliances,
acupuncture, behavioural therapy, jaw exercises, postural training, and some pharmacological treatments
can be effective in alleviating pain in patients with
TMD. Evidence is insufficient for the effect of electrophysical modalities and surgery. Occlusal adjustment
seems to have no effect according to the available
evidence. One limitation of most of the SRs reviewed
was that the considerable variation in methodology
between the primary studies made definitive conclusions impossible.

Acknowledgments
To the participants of the 2009 Colloquium on Oral
Rehabilitation in Sienna, who provided valuable feedback on the manuscript.

Declaration of interests
Dr Axelsson is a staff member and a project director at
the Swedish Council on Technology Assessment in
Health Care (SBU).

Authors contributions
Dr List conceived the project, developed the protocol,
conducted searches, and prepared the manuscript. Both
authors undertook data collection and extraction. Dr
Axelsson contributed to manuscript preparation.

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Correspondence: Thomas List, DDS, Odont. dr, Department of
Stomatognathic Physiology, Faculty of Odontology, Malmo University, SE-205 06 Malmo, Sweden. E-mail: Thomas.list@mah.se

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