Prevention of temporomandibular disorder-related signs and symptoms in orthodontically treated adolescents. A 3-year follow-up of a prospective randomized trial

Systematic review versus structured critical analysis

Objective: This analysis discusses common problems with systematic reviews (SRs) and presents a novel solution, the structured critical analysis (SCA) that can be incorporated into a SR or used as an alternative literature review design.Methods: A cross-sectional survey of current SRs related to interdisciplinary restorative dentistry was obtained by evaluating 100 current SRs for their self-reported methodological quality and its effect on scientific validity.Results: The preferred reporting items for systematic reviews and meta-analyses protocol (PRISMA) was used in 99/100 SRs, but only 8/100 reported a low risk of bias. High statistical heterogeneity precluding meta-analysis was found in 44/100 SRs. Only 94 paragraphs/100 SRs provided critical analysis.Discussion: Significant problems were found with current SRs that can compromise their reliability as the premier level of evidence for clinical science research. The reader must be aware of these deficiencies to correctly interpret the SR and cannot rely on the format alone.

Evaluation of Pain Syndromes, Headache, and Temporomandibular Joint Disorders in Children

After a thorough review of the history and presentation of a child's facial pain, a targeted head and neck examination is critical to the appropriate diagnosis of facial pain and temporomandibular joint disorders. It is critical to distinguish between the structural (trauma, degenerative disease, and tumor) and nonstructural (neurogenic, myogenic, and psychological) causes of pain, which will allow for incorporation of appropriate strategies of medical, psychological, dental, and surgical therapies.

Temporomandibular Disorders: "Occlusion" Matters!

By analogy with the journal's title Pain Research and Management, this review describes TMD Research and Management. More specific are the (1) research aspects of “occlusion,” still one of the most controversial topics in TMD, and (2) as much as possible evidence-based management aspects of “TMD” for the dental practitioner. Research. The disorders temporomandibular dysfunction and the synonymous craniomandibular dysfunction are still being discussed intensely in the literature. Traditionally, attention is mostly devoted to occlusion and its relationship with these disorders. The conclusions reached are often contradictory. Considering the definitions of temporomandibular and craniomandibular dysfunctions/disorders and “occlusion,” a possible explanation for this controversy can be found in the subsequent methodological problems of the studies. Based on a Medline search of these terms over the past 40 years related to contemporary terms such as “Evidence Based Dentistry” and “Pyramid of Evidence,” these methodological aspects are examined, resulting in recommendations for future research and TMD-occlusal therapy. Management. To assist the dental practitioner in his/her daily routine to meet the modern standards of best practice, 7 guidelines are formulated that are explained and accompanied with clinical examples for an evidence-based treatment of patients with this disorder in general dental practices.

WITHDRAWN: Occlusal adjustment for treating and preventing temporomandibular joint disorders

The Cochrane Oral Health Group withdrew this review as of Issue 1, 2016. The review is out of date and does not meet current Cochrane methodological standards. It will be superseded by a new Cochrane review on Occlusal interventions for managing temporomandibular disorders.

The editorial group responsible for this previously published document have withdrawn it from publication.

TMD in Relation to Malocclusion and Orthodontic Treatment

OBJECTIVE

The aim of this systematic literature review was to evaluate associations between different malocclusions, orthodontic treatment, and signs and symptoms of temporomandibular disorders (TMD).

MATERIALS AND METHODS

This review was part of a project at the Swedish Council on Technology Assessment in Health Care focusing on malocclusion and orthodontic treatment from a health perspective. As a first step, the literature was searched in the Medline and Cochrane Library databases from 1966 to May 2003. A later update was made in January 2005. Human studies in English or in Scandinavian languages were included.

