Tailored Treatments in Temporomandibular Disorders: Where Are We Now? A Systematic Qualitative Literature Review

Aims: To conduct a systematic review to evaluate the evidence of possible benefits of tailored treatments for temporomandibular disorders (TMD) based on randomized controlled trials (RCTs). Methods: Reports of RCTs investigating treatments tailored to TMD patients’ psychosocial characteristics were systematically searched for through March 2013 in the following databases: Cochrane Central Register of Controlled Trials, PubMed, and Web of Science. The methodological quality of the RCTs was assessed using the Cochrane Collaboration’s tool for assessing risk of bias. Results: Seven reports met the inclusion criteria. In all studies a subgroup of TMD patients, mainly identified by multidimensional diagnostic systems such as the Research Diagnostic Criteria for TMD Axis II or Multidimensional Pain Inventory, were offered a treatment intervention hypothesized to be suitable for that particular patient group. The quality of the trials was compromised in all cases. Two studies focused on well-functioning TMD patients. In both studies, self-care gave results equal to or better than usual conservative TMD treatment. The treatments were targeted for patients with compromised psychosocial adaptation in five studies, and typically included a cognitive behavioral treatment component. In all trials the results supported the efficacy of tailored treatment, albeit in one trial only in the short-term. Conclusion: The identified studies offer cautious support to the notion that treatment targeted to different psychosocial subgroups of TMD pain patients may be beneficial.

psychosocial; RDC/TMD Axis II; systematic reviews; temporomandibular disorders; treatment tailoring

1. Drangsholt M, LeResche L. Temporomandibular disorder pain. In: Crombie IK (ed). Epidemiology of Pain. Seattle: IASP Press, 1999:203–233.

2. Dworkin SF. Psychological and psychosocial assessment. In: Laskin DM, Greene CS, Hylander WI (eds). Temporomandibular Disorders. An Evidence-Based Approach to Diagnosis and Treatment. Chicago: Quintessence, 2006:203–217.

3. Maixner W. Biopsychological and genetic risk factors for temporomandibular joint disorders and related conditions. In: Graven-Nielsen T, Arendt-Nielsen L, Mense S (eds). Fundamentals of Musculoskeletal Pain. Seattle: IASP Press, 2008:263–279.

4. Benoliel R, Svensson P, Heir GM, et al. Persistent orofacial muscle pain. J Oral Diseases 2011;17:23–41.

5. Ommerborn MA, Kollmann C, Handschel J, Depprich RA, Lang H, Raab WH-M. A survey on German dentists regarding the management of craniomandibular disorders. Clin Oral Investig 2010;14:137–144.

6. Ohrbach R, Dworkin SF. Five-year outcomes in TMD: Relationship of changes in pain to changes in physical and psychological variables. Pain 1998;74:315–326.

7. Epker J, Gatchel RJ, Ellis E 3rd. A model for predicting chronic TMD: Practical application in clinical settings. J Am Dent Assoc 1999;130:1470–1475.

8. Grossi ML, Goldberg MB, Locker D, Tenenbaum HC. Reduced neuropsychologic measures as predictors of treatment out-come in patients with temporomandibular disorders. J Orofac Pain 2001;15:329–339.

9. Rammelsberg P, LeResche L, Dworkin SF, Mancl L. Longitudinal outcome of temporomandibular disorders: A 5- year epidemiologic study of muscle disorders defined by research diagnostic criteria for temporomandibular disorders. J Orofac Pain 2003;17:9–20.

10. Wright AR, Gatchel RJ, Wildenstein L, Riggs R, Buschang P, Ellis E 3rd. Biopsychosocial differences between high-risk and low-risk patients with acute TMD-related pain. J Am Dent Assoc 2004;135:474–483.

11. Turk DC, Rudy TE, Zaki HS. Multiaxial assessment and classification of temporomandibular disorder pain patients. Implications for treatment. In: Fricton JR, Dubner R (eds). Orofacial Pain and Tempormandibular Disorders. New York: Raven Press, 1995:145–163.

