A clinical practice guideline for temporomandibular disorders in traditional Korean medicine: An evidence-based approach

Effectiveness and safety of hominis placental pharmacopuncture for chronic temporomandibular disorder: A multi-center randomized controlled trial

Background

Hominis placental (HPP) extract has been approved by the Ministry of Food and Drug Safety in Korea for treating chronic liver diseases and postmenopausal syndrome. However, its efficacy and safety for treating chronic temporomandibular disorder (TMD) remains unclear. We aimed to assess the effectiveness and safety of HPP for treating chronic TMD compared with physical therapy (PT).

Methods

This study is a 2-arm parallel, multi-center, randomized controlled trial. We enrolled 82 chronic TMD patients from 2 Korean medicine hospitals between December 2019 and January 2021. We included patients with chronic TMD and randomly assigned them to undergo HPP or PT. The primary outcome was the difference in the scores for temporomandibular joint (TMJ) pain at baseline and week 6. The secondary outcomes were the scores for TMJ pain and bothersomeness, TMJ range of motion, the Korean version of Beck's depression index-Ⅱ, jaw functional limitation scale (JFLS) score, patient global impression of change (PGIC) scores, EuroQoL 5-dimension 5-level score, and short form-12 health survey (SF-12) scores.

Results

Compared with PT, HPP showed significantly superior effects on TMJ pain and bothersomeness, protrusive movement pain, JFLS (verbal, emotional, and global), SF-12, and PGIC scores at week 6 (P < 0.05). Compared with the PT group, the HPP group showed a significantly higher recovery rate (≥50 % reduction in the scores for TMJ pain at the 24-week follow-up).

Conclusion

HPP was more effective than PT managing pain and improving function and quality of life. Our findings demonstrate the effectiveness and safety of HPP for TMD treatment.

Trial registration

This study has been registered at clinicalTrials.gov (NCT04087005), Clinical Research Information Service (CRIS) (KCT0004437), and Ministry of Food and Drug Safety (No. 31886).

Management of chronic pain associated with temporomandibular disorders: a clinical practice guideline

CLINICAL QUESTION

What is the comparative effectiveness of available therapies for chronic pain associated with temporomandibular disorders (TMD)?

CURRENT PRACTICE

TMD are the second most common musculoskeletal chronic pain disorder after low back pain, affecting 6-9% of adults globally. TMD are associated with pain affecting the jaw and associated structures and may present with headaches, earache, clicking, popping, or crackling sounds in the temporomandibular joint, and impaired mandibular function. Current clinical practice guidelines are largely consensus-based and provide inconsistent recommendations.

RECOMMENDATIONS

For patients living with chronic pain (≥3 months) associated with TMD, and compared with placebo or sham procedures, the guideline panel issued: (1) strong recommendations in favour of cognitive behavioural therapy (CBT) with or without biofeedback or relaxation therapy, therapist-assisted mobilisation, manual trigger point therapy, supervised postural exercise, supervised jaw exercise and stretching with or without manual trigger point therapy, and usual care (such as home exercises, stretching, reassurance, and education); (2) conditional recommendations in favour of manipulation, supervised jaw exercise with mobilisation, CBT with non-steroidal anti-inflammatory drugs (NSAIDS), manipulation with postural exercise, and acupuncture; (3) conditional recommendations against reversible occlusal splints (alone or in combination with other interventions), arthrocentesis (alone or in combination with other interventions), cartilage supplement with or without hyaluronic acid injection, low level laser therapy (alone or in combination with other interventions), transcutaneous electrical nerve stimulation, gabapentin, botulinum toxin injection, hyaluronic acid injection, relaxation therapy, trigger point injection, acetaminophen (with or without muscle relaxants or NSAIDS), topical capsaicin, biofeedback, corticosteroid injection (with or without NSAIDS), benzodiazepines, and β blockers; and (4) strong recommendations against irreversible oral splints, discectomy, and NSAIDS with opioids.

