Home-based rehabilitation versus centre-based programs in patients with temporomandibular disorders—a systematic review and meta-analysis

To compare the effects of home-based rehabilitation and occlusal splints or centre-based rehabilitation in patients with temporomandibular joint disorders (TMD). A systematic review and meta-analysis. PubMed, Embase, Cochrane Library, Web of Science and ClinicalTrials.gov electronic databases were consulted from inception to August 2023, searching for randomized controlled trials (RCTs) that compared home-based rehabilitation for TMD with splints or centre-based rehabilitation. The risk of bias was assessed using the Cochrane risk of bias tool. 23 RCTs (1402 participants, three comparator interventions) were identified. Very low-certainty evidence suggested there are no clinically difference between home-based rehabilitation and splints in pain intensity (mean difference (MD) 7.75, 95% confidence interval (CI): 2.17 to 13.32), maximal mouth opening (MMO) (MD 1.83, 95% CI: −0.27 to 3.93) at short and long-term follow-up, in sleep quality (MD: 1.67, 95% CI: −2.04 to 3.56) and quality of life (psychological: MD 0.94, 95% CI: −4.43 to 6.31; general: MD −1.18, 95% CI: −5.72 to 5.37) at short-term follow-up. Low-certainty evidence suggested that home-based rehabilitation plus manual therapy is more effective for TMD treatment compared to home-based rehabilitation at short-term follow-up (pain intensity: MD: 14.93, 95% CI: 7.72 to 21.93; MMO: MD −2.93, 95% CI: −5.3 to −0.54; sleep quality: MD 1.4, 95%CI: 0.09 to 2.71). Compared with home-based rehabilitation, Transcutaneous Electrical Nerve Stimulation (TENS) and Low-Level Laser Therapy (LLLT) was superior in pain relief at short-term follow-up. Low and very low-certainty evidence suggests home-based rehabilitation could be considered a low-cost, beneficial therapy alternative for TMD patients to relieve symptoms.

Temporomandibular joint disorders; Home care service; Pain intensity; Maximal mouth opening; Meta-analysis

[1] Liu F, Steinkeler A. Epidemiology, diagnosis, and treatment of temporomandibular disorders. Dental Clinics of North America. 2013; 57: 465–479.

[2] Steigerwald DP. $4 billion spent annually on tmd: an opportunity for chiropractic. Dynamic Chiropractic. 2009; 27: 4p.

[3] Buergers R, Kleinjung T, Behr M, Vielsmeier V. Is there a link between tinnitus and temporomandibular disorders? The Journal of Prosthetic Dentistry. 2014; 111: 222–227.

[4] Schiffman E, Ohrbach R, Truelove E, Look J, Anderson G, Goulet JP, et al; International RDC/TMD Consortium Network, International association for Dental Research; Orofacial Pain Special Interest Group, International Association for the Study of Pain. 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†. The Journal of Oral & Facial Pain and Headache. 2014; 28: 6–27.

[5] Valesan LF, Da-Cas CD, Réus JC, Denardin ACS, Garanhani RR, Bonotto D, et al. Prevalence of temporomandibular joint disorders: a systematic review and meta-analysis. Clinical Oral Investigations. 2021; 25: 441–453.

[6] Greene CS. Managing the care of patients with temporomandibular disorders. The Journal of the American Dental Association. 2010; 141: 1086–1088.

[7] Jacobson A. Etiology of temporomandibular disorders: implications for treatment. American Journal of Orthodontics and Dentofacial Orthopedics. 2001; 120: 568.

[8] Anderson L, Sharp GA, Norton RJ, Dalal H, Dean SG, Jolly K, et al. Home-based versus centre-based cardiac rehabilitation. Cochrane Database of Systematic Reviews. 2017; 6: CD007130.

[9] Thomas RJ, Beatty AL, Beckie TM, Brewer LC, Brown TM, Forman DE, et al. Home-based cardiac rehabilitation: a scientific statement from the american association of cardiovascular and pulmonary rehabilitation, the American Heart Association, and the American College of Cardiology. Circulation. 2019; 140: e69–e89.

[10] Bravo-Escobar R, González-Represas A, Gómez-González AM, Montiel-Trujillo A, Aguilar-Jimenez R, Carrasco-Ruíz R, et al. Effectiveness and safety of a home-based cardiac rehabilitation programme of mixed surveillance in patients with ischemic heart disease at moderate cardiovascular risk: a randomised, controlled clinical trial. BMC Cardiovascular Disorders. 2017; 17: 66.

[11] Chen Y, Wang C, Lai Y, Liao Y, Wen Y, Chang S, et al. Home-based cardiac rehabilitation improves quality of life, aerobic capacity, and readmission rates in patients with chronic heart failure. Medicine. 2018; 97: e9629.