12. Suvinen TI, Reade PC, Kemppainen P, Könönen M, Dworkin SF. Review of aetiological concepts of temporomandibular pain disorders: Towards a biopsychosocial model for integration of physical disorder factors with psychological and psychosocial illness impact factors. Eur J Pain 2005;9:613–633.

13. Fillingim RB, Ohrbach R, Greenspan JD, et al. Potential psychosocial risk factors for chronic TMD: Descriptive data and empirically identified domains from the OPPERA case-control study. J Pain 2011;12:T46–T60.

14. Rudy TE, Turk DC, Zaki HS, Curtin HD. An empirical taxometric alternative to traditional classification of temporomandibular disorders. Pain 1989;36:311–320.

15. Von Korff M, Ormel J, Keefe FJ, Dworkin SF. Grading the severity of chronic pain. Pain 1992;50:133–149.

16. Dworkin SF. Personal and societal impact of orofacial pain. In: Fricton JR, Dubner RB (eds). Orofacial Pain and Temporomandibular Disorders. New York: Raven Press, 1995: 15–32.

17. Turner JA, Dworkin SF. Screening for psychosocial factors in patients with chronic orofacial pain: Recent advances. J Am Dent Assoc 2004;135:1119–1125.

18. Manfredini D, Ahlberg J, Winocur E, Guarda-Nardini L, Lobbezoo F. Correlation of RDC/TMD Axis I and Axis II pain-related disability. A multicenter study. Clin Oral Investig 2011;15:749–756.

19. Rudy TE, Turk DC, Kubinski JA, Zaki HS. Differential treatment responses of TMD patients as a function of psychological characteristics. Pain 1995;61:103–112.

20. Litt MD, Shafer DM, Kreutzer DL. Brief cognitive-behavioral treatment for TMD pain: Long-term outcomes and moderators of treatment. Pain 2010;151:110–116.

21. Velly AM, Look JO, Carlson C, et al. The effect of catastrophizing and depression on chronic pain—A prospective cohort study of temporomandibular muscle and joint pain disorders. Pain 2011;152:2377–2383.

22. Turk DC. Customizing treatment for chronic pain patients: Who, what, and why. Clin J Pain 1990;6:255–270.

23. Keefe FJ, Rumble ME, Scipio CD, Giordano LA, Perri LCM. Psychological aspects of persistent pain: Current state of the science. J Pain 2004;5:195–211.

24. Turp JC, Jokstad A, Motschall E, Schindler HJ, Windecker-Getaz I, Ettlin DA. Is there a superiority of multimodal as opposed to simple therapy in patients with temporomandibular disorders? A qualitative systematic review of the literature. Clin Oral Implants Res 2007;18:138–150.

25. Palla S. Biopsychosocial pain model crippled? [Editorial]. J Orofac Pain 2011;25:289–290.

26. Eversole LR, Stone CE, Matheson D, Kaplan H. Psychometric profiles and facial pain. Oral Surg Oral Med Oral Pathol 1985;60:269–274.

27. McCreary CP, Clark GT, Merril RL, Flack V, Oakley ME. Psychological distress and diagnostic subgroups of temporo-mandibular disorder patients. Pain 1991;44:29–34.

28. Schulte JK, Anderson GC, Hathaway KM, Will TE. Psychometric profiles and related pain characteristics of temporomandibular disorder patients. J Orofac Pain 1993;7:247–253.

29. Turk DC, Rudy E. Toward an empirically derived taxonomy of chronic pain patients: Integration of psychological assessment data. J Consult Clin Psychol 1988;56:233–238.

30. Turk DC. The potential of treatment matching for subgroups of patients with chronic pain: Lumping versus splitting. Clin J Pain 2005;21:44–55.

31. Dworkin S, LeResche L. Research diagnostic criteria for tem-poromandibular disorders: Review, criteria, examinations and specifications, critique. J Craniomandib Dis 1992;6:301–355.

32. Manfredini D, Borella L, Favero L, Ferronato G, Guarda-Nardini L. Chronic pain severity and depression/somatization levels in TMD patients. Int J Prosthodont 2010; 23:529–534.