RESULTS

Associations between certain malocclusions and TMD were found in some studies, whereas the majority of the reviewed articles failed to identify significant and clinically important associations. TMD could not be correlated to any specific type of malocclusion, and there was no support for the belief that orthodontic treatment may cause TMD. Obvious individual variations in signs and symptoms of TMD over time according to some longitudinal studies further emphasized the difficulty in establishing malocclusion as a significant risk factor for TMD. A considerable reduction in signs and symptoms of TMD between the teenage period and young adulthood has been shown in some recent longitudinal studies.

CONCLUSIONS

Associations between specific types of malocclusions and development of significant signs and symptoms of TMD could not be verified. There is still a need for longitudinal studies.

Occlusal Risk Factors for Temporomandibular Disorders

OBJECTIVE

To determine the role of occlusal variables (overbite; overjet; number of anterior and posterior teeth; bilateral canine guidance on lateral and protrusive movements; anterior centric slide; Angle Classes I, II, and III malocclusion) as risk indicators for the development of temporomandibular disorders (TMDs).

MATERIALS AND METHODS

Seventy-two TMD patients with myofascial pain, with or without limited opening and arthralgia, as well as 30 age- and gender-matched pain-free concurrent controls were included. The association (critical odds ratio [OR] = 2.0) between the significant occlusal variables and TMD was calculated. Confounders were controlled in the inclusion-exclusion criteria as well as in the analysis stage (unconditional logistic regression) by variation in the OR (15%).

RESULTS

Angle Class II malocclusion (crude OR = 8.0, confidence interval [CI] = 2.2 to 29.3) and the absence of bilateral canine guidance on lateral excursion (crude OR = 3.9, CI = 1.6 to 9.7) were statistically more common in patients than in controls. Spontaneous pain as well as pain on palpation (Class II or higher) were also statistically worse in TMD patients. Significant confounders (ie, employment, age, cigarette and alcohol consumption) acted as effect modifiers not changing the critical OR (adjusted OR Angle Class II and bilateral canine guidance = 8.3 to 12.4 and 2.2 to 4.1, respectively).

CONCLUSIONS

Absence of bilateral canine guidance on lateral excursion and particularly Angle Class II malocclusion were considered important risk indicators for the development of TMD in this investigation, even when some sociodemographic factors were considered as effect modifiers.

TMD and occlusion part II. Damned if we don't? Functional occlusal problems: TMD epidemiology in a wider context

OBJECTIVES

To review studies investigating how functional occlusion may relate to TMD and how bruxism may relate to TMD; to review the epidemiology of TMD and relate this to the context of clinical occlusal studies and other aetiological factors. Deficiencies in study design are highlighted and suggestions made to improve future study designs in order to provide an evidence-base for clinical practice.

DESIGN

Review article.

METHODS

Electronic databases (MEDLINE and the Cochrane Database of Systematic Reviews) were used to select relevant and frequently cited studies (mean: 40 citations). Citation rate was confirmed using the Web of Science. Study designs are reviewed and weaknesses and implications discussed.

RESULTS

Evidence is lacking to suggest functional occlusal factors cause TMD. Investigation of other aetiological factors has been relatively neglected.

CONCLUSIONS

Neither static nor dynamic occlusal factors (including orthodontics) can be said to 'cause' TMD. However, other potential aetiological factors exist which would benefit from more investigation. This, together with improved study designs, would help provide a stronger evidence-base for clinical practice in the future.

Occlusal adjustment for treating and preventing temporomandibular joint disorders

To assess the effectiveness of occlusal adjustment (OA) for treating temporomandibular disorders (TMD) in adults and preventing TMD. The Cochrane Controlled Trials Register, MEDLINE and EMBASE were comprehensively searched using the Cochrane methods. Reports and review articles were retrieved. Unpublished reports or abstracts were considered from the SIGLE database. All randomized or quasi-randomized controlled trials comparing OA with placebo, reassurance or no treatment in adults with TMD. The outcomes were global measures of symptoms, pain, headache and limitation of movement. Data collection and analysis followed the Cochrane Oral Health Group's statistical guidelines. Results showed no difference between OA and control group in symptom-based outcomes for treatment or incidence of symptoms for prevention. There is no evidence that OA treats or prevents TMD. OA cannot be recommended for the management or prevention of TMD. Future trials should use standardized diagnostic criteria and outcome measures when evaluating TMD.

