Practitioner/Practice- and Patient-Based Factors Contributing to Dental Practitioner Treatment Recommendations for Patients with Pain-Related TMDs: Findings from the National Dental PBRN

Aims: To document National Dental Practice-Based Research Network (PBRN) practitioner treatment recommendations for patients with painful temporomandibular disorders (TMDs) and to identify practitioner/practice- and patient-related factors contributing to treatment recommendations made at the initial clinical visit. Methods: This prospective single-sample cohort study formed groups based on treatment recommendations made by 185 dental practitioners who treated 1,901 patients with painful TMDs. At the baseline visit, which this article describes, practitioners provided patients with their diagnoses and a treatment plan and then completed a comprehensive questionnaire. Results: Self-care, an intraoral appliance, medication, and practitioner-recommended jaw exercises were the most frequently recommended treatments. Practitioners recommended multiple treatments to most patients. TMD signs, symptoms, and diagnoses were primary considerations in treatment planning, but the practitioner's expectations for improvement were only significant for intraoral appliances and self-care. Female practitioners and those with expertise in TMDs more frequently recommended patient-directed and multidisciplinary treatments compared to their counterparts. Conclusions: Practitioners used a wide range of treatments for patients with few consistent patterns. The propensity to use TMD signs, symptoms, and diagnoses when making treatment recommendations suggests a tendency to conceptualize patients using the biomedical model. Infrequent referral to nondental providers suggests a lack of availability of these providers, a misunderstanding of the complexity of TMDs, and/or discomfort with assessment of psychosocial factors. Implications include the need for comprehensive training in the assessment and management of TMD patients during dental school and participation in TMD continuing education courses following evidence-based guidelines.

temporomandibular disorders; National Dental Practice-Based Research Network; intraoral appliance; self-care; treatment recommendations

1. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Care Services; Board on Health Sciences Policy; Committee on Temporomandibular Disorders: From Research Discoveries to Clinical Treatment. Temporomandibular disorders: Priorities for research and care. National Academies Press (US); 12 March 2020. PMID: 32200600.

2. Slade GD, Bair E, Greenspan JD, et al. Signs and symptoms of first-onset TMD and sociodemographic predictors of its development: The OPPERA prospective cohort study. J Pain 2013;14:T75–T90.

3. 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.

4. Ohrbach R. Disability assessment in temporomandibular disorders and masticatory system rehabilitation. J Oral Rehabil 2010;37:452–480.

5. Velly AM, Schiffman EL, Rindal DB, et al. The feasibility of a clinical trial of pain related to temporomandibular muscle and joint disorders: The results of a survey from the collaboration on networked dental and oral research dental practice-based research networks. J Am Dent Assoc 2013;144:e1–e10.

6. Garrigós-Pedrón M, Elizagaray-García I, Domínguez-Gordillo AA, Del-Castillo-Pardo-de-Vera JL, Gil-Martínez A. Temporomandibular disorders: Improving outcomes using a multidisciplinary approach. J Multidiscip Healthc 2019;12:733–747.

7. List T, Axelsson S. Management of TMD: Evidence from systematic reviews and meta-analyses. J Oral Rehabil 2010;37:430–451.

8. Al-Moraissi EA, Conti PCR, Alyahya A, Alkebsi K, Elsharkawy A, Christidis N. The hierarchy of different treatments for myogenous temporomandibular disorders: A systematic review and network meta-analysis of randomized clinical trials. Oral Maxillofac Surg 2022;26:519–533

9. Clarke EB, French B, Bilodeau ML, Capasso VC, Edwards A, Empoliti J. Pain management knowledge, attitudes and clinical practice: the impact of nurses’ characteristics and education. J Pain Symptom Manage 1996;11:18–31.

10. Greene CS, Menchel HF. The use of oral appliances in the management of temporomandibular disorders. Oral Maxillofac Surg Clin North Am 2018;30:265–277.

11. Thomas RK. The feminization of American medicine. Mkt Hlth Svcs 2000;20:13–18.

12. Riley JL 3rd, Gordan VV, Rouisse KM, McClelland J, Gilbert GH, Dental Practice-Based Research Network Collaborative Group. Differences in male and female dentists’ practice patterns regarding diagnosis and treatment of dental caries: Findings from the Dental Practice-Based Research Network. J Am Dent Assoc 2011;142:429–440.

13. Gilbert GH, Fellows JL, Allareddy V, et al. Structure, function, and productivity from the national dental practice-based research network. J Clin Transl Sci 2022;6:e87.