HOW THIS GUIDELINE WAS CREATED

An international guideline development panel including patients, clinicians with content expertise, and methodologists produced these recommendations in adherence with standards for trustworthy guidelines using the GRADE approach. The MAGIC Evidence Ecosystem Foundation (MAGIC) provided methodological support. The panel approached the formulation of recommendations from the perspective of patients, rather than a population or health system perspective.

THE EVIDENCE

Recommendations are informed by a linked systematic review and network meta-analysis summarising the current body of evidence for benefits and harms of conservative, pharmacologic, and invasive interventions for chronic pain secondary to TMD.

UNDERSTANDING THE RECOMMENDATION

These recommendations apply to patients living with chronic pain (≥3 months duration) associated with TMD as a group of conditions, and do not apply to the management of acute TMD pain. When considering management options, clinicians and patients should first consider strongly recommended interventions, then those conditionally recommended in favour, then conditionally against. In doing so, shared decision making is essential to ensure patients make choices that reflect their values and preference, availability of interventions, and what they may have already tried. Further research is warranted and may alter recommendations in the future.

Korean Medicine Clinical Practice Guideline Update for Temporomandibular Disorders: An Evidence-Based Approach

Many updated clinical research results have been published since the Korean Medicine Clinical Practice Guidelines (KMCPGs) for temporomandibular disorders (TMDs) were published in 2018. Therefore, it is necessary to update the existing clinical practice guidelines (CPGs). This study presents updated recommendations for TMD treatment based on current research data published up to February 2020. The draft version of the level of evidence and grade of recommendation was determined through an assessment of the risk of bias and a meta-analysis of selected literature based on the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). The final guidelines were derived using the Delphi method. Eighteen recommendations were derived for eight items of Korean medicine treatment for TMDs. Compared with previous Korean medicine CPGs for TMDs, the grades of seven recommendations, including acupuncture, pharmacopuncture, and Chuna manual therapy, were increased. The grades of the two recommendations have been changed. Six new recommendations were added to fully reflect clinical reality. Acupuncture, pharmacopuncture, and Chuna manual therapy are recommended for TMD patients in clinical practice. Concurrent conventional conservative therapy with Korean medicine or a combination of Korean medicines should be considered in clinical practice in patients with temporomandibular disorders.

Quality appraisal of clinical practice guidelines for temporomandibular joint disorders using the AGREE II instrument

OBJECTIVE

We sought to systematically assess the quality of all clinical practice guidelines (CPGs) describing diagnosis and management of temporomandibular joint disorders (TMDs) using the Appraisal of Guidelines for Research and Evaluation instrument.

STUDY DESIGN

CPGs detailing all aspects of diagnosis and management (both conservative and nonconservative) for TMDs were reviewed.

RESULTS

Thirteen guidelines met inclusion criteria. The highest-scoring domain across guidelines was clarity of presentation (68.3%); the lowest-scoring domain was editorial independence (31.9%). The highest-scoring guideline described traditional Korean medicine approaches to the management of TMDs, earning a mean score of 79.2% across the six quality domains. Only three CPGs met a quality threshold of >60% in at least five domains, qualifying as 'high' per the Appraisal of Guidelines for Research and Evaluation criteria: these guidelines were the Korean medicine guidelines, Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) guidelines for diagnostic classification of TMDs, and the Japanese Society for the Temporomandibular Joint guidelines. An average intraclass correlation coefficient of 0.79 was calculated across all domains, denoting very strong agreement between independent reviewers.

CONCLUSION

We identified a significant lack of quality in multiple areas of CPG development for the diagnosis and therapeutic management of TMDs, suggesting a need for new comprehensive and rigorously developed guidelines addressing TMDs.