33. Dworkin SF, Turner JA, Wilson L, et al. Brief group cognitive-behavioral intervention for temporomandibular disorders. Pain 1994;59:175–187.

34. Higgins JPT, Green S (eds). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011.

35. Turner JA, Mancl L, Aaron LA. Brief cognitive-behavioral therapy for temporomandibular disorder pain: Effects on daily electronic outcome and process measures. Pain 2005; 117:377–387.

36. Turner JA, Holtzman S, Mancl L. Mediators, moderators, and predictors of therapeutic change in cognitive-behavioral therapy for chronic pain. Pain 2007;127:276–286.

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

38. Stowell AW, Gatchel RJ, Widenstein L. Cost-effectiveness of treatments for temporomandibular disorders: Biopsychological intervention versus treatment as usual. J Am Dent Assoc 2007; 138:202–208.

39. Gatchel RJ, Stowell AW, Wildenstein L, Riggs R, Ellis E 3rd. Efficacy of an early intervention for patients with acute tem-poromandibular disorder-related pain. A one-year outcome study. J Am Dent Assoc 2006;137:339–347.

40. Dworkin SF, Huggins KH, Wilson L, et al. 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. J Orofac Pain 2002a;16:48–63.

41. Dworkin SF, Turner JA, Mancl L, Wilson L, Massoth D, Huggins KH et al. A randomized clinical trial of a tailored comprehensive care treatment program for temporomandibular disorders. J Orofac Pain 2002b;16:259–276.

42. Truelove E, Huggins KH, Mancl L, Dworkin SF. The efficacy of traditional, low-cost and nonsplint therapies for temporo-mandibular disorder: A randomized controlled trial. J Am Dent Assoc 2006;137:1099–1107.

43. Turk DC, Rudy TE, Kubinski JA, Zaki HS, Greco CM. Dysfunctional patients with temporomandibular disorders: Evaluating the efficacy of a tailored treatment protocol. J Consult Clin Psychol 1996;64:139–146.

44. Tversky J, Reade PC, Gerschman JA, Holwill BJ, Wright J. Role of depressive illness in the outcome of treatment of temporo-mandibular joint pain-dysfunction syndrome. Oral Surg Oral Med Oral Pathol 1991;71:696–699.

45. Dworkin SF, Sherman J, Mancl L, Ohrbach R, LeResche L, Truelove E. Reliability, validity, and clinical utility of the Research Diagnostic Criteria for Temporomandibular Disorders Axis II scales: Depression, non-specific physical symptoms, and graded chronic pain. J Orofac Pain 2002c;16:207–220.

46. Ohrbach R, Turner JA, Sherman JJ, Mancl LA, Truelove EL, Schiffman EL. The Research Diagnostic Criteria for Temporomandibular Disorders: IV: Evaluation of psychomet-ric properties of the Axis II measures. J Orofac Pain 2010; 24:48–62.

47. Yap AU, Dworkin SF, Chua EK, List T, Tan KB, Tan HH. Prevalence of temporomandibular disorder subtypes, psychologic distress, and psychosocial dysfunction in Asian patients. J Orofac Pain 2003;17:21–28.

48. Turner JA, Mancl L, Huggins KH, Sherman JJ, Lentz G, LeResche L. Targeting temporomandibular disorder pain treatment to hormonal fluctuations: A randomized clinical trial. Pain 2011;152:2074–2084.

49. Williams AC, Eccleston C, Morley S. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database of Systematic Reviews 2012 Nov 14;11:CD007407.

50. Flor H, Turk DC. Identifying patient subgroups and matching patients with treatment. In: Flor H, Turk DC (eds). Chronic Pain: An integrated Biobehavioral Approach. Seattle: IASP Press, 2011:289–317.

51. Aggarwall VR, Lovell K, Peters S, Javidi H, Goldthorpe J. Psychosocial interventions for the management of chronic orofacial pain. Cochrane Database of Systematic Reviews 2011 Nov 9;11: CD008456.

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

53. Dworkin RH, Turk DC, Farrar JT, et al. Core outcome measures for chronic pain clinical trials: IMMPACT recommendations. Pain 2005;113:9–19.