Occlusal adjustment for treating and preventing temporomandibular joint disorders

BACKGROUND

There has been a long history of using occlusal adjustment in the management of temporomandibular disorders (TMD). It is not clear if occlusal adjustment is effective in treating TMD.

OBJECTIVES

To assess the effectiveness of occlusal adjustment for treating TMD in adults and preventing TMD.

SEARCH STRATEGY

We searched the Cochrane Oral Health Group's Trials Register (April 2002); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2002); MEDLINE (1966 to 8th April 2002); EMBASE (1980 to 8th April 2002) and handsearched journals of particular importance to this review. Additional reports were identified from the reference lists of retrieved reports and from review articles of treating TMD. There were no language restrictions. Unpublished reports or abstracts were considered from the SIGLE database.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials (RCTs) comparing occlusal adjustment to placebo, reassurance or no treatment in adults with TMD. The outcomes were global measures of symptoms, pain, headache and limitation of movement.

DATA COLLECTION AND ANALYSIS

Data were independently extracted, in duplicate, by two reviewers, Holy Koh (HK) and Peter G Robinson (PR). Authors were contacted for details of randomisation and withdrawals and a quality assessment was carried out. The Cochrane Oral Health Group's statistical guidelines were followed and relative risk values calculated using random effects models where significant heterogeneity was detected (P<0.1).

MAIN RESULTS

Over 660 trials were identified by the initial search. Six of these trials, which reported results from a total of 392 patients, were suitable for inclusion in the review. From the data provided in the published reports, symptom-based outcomes were extracted from trials on treatment. Data on incidence of symptoms were extracted from trials on prevention. Neither showed any difference between occlusal adjustment and control group.

REVIEWER'S CONCLUSIONS

There is an absence of evidence, from RCTs, that occlusal adjustment treats or prevents TMD. Occlusal adjustment cannot be recommended for the management or prevention of TMD. Future trials should use standardised diagnostic criteria and outcome measures when evaluating TMD.

Analysis of occlusal variables, dental attrition, and age for distinguishing healthy controls from female patients with intracapsular temporomandibular disorders

STATEMENT OF PROBLEM

Confusion about the relationship of occlusion to temporomandibular disorders (TMD) persists.

PURPOSE

This study attempted to identify occlusal and attrition factors plus age that would characterize asymptomatic normal female subjects.

METHODS AND MATERIAL

A total of 124 female patients with intracapsular TMD were compared with 47 asymptomatic female controls for associations to 9 occlusal factors, 3 attrition severity measures, and age using classification tree, multiple stepwise logistic regression, and univariate analyses. Models were tested for accuracy (sensitivity and specificity) and total contribution to the variance.

RESULTS

The classification tree model had 4 terminal nodes that used only anterior attrition and age. "Normals" were mainly characterized by low attrition levels, whereas patients had higher attrition and tended to be younger. The tree model was only moderately useful (sensitivity 63%, specificity 94%) in predicting normals. The logistic regression model incorporated unilateral posterior crossbite and mediotrusive attrition severity in addition to the 2 factors in the tree, but was slightly less accurate than the tree (sensitivity 51%, specificity 90%). When only occlusal factors were considered in the analysis, normals were additionally characterized by a lack of anterior open bite, smaller overjet, and smaller RCP-ICP slides. The log likelihood accounted for was similar for both the tree (pseudo R(2) = 29.38%; mean deviance = 0.95) and the multiple logistic regression (Cox Snell R(2) = 30.3%, mean deviance = 0.84) models.

CONCLUSION

The occlusal and attrition factors studied were only moderately useful in differentiating normals from TMD patients.