Journal of Dental Research

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TMJ Disc Displacement without Reduction Management: A Systematic Review

M. Al-Baghdadi, J. Durham, V. Araujo-Soares, S. Robalino, L. Errington and J. Steele
J DENT RES published online 21 March 2014
DOI: 10.1177/0022034514528333

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 vol. XX • issue X • suppl no. X JDR Clinical Research Supplement

clinical review

TMJ Disc Displacement without

Reduction Management:
A Systematic Review
M. Al-Baghdadi1,2*, J. Durham1,2, V. Araujo-Soares2, S. Robalino2, L. Errington3, and J. Steele2,4

ABSTRACT: Various interventions or no intervention. Meta-analysis on reduction (DDwoR) is a specific

have been used for the management of homogenous groups was conducted in temporomandibular disorder (TMD) that
patients with temporomandibular joint 4 comparisons. In most comparisons can cause TMJ pain and limited mouth
(TMJ) disc displacement without reduc- made, there were no statistically signif- opening (painful locking), sometimes
tion (DDwoR), but their clinical effec- icant differences between interventions called a “closed lock” (Okeson, 2007).
tiveness remains unclear. This system- relative to primary outcomes at short- DDwoR can be acute or chronic
atic review investigated the effects of or long-term follow-up (p > .05). In a depending on the duration of locking
these interventions and is reported in separate analysis, however, the major- (Sembronio et al., 2008; Saitoa et al.,
accordance with Preferred Reporting ity of reviewed interventions reported 2010). Its incidence among TMD patients
Items for Systematic Reviews and significantly improved primary out- is estimated at 2% to 8% (Manfredini
Meta-Analyses (PRISMA) guidelines. come measures from their baseline lev- et al., 2011; Poveda-Roda et al., 2012).
Electronic and manual searches up to els over time (p < .05). Evidence lev- Various interventions have been
November 1, 2013, were conducted for els, however, are currently insufficient suggested for DDwoR, but to date, the
English-language, peer-reviewed, pub- for definitive conclusions, because the most efficacious/effective approach
lications of randomized clinical trials included studies were too heteroge- is still unclear, which may result in
comparing any form of conservative neous and at an unclear to high risk of management being based more on
or surgical interventions for patients bias. In view of the comparable experience than evidence (Durham et al.,
with clinical and/or radiologic diag- therapeutic effects, paucity of high- 2007). The aim of this systematic review,
nosis of acute or chronic DDwoR. Two quality evidence, and the greater risks therefore, was to investigate the effects
primary outcomes (TMJ pain inten- and costs associated with more com- of different conservative and surgical
sity and maximum mouth opening) plex interventions, patients with symp- interventions used in the management of
and a number of secondary outcomes tomatic DDwoR should be initially TMJ DDwoR.
were examined. Two reviewers per- treated by the simplest and least inva-
formed data extraction and risk of sive intervention. Methods
bias assessment. Data collection and Protocol and Registration
Key Words: temporomandibular joint
analysis were performed according to surgery, internal derangement, closed This systematic review was conducted
Cochrane recommendations. Twenty lock, meta-analysis, disc disorder, TMD. in accordance with the Cochrane
studies involving 1,305 patients were Collaboration (Higgins and Green,
included. Data analysis involved 21 2011) and the Centre for Reviews and
comparisons between a variety of inter- Introduction Dissemination (Akers et al., 2009)
ventions, either between interventions, Temporomandibular joint guidance, and is reported according
or between intervention and placebo (TMJ) disc displacement without to the Preferred Reporting Items for

DOI: 10.1177/0022034514528333. 1Department of Oral and Maxillofacial Surgery, School of Dental Sciences, Newcastle University, UK; 2Institute of Health and Society,
Newcastle University, UK; 3Walton Library, Newcastle University, UK; and 4Department of Restorative Dentistry, School of Dental Sciences, Newcastle University, Newcastle
upon Tyne, UK; *corresponding author, [email protected] or [email protected]
Protocol Registration Number: PROSPERO 2012, CRD42012003153. Available from: http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42012003153.
A supplemental appendix to this article is published electronically only at http://jdr.sagepub.com/supplemental.
© International & American Associations for Dental Research
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 JDR Clinical Research Supplement Month XXXX

