The provision of occlusal splints in primary dental care

Oral splints for patients with temporomandibular disorders or bruxism: a systematic review and economic evaluation

BACKGROUND

Splints are a non-invasive, reversible management option for temporomandibular disorders or bruxism. The clinical effectiveness and cost-effectiveness of splints remain uncertain.

OBJECTIVES

The objectives were to evaluate the clinical effectiveness and cost-effectiveness of splints for patients with temporomandibular disorders or bruxism. This evidence synthesis compared (1) all types of splint versus no/minimal treatment/control splints and (2) prefabricated versus custom-made splints, for the primary outcomes, which were pain (temporomandibular disorders) and tooth wear (bruxism).

REVIEW METHODS

Four databases, including MEDLINE and EMBASE, were searched from inception until 1 October 2018 for randomised clinical trials. The searches were conducted on 1 October 2018. Cochrane review methods (including risk of bias) were used for the systematic review. Standardised mean differences were pooled for the primary outcome of pain, using random-effects models in temporomandibular disorder patients. A Markov cohort, state-transition model, populated using current pain and Characteristic Pain Intensity data, was used to estimate the incremental cost-effectiveness ratio for splints compared with no splint, from an NHS perspective over a lifetime horizon. A value-of-information analysis identified future research priorities.

RESULTS

Fifty-two trials were included in the systematic review. The evidence identified was of very low quality with unclear reporting by temporomandibular disorder subtype. When all subtypes were pooled into one global temporomandibular disorder group, there was no evidence that splints reduced pain [standardised mean difference (at up to 3 months) -0.18, 95% confidence interval -0.42 to 0.06; substantial heterogeneity] when compared with no splints or a minimal intervention. There was no evidence that other outcomes, including temporomandibular joint noises, decreased mouth-opening, and quality of life, improved when using splints. Adverse events were generally not reported, but seemed infrequent when reported. The most plausible base-case incremental cost-effectiveness ratio was uncertain and driven by the lack of clinical effectiveness evidence. The cost-effectiveness acceptability curve showed splints becoming more cost-effective at a willingness-to-pay threshold of ≈£6000, but the probability never exceeded 60% at higher levels of willingness to pay. Results were sensitive to longer-term extrapolation assumptions. A value-of-information analysis indicated that further research is required. There were no studies measuring tooth wear in patients with bruxism. One small study looked at pain and found a reduction in the splint group [mean difference (0-10 scale) -2.01, 95% CI -1.40 to -2.62; very low-quality evidence]. As there was no evidence of a difference between splints and no splints, the second objective became irrelevant.

LIMITATIONS

There was a large variation in the diagnostic criteria, splint types and outcome measures used and reported. Sensitivity analyses based on these limitations did not indicate a reduction in pain.

CONCLUSIONS

The very low-quality evidence identified did not demonstrate that splints reduced pain in temporomandibular disorders as a group of conditions. There is insufficient evidence to determine whether or not splints reduce tooth wear in patients with bruxism. There remains substantial uncertainty surrounding the most plausible incremental cost-effectiveness ratio.

FUTURE WORK

There is a need for well-conducted trials to determine the clinical effectiveness and cost-effectiveness of splints in patients with carefully diagnosed and subtyped temporomandibular disorders, and patients with bruxism, using agreed measures of pain and tooth wear.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017068512.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 7. See the NIHR Journals Library website for further project information.

Effect of thermocycling on the shear bond strength of different resins bonded to thermoplastic foil applied in occlusal splint therapy

PURPOSE

Temporomandibular disorders are a group of symptoms related to the impaired function of the temporomandibular joints and associated muscles. Occlusal splint therapy is a common treatment in the aforementioned syndrome. One of the methods of manufacturing occlusal splints is to place a polymer on thermoplastic foil. The aim of this study was to evaluate the shear bond strength of light- and self-cured resins bonded to thermoplastic foil dependent on artificial aging.

MATERIALS AND METHODS

Thirty cylinders composed of light-cured resin and 30 cylinders made of self-cured resin were attached to 60 rectangular thermoplastic plates. All specimens were divided into six groups. A control study was conducted for groups 1 and 2. The other preparation groups were subjected to thermocycling by setting appropriately 1000 cycles for groups 3 and 4 and 3000 cycles for groups 5 and 6 in distilled water. Bond strength was measured in a universal testing machine. The results were subjected to statistical analysis using the Mann-Whitney U test (p ≤ 0.05).

RESULTS

The statistics revealed that the values of the shear bond strength for specimens composed of self-cured resin after 1000 and 3000 thermocycles were significantly higher than on those made of light-cured resin (p = 0.003 and p = 0.002).

CONCLUSION

The shear bond strength between the self-cured resin and the thermoplastic foil was higher and more resistant to aging than the shear bond strength between the light-cured resin and the thermoplastic foil.

Weight Loss and Medication in Polycystic Ovary Syndrome Therapy

Polycystic ovary syndrome, which is a complex syndrome, affects approximately 6% of reproductive-age women. Many abnormalities are associated with polycystic ovary syndrome, but confusion still exists about their causation. Diagnosis of polycystic ovary syndrome is by exclusion. Management of the metabolic aspects of polycystic ovary syndrome focuses on minimizing insulin resistance and hyperinsulinemia with diet therapy or insulin-lowering drugs.