Management of temporomandibular disorders: a rapid review of systematic reviews and guidelines

Temporomandibular disorders (TMD) impact a significant proportion of the population. Given the range of management strategies, contemporary care should be evidence-informed for different TMD types. A knowledge-to-action rapid review of systematic reviews published in the past 5 years and guidelines published in the past 10 years concerning the management of TMD was conducted. The Cochrane, Embase, MEDLINE, PEDro, and PubMed databases were searched. A qualitative data analysis was undertaken, with quality assessment completed using the AMSTAR 2 checklist. In total, 62 systematic reviews and nine guidelines considering a range of treatment modalities were included. In concordance with current guidelines, moderate evidence supports a multi-modal conservative approach towards initial management. Contrary to existing guidelines, occlusal splint therapy is not recommended due to a lack of supporting evidence. The evidence surrounding oral and topical pharmacotherapeutics for chronic TMD is low, whilst the evidence supporting injected pharmacotherapeutics is low to moderate. In concordance with current guidelines, moderate quality evidence supports the use of arthrocentesis or arthroscopy for arthrogenous TMD insufficiently managed by conservative measures, and open joint surgery for severe arthrogenous disease. Based on this, a management pathway showing escalation of treatment from conservative to invasive is proposed.

A systematic review of clinical practice guidelines for persons with osteoarthritis. A "Best Evidence for Rehabilitation" (be4rehab) paper to develop the WHO's Package of Interventions for Rehabilitation: A systematic review of Clinical Practice Guidelines for persons with osteoarthritis for the identification of best evidence for rehabilitation

AIM

Identifying existing interventions for rehabilitation and related evidence presents a crucial step in developing the World Health Organization's (WHO) Package of Interventions for Rehabilitation. This paper reports the results of a systematic search that aimed to identify clinical practice guidelines (CPGs) relevant to the rehabilitation of people with osteoarthritis and presents the CPG recommendations and the current state of evidence available for the interventions in the CPGs.

METHODS

This paper is part of the "Best Evidence for Rehabilitation" (be4rehab) series, developed according to the methodology presented in the WHO's Package of Interventions for Rehabilitation introductory paper by Rauch et al, published in 2019. It is a systematic review of the existing CPGs on osteoarthritis published between 2009 and 2019. Identified CPGs were screened taking into consideration conflict of interest, the provision of information regarding the strength of recommendation(s), and quality to be selected. Quality of CPGs was assessed using the AGREE II tool.

RESULTS

After title and abstract screening, 51 CPGs were identified. Considering the inclusion/exclusion criteria, 26 CPGs were selected. After checking for quality, comprehensiveness, multi-professionality, and publication date, five CPGs were finally included in the review. The strong recommendations for people with knee and hip osteoarthritis consistently included in all the selected CPGs, sometimes called "core treatments", were patient education, exercise training, and weight reduction if overweight or obese. Generally, recommendations overlap in the CPGs.

CONCLUSION

The systematic search revealed high-quality CPGs on osteoarthritis for the identification of "Best Evidence for Rehabilitation (be4rehab)" regarding interventions for rehabilitation of people with osteoarthritis.

Effects of different energy density low-level laser therapies for temporomandibular joint disorders patients: a systematic review and network meta-analysis of parallel randomized controlled trials

PURPOSE

To compare the effects of different energy density LLLT on TMD patients' pain reduction.

METHODS

Reviewers searched RCTs published in Embase, PubMed and The Cochrane Library before 1 April 2020. Reviewers included parallelRCTs that compared the effects of LLLT with placebo or different energy density LLLT for TMD patients' pain reduction. Reviewers did network meta-analysis and evaluated the quality of evidence using the GRADE process.

RESULTS

From 352 studies, reviewers included 16 RCTs. Immediately after treatment, the d1 laser therapy (energy density ranging from 0 to 10 J/cm²) ranked first. The d1 laser therapy showed more pain reduction than placebo ( MD = 2.49, 95% CI ranging from 1.28 to 3.71). The quality of "d1 vs p" comparison was assessed as "moderate" quality. A month after treatment, the d1 laser therapy also performed better than placebo (MD = 1.69, 95%CI = [-0.78, 4.16]). The quality of secondary outcome was assessed as "low" quality.