[12] Lim J, Cho J, Kim T, Yoon B. Isokinetic knee strength and proprioception before and after anterior cruciate ligament reconstruction: a comparison between home-based and supervised rehabilitation. Journal of Back and Musculoskeletal Rehabilitation. 2019; 32: 421–429.

[13] Taylor RS, Dalal H, Jolly K, Moxham T, Zawada A. Home-based versus centre-based cardiac rehabilitation. Cochrane Database of Systematic Reviews. 2010; CD007130.

[14] Wu D, Zhu X, Zhang S. Effect of home-based rehabilitation for hip fracture: a meta-analysis of randomized controlled trials. Journal of Rehabilitation Medicine. 2018; 50: 481–486.

[15] Wuytack F, Devane D, Stovold E, McDonnell M, Casey M, McDonnell TJ, et al. Comparison of outpatient and home‐based exercise training programmes for COPD: a systematic review and meta-analysis. Respirology. 2018; 23: 272–283.

[16] Buescher JJ. Temporomandibular joint disorders. American Family Physician. 2007; 76: 1477–1482

[17] Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. The BMJ. 2021; 372: n71.

[18] Kay TM, Gross A, Goldsmith CH, Rutherford S, Voth S, Hoving JL, et al. Exercises for mechanical neck disorders. Cochrane Database of Systematic Reviews. 2012; CD004250.

[19] Hayden JA, Ellis J, Ogilvie R, Malmivaara A, van Tulder MW. Exercise therapy for chronic low back pain. Cochrane Database of Systematic Reviews. 2021; 9: CD009790.

[20] Higgins JPT, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD, et al. The cochrane collaboration’s tool for assessing risk of bias in randomised trials. The BMJ. 2011; 343: d5928.

[21] Calixtre LB, Oliveira AB, Alburquerque-Sendín F, Armijo-Olivo S. What is the minimal important difference of pain intensity, mandibular function, and headache impact in patients with temporomandibular disorders? Clinical significance analysis of a randomized controlled trial. Musculoskeletal Science and Practice. 2020; 46: 102108.

[22] Kropmans T, Dijkstra P, Stegenga B, Stewart R, De Bont L. Smallest detectable difference of maximal mouth opening in patients with painfully restricted temporomandibular joint function. European Journal of Oral Sciences. 2000; 108: 9–13.

[23] Grondin F, Hall T. Changes in cervical movement impairment and pain following orofacial treatment in patients with chronic arthralgic temporomandibular disorder with pain: a prospective case series. Physiotherapy Theory and Practice. 2017; 33: 52–61.

[24] Stoustrup P, Verna C, Kristensen KD, Küseler A, Herlin T, Pedersen TK. Smallest detectable differences in clinical functional temporomandibular joint examination variables in juvenile idiopathic arthritis. Orthodontics & Craniofacial Research. 2013; 16: 137–145.

[25] Cohen J. Chapter 2. Title of chapter. In Surname of the editor(s) Initial(s) (ed(s).) Statistical Power Analysis for the Behavioural Sciences (p. 20). 2nd edn. Hilldale, NJ: Lawance Erlbaum. 1988.

[26] Higgins JPT. Measuring inconsistency in meta-analyses. The BMJ. 2003; 327: 557–560.

[27] Hutton B, Salanti G, Caldwell DM, Chaimani A, Schmid CH, Cameron C, et al. The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations. Annals of Internal Medicine. 2015; 162: 777–784.

[28] Huedo-Medina TB, Sánchez-Meca J, Marín-Martínez F, Botella J. Assessing heterogeneity in meta-analysis: Q statistic or I2 index? Psychol Methods. 2006; 11: 193–206.

[29] Furlan AD, Pennick V, Bombardier C, van Tulder M. 2009 updated method guidelines for systematic reviews in the cochrane back review group. Spine. 2009; 34: 1929–1941.

[30] Truelove E, Huggins KH, Mancl L, Dworkin SF. The efficacy of traditional, low-cost and nonsplint therapies for temporomandibular disorder. The Journal of the American Dental Association. 2006; 137: 1099–1107.

[31] Haketa T, Kino K, Sugisaki M, Takaoka M, Ohta T. Randomized clinical trial of treatment for TMJ disc displacement. Journal of Dental Research. 2010; 89: 1259–1263.

[32] Craane B, Dijkstra PU, Stappaerts K, De Laat A. Randomized controlled trial on physical therapy for TMJ closed lock. Journal of Dental Research. 2012; 91: 364–369.

