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History of and Examination for Temporomandibular Disorders Diagnosis of Temporomandibular Disorders. General Considerations in the Treatment of Temporomandibular Disorders Treatment of Masticatory Muscle Disorders Treatment of Temporomandibular Joint Disorders Occlusal Appliance Therapy Treatment Sequencing and Diagnostic Algorithms. Part IV: Occlusal Therapy General Considerations in Occlusal Therapy Use of Articulators in Occlusal Therapy Selective Grinding Restorative Considerations in Occlusal Therapy.

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Manual of Temporomandibular Disorders

Authors: Jeffrey Okeson. Hardcover ISBN: Imprint: Mosby. Manual therapy including joint mobilization, manipulation, or treatment of the soft tissues and therapeutic exercises in physical therapy treatments have been increasingly used by clinicians and researched due to positive outcomes in some conditions, especially for low back pain, neck pain, and related disorders.

In the area of orofacial pain, several systematic reviews have been conducted regarding physical therapy and specifically MT and exercise interventions for TMD.

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However, 2 reviews 19 , 23 were conducted 9 years previously and included few randomized controlled trials RCTs. Research has expanded over the last few years, and new RCTs have been conducted, which implies that the information from earliest reviews is now outdated. Another recent systematic review 25 combined pathologies of the upper extremity and TMD.

That review included several types of designs and did not focus on RCTs, which are the best evidence when looking at interventions. In addition, based on a preliminary search performed by our team, it was realized that this review missed important RCTs in the area included only 5 studies. In addition, none of these systematic reviews provided a meta-analysis of the trials.

Therefore, the objectives of this systematic review were: 1 to summarize the evidence from and evaluate the methodological quality of RCTs that examined the effectiveness of MT and therapeutic exercise interventions in the management of TMD and 2 to determine the magnitude of the effect of these interventions to manage TMD.

It consists of a item checklist and 4-phase flow diagram. This review targeted RCTs comparing any type of MT intervention eg, mobilization, manipulation, soft tissue mobilization or exercise therapy alone or in combination with other therapies with a placebo intervention, controlled comparison intervention, or standard care ie, treatment that normally is offered. The primary outcomes of interest for this systematic review were pain, ROM, and oral function.

Oral function for this systematic review focused on limitations of daily activities of patients with TMD measured through different questionnaires. A secondary outcome of interest was pressure pain threshold PPT. The minimal clinically important difference for pain has been reported to range from 1. Key words and medical subject headings were identified with the assistance of a librarian who specialized in health science databases and experts in the orofacial pain field.

No restrictions were made regarding the language of publication. Two independent investigators screened the titles of publications found in the databases and, if available, the abstract of the publication. In order for papers to be included in the review, the paper had to meet all inclusion criteria of this systematic review on the rating form created in EROS software.

Studies were analyzed with the available information. Authors were not contacted.

Temporomandibular Disorders

Disagreements between reviewers on inclusion were resolved by consensus. Criteria proposed by Byrt 41 were used to interpret kappa values. The information of each study included in this review was extracted and entered into Excel or Microsoft Word Microsoft Corp, Redmond, Washington files. For each part of the review, data extraction was carried out independently by 2 reviewers.

Data were extracted on study characteristics, including the design, type of TMD, type of interventions, main and secondary outcomes, and treatment estimates. Any disagreements on data extraction were resolved by consensus. Assessments of quality risk of bias were completed by 2 independent reviewers any 2 members of the research team.

For the assessment of RCTs, our team used a compiled set of items based on the 7 tools most commonly used to evaluate the risk of bias in complex physical therapy trials. We followed the guidelines established by the Cochrane Collaboration to perform assessments of risk of bias; however, we developed specific decision rules to make decisions as described elsewhere. Finally, an overall assessment of high risk of bias was considered if at least one domain was rated as high.

These criteria have been used previously by our team and other authors.

Temporomandibular Joint (TMJ) Anatomy and Disc Displacement Animation

Any discrepancies in quality ratings were resolved by discussion. If consensus could not be reached, a third member of the review team with expertise in quality assessments S. Data analysis was performed based on type of intervention ie, exercise, mobilization, and manipulation , TMD diagnosis myogenous TMD, arthrogenous TMD, mixed TMD , and type of outcome eg, pain intensity, range of mouth opening [ROM], oral function oral-related quality of life].

Heterogeneity was evaluated statistically using the I 2 statistic. The MD and SMD were defined according to the Cochrane Collaboration, 45 as follows: MD is a standard statistic that measures the absolute difference between the mean value in 2 groups in a clinical trial. It estimates the amount by which the experimental intervention changes the outcome on average compared with the control. It can be used as a summary statistic in meta-analysis when outcome measurements in all studies are made on the same scale.

