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The Effectiveness of Noninvasive Interventions for Temporomandibular Disorders: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

Randhawa, Kristi BHSc, MPH; Bohay, Richard DMD, MSc, MRCD(C); Côté, Pierre DC, PhD; van der Velde, Gabrielle DC, PhD; Sutton, Deborah BScOT, Med, MSc; Wong, Jessica J. BSc, DC, FCCS(C); Yu, Hainan MBBS, MSc; Southerst, Danielle BScH, DC, FCCS(C); Varatharajan, Sharanya BSc, MSc; Mior, Silvano DC, PhD; Stupar, Maja DC, PhD; Shearer, Heather M. DC, MSc, FCCS(C); Jacobs, Craig BFA, DC, MSc, FCCS(C); Taylor-Vaisey, Anne MLS

doi: 10.1097/AJP.0000000000000247
Review Articles

Objective: To determine the effectiveness and cost-effectiveness of noninvasive interventions for temporomandibular disorders (TMD).

Methods: We systematically searched MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Central register from 1990 to 2014 for effectiveness studies and the Cochrane Health Technology Assessment Database, EconLit, NHS Economic Evaluation Database, and Tufts Medical Center Cost-Effectiveness Analysis Register from 1990 to 2014 for cost-effectiveness studies. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. Evidence from eligible studies was synthesized using best-evidence synthesis methodology.

Results: Our search for effectiveness studies yielded 16,995 citations; 31 were relevant and 7 randomized controlled trials (published in 8 articles) had a low risk of bias. We found no relevant cost-effectiveness studies. The evidence suggests that for persistent TMD: (1) cognitive-behavioral therapy and self-care management lead to similar improvements in pain and disability but cognitive-behavioral therapy is more effective for activity interference and depressive symptoms; (2) cognitive-behavioral therapy combined with usual treatment provides short-term benefits in pain and ability to control pain compared with usual treatment alone; (3) intraoral myofascial therapy may reduce pain and improve jaw opening; and (4) structured self-care management may be more effective than usual treatment. The evidence suggests that occlusal devices may not be effective in reducing pain and improving motion for TMD of variable duration. Evidence on the effectiveness of biofeedback is inconclusive.

Discussion: The available evidence suggests that cognitive-behavioral therapy, intraoral myofascial therapy, and self-care management are therapeutic options for persistent TMD.

Supplemental Digital Content is available in the text.

*UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT)-Canadian Memorial Chiropractic College (CMCC)

Divisions of Graduate Education and Research

Undergraduate Education

§§Clinical Education, Canadian Memorial Chiropractic College (CMCC)

#Toronto Health Economics and Technology Assessment (THETA) Collaborative

**Leslie Dan Faculty of Pharmacy, University of Toronto

††Institute for Work and Health

‡‡UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, Toronto

Canada Research Chair in Disability Prevention and Rehabilitation

Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), Oshawa

§Schulich School of Medicine and Dentistry, Western University, London, ON, Canada

Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website,

This research was undertaken, in part, thanks to funding from the Canada Research Chairs program to P.C.

Supported by the Ontario Ministry of Finance and the Financial Services Commission of Ontario, Toronto, Canada (RFP No.: OSS_00267175). The authors declare no conflict of interest.

Reprints: Kristi Randhawa, MPH, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, 6100 Leslie Street, Toronto, ON, Canada M2H 3J1 (e-mail:

Received April 24, 2014

Received in revised form May 13, 2015

Accepted April 7, 2015

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