[33] Niemelä K, Korpela M, Raustia A, Ylöstalo P, Sipilä K. Efficacy of stabilisation splint treatment on temporomandibular disorders. Journal of Oral Rehabilitation. 2012; 39: 799–804.

[34] Ficnar T, Middelberg C, Rademacher B, Hessling S, Koch R, Figgener L. Evaluation of the effectiveness of a semi-finished occlusal appliance—a randomized, controlled clinical trial. Head & Face Medicine. 2013; 9: 5.

[35] Tuncer A, Ergun N, Karahan S. Temporomandibular disorders treatment: comparison of home exercise and manual therapy. Fizyoterapi Rehabilitasyon. 2013; 24: 9–16.

[36 Tuncer AB, Ergun N, Tuncer AH, Karahan S. Effectiveness of manual therapy and home physical therapy in patients with temporomandibular disorders: a randomized controlled trial. Journal of Bodywork and Movement Therapies. 2013; 17: 302–308.

[37 Costa Y, Porporatti A, Stuginski-Barbosa J, Bonjardim L, Speciali J, Conti P. Headache attributed to masticatory myofascial pain: clinical features and management outcomes. Journal of Oral & Facial Pain and Headache. 2015; 29: 323–330.

[38] Qvintus V, Suominen AL, Huttunen J, Raustia A, Ylöstalo P, Sipilä K. Efficacy of stabilisation splint treatment on facial pain—1‐year follow‐up. Journal of Oral Rehabilitation. 2015; 42: 439–446.

[39 Cavalcanti MFXB, Silva UH, Leal-Junior ECP, Lopes-Martins RAB, Marcos RL, Pallotta RC, et al. Comparative study of the physiotherapeutic and drug protocol and low-level laser irradiation in the treatment of pain associated with temporomandibular dysfunction. Photomedicine and Laser Surgery. 2016; 34: 652–656.

[40] Machado BCZ, Mazzetto MO, Da Silva MAMR, de Felício CM. Effects of oral motor exercises and laser therapy on chronic temporomandibular disorders: a randomized study with follow-up. Lasers in Medical Science. 2016; 31: 945–954.

[41] Patil SR, Aileni KR. Effect of transcutaneous electrical nerve stimulation versus home exercise programme in management of temporomandibular joint disorder. Journal of Clinical and Diagnostic Research. 2017; 11: ZC19–ZC22.

[42] Corum M, Basoglu C, Topaloglu M, Dıracoglu D, Aksoy C. Spinal high-velocity low-amplitude manipulation with exercise in women with chronic temporomandibular disorders. Manuelle Medizin. 2018; 56: 230–238.

[43] Nagata K, Hori S, Mizuhashi R, Yokoe T, Atsumi Y, Nagai W, et al. Efficacy of mandibular manipulation technique for temporomandibular disorders patients with mouth opening limitation: a randomized controlled trial for comparison with improved multimodal therapy. Journal of Prosthodontic Research. 2019; 63: 202–209.

[44 Brandão RDAFS, Mendes CMC, Brandão Filho RA, De Sena EP. Isotonic exercises and relaxing techniques in individuals with temporomandibular dysfunction. CRANIO®. 2022; 40: 199–206.

[45] Delgado de la Serna P, Plaza-Manzano G, Cleland J, Fernández-de-las-Peñas C, Martín-Casas P, Díaz-Arribas MJ. Effects of cervico-mandibular manual therapy in patients with temporomandibular pain disorders and associated somatic tinnitus: a randomized clinical trial. Pain Medicine. 2020; 21: 613–624.

[46] Melo RA, de Resende CMBM, Rêgo CRDF, Bispo ADSL, Barbosa GAS, de Almeida EO. Conservative therapies to treat pain and anxiety associated with temporomandibular disorders: a randomized clinical trial. International Dental Journal. 2020; 70: 245–253.

[47] 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 randomised clinical trial. Journal of Oral Rehabilitation. 2020; 47: 143–149.

[48] de Resende CMBM, de Oliveira Medeiros FGL, de Figueiredo Rêgo CR, Bispo ADSL, Barbosa GAS, de Almeida EO. Short-term effectiveness of conservative therapies in pain, quality of life, and sleep in patients with temporomandibular disorders: a randomized clinical trial. CRANIO®. 2021; 39: 335–343.

[49] Peixoto KO, da Silva Bezerra A, Melo RA, de Resende CMBM, de Almeida EO, Barbosa GAS. Short-term effect of scalp acupuncture on pain, sleep disorders, and quality of life in patients with temporomandibular disorders: a a randomized clinical trial. Pain Medicine. 2021; 22: 905–914.

[50] Ram H, Shah D. Comparative evaluation of occlusal splint therapy and muscle energy technique in the management of temporomandibular disorders: a randomized controlled clinical trial. The Journal of Indian Prosthodontic Society. 2021; 21: 356.