The SMD is used as a summary statistic in meta-analysis when the studies assess the same outcome but measure it in a variety of ways ie, use different psychometric scales. In this circumstance, it is necessary to standardize the results of the studies to a uniform scale before they can be combined.


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The standardized mean difference expresses the size of the intervention effect in each study relative to the variability observed in that study. We decided to pool studies based on TMD diagnosis, intervention provided, and outcome. We grouped studies that had the same diagnosis myogenous, arthrogenous, or mixed , similar intervention of interest ie, MT, exercises , and the same underlying outcome.

Thus, we created groups of studies that were similar in terms of these characteristics and pooled them. In the presence of clinical heterogeneity in the study population or intervention, the DerSimonian and Laird random-effects model of pooling was used based on the assumption of the presence of interstudy variability to provide a more conservative estimate of the true effect. Cohen's criteria were used to interpret values of effect sizes found for our pooled estimates.

In order to investigate and accommodate heterogeneity clinical heterogeneity in the study population or intervention as explained above, a random-effects model was used across all the comparisons. Furthermore, in order to explain the heterogeneity in terms of study-level covariates, we could have attempted a meta-regression model.

We attempted to perform sensitivity analyses when possible. We did not perform sensitivity analyses based on quality because the risk of bias of the analyzed studies was either unclear or high, with no study being classified as low risk.

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These factors precluded sensitivity analyses by different levels of biases. Therefore, the pooled data should be interpreted carefully. The funding bodies had no input in the design, collection, analysis, or interpretation of data; writing of the manuscript; or the decision to submit the manuscript for publication. The search of the literature resulted in a total of 3, published articles.

Of the 3, published articles, were considered to be potentially relevant. Independent review in duplicate of these articles led to the inclusion of 58 articles representing 50 studies some studies reported data from the same population in 2 manuscripts. There were 5 articles in other languages 50 — 54 that were not possible to translate by our study team and were not included in the final analysis.

Thus, 45 studies were included for this review from the search of the databases.


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  • In addition, 3 studies 55 — 57 were obtained through a manual search. Therefore, a total of 48 studies were included in the final analysis Fig. According to Byrt's criteria, 41 the agreement between reviewers was excellent. Details of included studies are provided in eTable 1 available at ptjournal. There was considerable diversity in the clinical presentations and diagnoses of participants with TMD among the included studies eTab.

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    The remaining 27 studies used their own diagnostic criteria, based on signs and symptoms of the patients. The results of the critical appraisal of the selected studies are presented in eTable 2 available at ptjournal. For example, study flaws regarding patient selection were mainly related to description and appropriateness of the randomization procedure and concealment of allocation, with only 20 As expected, items related to blinding were not achieved by the majority of the studies.

    Only 3 of the studies used a double-blinded design and could blind participants. These studies used a placebo arm, which is hard to obtain in these types of interventions. Thus, blinding was the area that was the hardest section to be met by the analyzed studies. When analyzing issues regarding intervention, we found that although it is expected that interventions would be well described to be reproducible, only In addition, most studies failed to control for cointerventions. Only 6 studies met this item. Testing participants' adherence to intervention and having adequate adherence was another issue that was not met by many studies only 11 and 7 studies, respectively.

    Furthermore, adverse effects were reported on only 10 of the studies, but there was no specific description of such events when they occurred in all of the studies. Despite the fact that the adequate handling of dropouts is considered an important method used to prevent bias in data analysis, only 17 of the analyzed studies included information regarding the reasons of withdrawals and dropouts, and only 16 studies used intention-to-treat analysis.

    asasconi.tk The outcome measures were not described well in terms of validity, reliability, or responsiveness. Only a few studies reported these items 11, 17, and 3 studies, respectively. Moreover, the authors did not report intrarater or interrater reliability of the assessors who performed outcome measurements. Regarding statistical issues, it was uncertain if sample size was adequate in 30 of the studies, and only 18 studies reported an evaluation of the clinical significance of their results.

    Risk of bias assessments using the risk of bias tool determined that none of the studies was considered as low risk of bias.

    Most of them were classified as either unclear Two studies 59 , 60 evaluated the effectiveness of posture correction exercises for patients with myofascial pain. Both studies showed positive results of postural exercises for improving symptoms of muscular TMD. When pooling the data for these 2 studies, which had similar interventions, diagnoses, and outcomes, maximum pain-free mouth opening significantly increased in patients receiving postural training compared with a control group. The MD in maximum pain-free mouth opening was 5.

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    The SMD in symptoms and disturbance of symptoms with daily life was 1. Maximum pain-free opening: postural training versus control group in patients with myogenous temporomandibular disorders. Eight studies 56 — 58 , 62 , 63 , 66 , 79 , 80 looked at the effect of exercises alone or combined with other therapies for myogenous TMD.