14. Velly AM, Anderson GC, Look JO, et al. Management of painful temporomandibular disorders: Methods and overview of the national dental practice-based research network prospective cohort study. J Am Dent Assoc 2022;153:144–157.

15. Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for clinical and research applications: Recommendations of the International RDC/TMD Consortium Network and Orofacial Pain Special Interest Group. J Oral Facial Pain Headache 2014;28:6–27.

16. Costa YM, Porporatti AL, Stuginski-Barbosa J, Bonjardim LR, Conti PCR. Additional effect of occlusal splints on the improvement of psychological aspects in temporomandibular disorder subjects: A randomized controlled trial. Arch Oral Biol 2015;60:738–744.

17. Hardin JW, Hilbe JM. Generalized Estimating Equations. Chapman and Hall/CRC, 2003.

18. Onder H. Comparative study of generalized estimating equations and logistic regressions on different sample sizes and correlation levels. Communication in Statistics–Simulation and Computation 2016;45:3528–3655.

19. Pficer JK, Dodic S, Lazic V, Trajkovic G, Milic N, Milicic B. Occlusal stabilization splint for patients with temporomandibular disorders: Meta-analysis of short and long term effects. PLoS One 2017;12:e0171296.

20. Zhang C, Wu JY, Deng DL, et al. Efficacy of splint therapy for the management of temporomandibular disorders: A meta- analysis. Oncotarget 2016;7:84043–84053.

21. Bueno CH, Pereira DD, Pattussi MP, Grossi PK, Grossi ML. Gender differences in temporomandibular disorders in adult populational studies: A systematic review and meta-analysis. J Oral Rehabil 2018;45:720–729.

22. Pierce CJ, Weyant RJ, Block HM, Nemir DC. Dental splint prescription patterns: A survey. J Am Dent Assoc 1995;126:248–254.

23. Santiago V, Raphael KG. Perceived helpfulness of treatments for myofascial TMD as a function of comorbid widespread pain. Clin Oral Investig 2019;23:2929–2939.

24. Reissmann DR, Behn A, Schierz O, List T, Heydecke G. Impact of dentists’ years since graduation on management of temporomandibular disorders. Clin Oral Investig 2015;19:2327–2336.

25. Riley P, Glenny AM, Worthington HV, et al. Oral splints for temporomandibular disorder or bruxism: A systematic review. Br Dent J 2020;228:191–197.

26. Ouanounou A, Goldberg M, Haas DA. Pharmacotherapy in temporomandibular disorders: A review. J Can Dent Assoc 2017;83:h7.

27. Wieckiewicz M, Boening K, Wiland P, Shiau YY, Paradowska-Stolarz A. Reported concepts for the treatment modalities and pain management of temporomandibular disorders. J Headache Pain 2015;16:106.

28. Mujakperuo HR, Watson M, Morrison R, Macfarlane TV. Pharmacological interventions for pain in patients with temporomandibular disorders. Cochrane Database Syst Rev 2010;10:CD004715.

29. Durham J, Al-Baghdadi M, Baad-Hansen L, et al. Self-management programmes in temporomandibular disorders: Results from an international delphi process. J Oral Rehabil 2016;43:929–936.

30. Hatayama T, Kitamura S, Tamura C, Nagano M, Ohnuki K. The facial massage reduced anxiety and negative mood status, and increased sympathetic nervous activity. Biomed Res 2008;29:317–320.

31. Tabrizi R, Karagah T, Aliabadi E, Hoseini SA. Does gum chewing increase the prevalence of temporomandibular disorders in individuals with gum chewing habits? J Craniofac Surg 2014;25:1818–1821.

32. Herman CR, Schiffman EL, Look JO, Rindal DB. The effectiveness of adding pharmacologic treatment with clonazepam or cyclobenzaprine to patient education and self-care for the treatment of jaw pain upon awakening: A randomized clinical trial. J Orofac Pain 2002;16:64–70.

33. Mulet M, Decker KL, Look JO, Lenton PA, Schiffman EL. A randomized clinical trial assessing the efficacy of adding 6 x 6 exercises to self-care for the treatment of masticatory myofascial pain. J Orofac Pain 2007;21:318–328.

34. Wänman A, Marklund S. Treatment outcome of supervised exercise, home exercise and bite splint therapy, respectively, in patients with symptomatic disc displacement with reduction: A randomized clinical trial. J Oral Rehabil 2020;47:143–149.