[51] Gikić M, Vrbanović E, Zlendić M, Alajbeg IZ. Treatment responses in chronic temporomandibular patients depending on the treatment modalities and frequency of parafunctional behaviour. Journal of Oral Rehabilitation. 2021; 48: 785–797.

[52] Olbort C, Pfanne F, Schwahn C, Bernhardt O. Training of the lateral pterygoid muscle in the treatment of temporomandibular joint disc displacement with reduction: a randomized clinical trial. Journal of oral rehabilitation. 2023; 50: 921–930.

[53] Fouda AAH. No evidence on the effectiveness of oral splints for the management of temporomandibular joint dysfunction pain in both short and long-term follow-up systematic reviews and meta-analysis studies. Journal of the Korean Association of Oral and Maxillofacial Surgeons. 2020; 46: 87–98.

[54] Zhang L, Xu L, Wu D, Yu C, Fan S, Cai B. Effectiveness of exercise therapy versus occlusal splint therapy for the treatment of painful temporomandibular disorders: a systematic review and meta-analysis. Annals of Palliative Medicine. 2021; 10: 6122–6132.

[55] Fernández-de-Las-Peñas C, Von Piekartz H. Clinical reasoning for the examination and physical therapy treatment of temporomandibular disorders (TMD): a narrative literature review. Journal of Clinical Medicine. 2020; 9: 3686.

[56] Nicolakis P, Erdogmus B, Kopf A, Djaber-Ansari A, Piehslinger E, Fialka-Moser V. Exercise therapy for craniomandibular disorders. Archives of Physical Medicine and Rehabilitation. 2000; 81: 1137–1142.

[57] Schmitter M, Zahran M, Duc JP, Henschel V, Rammelsberg P. Conservative therapy in patients with anterior disc displacement without reduction using 2 common splints: a randomized clinical trial. Journal of Oral and Maxillofacial Surgery. 2005; 63: 1295–1303.

[58] Dao TT, Lavigne G. Oral splints: the crutches for temporomandibular disorders and bruxism? Critical Reviews in Oral Biology & Medicine. 1998; 9: 345–361.

[59] Chen Y, Abel KT, Janecek JT, Chen Y, Zheng K, Cramer SC. Home-based technologies for stroke rehabilitation: a systematic review. International Journal of Medical Informatics. 2019; 123: 11–22.

[60] Kok B, McNeely M, Watt M, Tandon P. Exercise only works if you do it! The Holy grail of adherence. American Journal of Gastroenterology. 2021; 116: 673–674.

[61] Williams FR, Vallance A, Faulkner T, Towey J, Durman S, Kyte D, et al. Home‐based exercise in patients awaiting liver transplantation: a feasibility study. Liver Transplantation. 2019; 25: 995–1006.

[62] Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Manual Therapy. 2009; 14: 531–538.

[63] 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. Physical Therapy. 2016; 96: 9–25.

[64] Fernández-de-las Peñas C, Ortega-Santiago R, de la Llave-Rincón AI, Martínez-Perez A, Fahandezh-Saddi Díaz H, Martínez-Martín J, et al. Manual physical therapy versus surgery for carpal tunnel syndrome: a randomized parallel-group trial. The Journal of Pain. 2015; 16: 1087–1094.

[65] Dunning J, Rushton A. The effects of cervical high-velocity low-amplitude thrust manipulation on resting electromyographic activity of the biceps brachii muscle. Manual Therapy. 2009; 14: 508–513.

[66] Reid KJ, Baron KG, Lu B, Naylor E, Wolfe L, Zee PC. Aerobic exercise improves self-reported sleep and quality of life in older adults with insomnia. Sleep Medicine. 2010; 11: 934–940.

[67] Hofmann SG, Curtiss J, Carpenter JK, Kind S. Effect of treatments for depression on quality of life: a meta-analysis. Cognitive Behaviour Therapy. 2017; 46: 265–286.

[68] Ren C, McGrath C, Jin L, Zhang C, Yang Y. The effectiveness of low‐level laser therapy as an adjunct to non‐surgical periodontal treatment: a meta-analysis. Journal of Periodontal Research. 2017; 52: 8–20.

[69] Essery R, Geraghty AWA, Kirby S, Yardley L. Predictors of adherence to home-based physical therapies: a systematic review. Disability and Rehabilitation. 2017; 39: 519–534.

[70] Christiansen DH, Hjort J. Group-based exercise, individually supervised exercise and home-based exercise have similar clinical effects and cost-effectiveness in people with subacromial pain: a randomised trial. Journal of Physiotherapy. 2021; 67: 124–131.