CONCLUSIONS

For clinical application, d1 laser therapy (energy density ranging from 0 to 10 J/cm²) is recommended for short-term pain management of TMD patients (moderate quality evidence). A month after treatment, the d1 laser therapy also performed better than placebo and other laser groups but the result didn't reach the point of statistical significance (low quality evidence).

TRIAL REGISTRATION

PROSPERO-CRD42018118313.

Efficacy, safety, and economic assessment of hominis placental pharmacopuncture for chronic temporomandibular disorder: a protocol for a multicentre randomised controlled trial

BACKGROUND

Temporomandibular disorder (TMD) is a condition encompassing clinical symptoms of the temporomandibular joint, masseter muscle, and surrounding structures. Hominis placental pharmacopuncture (HPP), consisting of human placental extract, has been reported as effective for treating chronic musculoskeletal disorders, but a lack of well-designed randomised controlled trial s (RCTs) mean there is insufficient evidence to prove the efficacy of HPP.

METHODS

This study is a two-arm parallel, assessor-blinded, multi-centre, randomised controlled trial. We will enrol 82 chronic TMD patients from rwo Korean Medicine hospitals in Axis 1, Group I according to RDC/TMD diagnostic criteria, and randomly allocate 41 patients each to an HPP group and a physical therapy (PT) group. Treatment will be administered in 10 rounds, after which there will be four follow-up visits 6, 9, 13, and 25 weeks from baseline. The primary end point is 6 weeks after baseline, and the primary outcome is the difference in Visual Analogue Scale (VAS) score for temporomandibular pain between baseline and week 6. Secondary outcomes will be Numeric Rating Scale (NRS) scores for temporomandibular pain and discomfort, temporomandibular joint range of motion, the Korean version of Beck's Depression Index-II (K-BDI-II), Jaw Functional Limitation Scale (JFLS), Patient Global Impression of Change (PGIC) scores, and quality of life. Using data on adverse events and cost-effectiveness in the two groups, we will perform a safety assessment and a cost-effectiveness analysis (economic assessment).

DISCUSSION

This study will assess the efficacy and safety of HPP for chronic TMD compared with PT. This RCT will provide evidence for the efficacy, safety, and economics of HPP.

TRIAL REGISTRATION

clinicaTrials.gov (NCT04087005) / Clinical Research Information Service (CRIS) (KCT0004437) / IRB (JASENG 2017-09-002-002, KHNMCOH 2019-08-002) / Ministry of Food and Drug Safety (No. 31886).

Integrative Korean medicine treatment for temporomandibular joint disorder-induced dysphagia leading to aspiration pneumonia: A case report (CARE-compliant)

INTRODUCTION

Severe temporomandibular joint disorder (TMD) could induce dysphagia, which could lead to aspiration pneumonia. However, no clinical study has reported that TMD-related dysphagia could result in aspiration pneumonia. Integrative Korean medicine (KM) is suggested to be an effective treatment for patients with severe TMD.

PATIENT CONCERNS

A 76-year-old female could not open her mouth because of TMD and subsequently experienced dysphagia. To clearly identify the cause of dysphagia and to treat the symptoms, she was admitted to the neurology department. However, she eventually developed aspiration pneumonia. Despite the inpatient treatment and even after pneumonia was cured, TMD symptoms and dysphagia persisted.

DIAGNOSIS

Based on the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) and the magnetic resonance imaging findings, the patient was diagnosed as having severe TMD with disc displacement without reduction and with limited opening.

INTERVENTIONS

Integrative KM treatment, including acupuncture, herbal acupuncture, cupping therapy, Chuna manual therapy, and herbal medicine, was performed during the admission period (23 days).

OUTCOMES

The following clinical improvements were detected: maximal unassisted opening from 8 to 28 mm, right lateral movement from 3 to 11 mm, left lateral movement from 10 to 15 mm, and protrusion movement from 5 to 7 mm. Dysphagia disappeared when the TMD symptoms improved.

CONCLUSION

Patients with severe TMD might experience dysphagia, which could lead to aspiration pneumonia. Symptoms of severe TMD could be treated with integrative KM treatment.