35. Armijo-Olivo S, Pitance L, Singh V, Neto F, Thie N, Michelotti A. Effectiveness of manual therapy and therapeutic exercise for temporomandibular disorders: Systematic review and meta- analysis. Phys Ther 2016;96:9–25.

36. Calixtre LB, Moreira RF, Franchini GH, Alburquerque-Sendín F, Oliveira AB. Manual therapy for the management of pain and limited range of motion in subjects with signs and symptoms of temporomandibular disorder: A systematic review of randomised controlled trials. J Oral Rehabil 2015;42:847–861.

37. Paço M, Peleteiro B, Duarte J, Pinho T. The effectiveness of hysiotherapy in the management of temporomandibular disorders: A systematic review and meta-analysis. J Oral Facial Pain Headache 2016;30:210–220.

38. Miernik M, Wieckiewicz M, Paradowska A, Wieckiewicz W. Massage therapy in myofascial TMD pain management. Adv Clin Exp Med 2012;21:681–685.

39. Eisensmith LP. Massage therapy decreases frequency and intensity of symptoms related to temporomandibular joint syndrome in one case study. J Bodywork Movement Therapies 2007;11:223–230.

40. Pierson MJ. Changes in temporomandibular joint dysfunction symptoms following massage therapy: A case report. Int J Ther Massage Bodywork 2011;4:37–47.

41. Chinappi AS Jr, Getzoff H. The dental-chiropractic cotreatment of structural disorders of the jaw and temporomandibular joint dysfunction. J Manipulative Physiol Ther 1995;18:476–481.

42. DeVocht JW, Goertz CM, Hondras MA, et al. A pilot study of a chiropractic intervention for management of chronic myofascial temporomandibular disorder. J Am Dent Assoc 2013;144:1154–1163.

43. Pavia S, Fischer R, Roy R. Chiropractic treatment of temporomandibular dysfunction: A retrospective case series. J Chiropractic Med 2015;14:279–284.

44. Ozkan F, Cakır Özkan N, Erkorkmaz U. Trigger point injection therapy in the management of myofascial temporomandibular pain. Agri 2011;23:119–125.

45. Manfredini D. Occlusal equilibration for the management of temporomandibular disorders. Oral Maxillofac Surg Clin North Am 2018;30:257–264.

46. Weyant RJ. Questional benefit from occlusal adjustment for TMD disorders. J Evid Based Dent Pract 2006;6:167–168.

47. Fernández-de-Las-Peñas C, Von Piekartz H. Clinical reasoning for the examination and physical therapy treatment of temporo-mandibular disorders (TMD): A narrative literature review. J Clin Med 2020;9:3686.

48. Ohrbach R, Durham J. Biopsychosocial aspects of orofacial pain. In: Farah C, Balasubramaniam R, McCullough M (eds). Contemporary Oral Medicine. Springer, 2019.

49. 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.

50. Sharma S, Breckons M, Brönnimann Lambelet B, et al. Challenges in the clinical implementation of a biopsychosocial model for assessment and management of orofacial pain. J Oral Rehabil 2020;47:87–100.

51. Bruera E, Sweeney C, Calder K, Palmer L, Benisch-Tolley S. Patient preferences versus physician perceptions of treatment decisions in cancer care. J Clin Oncol 2001;19:2883–2885.

52. Riley JL 3rd, Gordan VV, Hudak-Boss SE, et al. Concordance between patient satisfaction and the dentist’s view: Findings from the national dental practice-based research network. J Am Dent Assoc 2014;145:355–362.

53. Klasser GD, Gremillion HA. Past, present, and future of predoctoral dental education in orofacial pain and TMDs: A call for interprofessional education. J Dent Educ 2023;77:395–400.

54. Klasser GD, Greene CS. Predoctoral teaching of temporomandibular disorders: A survey of U.S. and Canadian dental schools. J Am Dent Assoc 2007;138:231–237.

55. Fricton JR. Development of orofacial pain programs in dental schools. J Orofac Pain 2002;16:191–197.

56. Hadlaq EM, Khan H, Mubayrik AB, Almuflehi NS, Mawardi H. Dentists’ knowledge of chronic orofacial pain. Niger J Clin Pract 2019;22:1365–1371.

57. Costa YM, De Koninck BP, Elsaraj SM, et al. Orofacial pain education in dentistry: A path to improving patient care and reducing the population burden of chronic pain. J Dent Educ 2020;85:349–358.