Systematic Reviews and Meta-Analyses third reviewer (JS). Studies excluded at and statistically homogeneous trials was
(PRISMA) statement (Moher et al., 2009). this stage were identified and reasons for done by a fixed-effect model if there were
All the methods of data collection/ exclusion recorded. 2 studies pooled and by a random-effects
analysis and inclusion/exclusion criteria model if more than 2 studies were pooled.
Data Extraction and Management
were pre-specified and documented in When there was substantial heterogeneity
the review protocol (Al-Baghdadi et al., A standardized, pre-piloted, between studies, meta-analysis was not
2012). extraction form based on Cochrane undertaken and the data were integrated
recommendations was used. Eligible into a narrative analysis of the findings. A
Criteria for Studies to be Considered studies’ data were extracted and
(PICOS, Appendix 1) test for funnel plot asymmetry to assess
recorded by the first reviewer (MA). The publication bias (Egger et al., 1997) was
• Participants: Any age, and gender with
second reviewer (JD), blinded to the planned, but was not performed because
clinical and/or radiologic diagnosis of
authors’ names, institutions, and journal, of insufficient numbers of studies pooled
acute or chronic DDwoR.
crosschecked the validity of all data in the meta-analyses. Where possible, a
• Interventions: Any form of conservative
extracted. Authors of included studies subgroup analysis based on chronicity of
or surgical interventions.
were contacted to clarify study design the locking condition (acute or chronic:
• Comparators/Control: Any alternative
and/or request missing data as required. according to duration of locking threshold
intervention, placebo, or no treatment.
• Outcomes: Primary outcomes: TMJ Risk-of-Bias Assessment for chronic lock where disc recapture
pain intensity and unassisted/active much less likely estimated at 4 wk) was
The methodologic quality of included conducted. Studies, without soft-tissue
maximum mouth opening (MMO). studies was assessed independently
Secondary outcomes: other mandibular imaging confirming the DDwoR clinical
and in duplicate by two reviewers (MA, diagnosis, were excluded in a sensitivity
movements, mandibular function or JD ‘blinded’) using the Cochrane risk
patient’s quality of life, therapy cost, analysis to identify any effect on primary
of bias tool (Higgins et al., 2011). Each outcomes in the meta-analysis.
operation/admission duration in domain in the tool was allocated one of
surgical trials, and adverse events. The Additional data analysis was also
the following judgments: low, unclear, or performed for examination of the changes
outcomes were evaluated over both high risk of bias. Sample size calculation
short-term (≤ 3 mo) and long-term from baseline in primary outcomes for
was also examined. each individual intervention at short- and
(> 3 mo) follow-up periods.
• Studies: Randomized and quasi- Data Analysis long-term follow-ups (i.e., within-group
randomized clinical trials (RCTs and The planned data analysis for this review statistical difference from baseline). This
q-RCTs). was performed according to Cochrane separate analysis was performed to help
statistical guidelines (Higgins and Green, readers interpret the potential clinical
Search Strategy (Appendix 2) 2011) with the Review Manager Software significance of improvement from baseline
Four databases – CENTRAL, (version 5.2) (RevMan, 2012) to compare for each intervention.
MEDLINE, EMBASE, and Scopus – were the effects of different interventions (i.e.,
electronically searched up to November between-group statistical differences). For Results
1, 2013. Other sources were manually dichotomous data, the estimates of effect
searched: citation search and reference Search
of an intervention were expressed as risk The search strategy identified a total of
lists of included studies, reference lists ratios (RR) together with 95% confidence
of relevant review articles and textbook 3,333 records from all databases. Of these,
intervals (CI). For continuous data, mean the full texts of 172 potentially eligible
chapters, and 7 journals highly likely to differences (MD) with 95% CI were used.
contain studies relevant to the review papers were retrieved and examined. Fig. 1
Clinical and statistical heterogeneities illustrates the screening process.
topic. were assessed across the studies prior
Data Collection and Analysis to pooling. Clinical heterogeneity was Description of Studies
Selection of Studies determined by examination of each study’s Twenty studies met the inclusion
Eligible studies were selected according clinical characteristics for any diversity/ criteria (Lundh et al., 1992; Petersson
to the inclusion/exclusion criteria. variation in, for example, technique/ et al., 1994; Linde et al., 1995; Fridrich
Irrelevant reports were identified by their delivery of interventions, severity/ et al., 1996; Schiffman et al., 1996;
title/abstract and were excluded by the chronicity of condition, and treatment Goudot et al., 2000; Holmlund et al.,
first reviewer (MA). The full texts of all outcomes. Statistical heterogeneity was 2001; Minakuchi et al., 2001; Yuasa and
potentially eligible studies were retrieved assessed by chi-square and I2 statistics Kurita, 2001; Maloney et al., 2002; Peroz
and independently examined in duplicate (Higgins and Thompson, 2002). A et al., 2004; Yoshida et al., 2005; Ismail
by two reviewers (MA, JD) to establish significant p value < .05 for chi-square test et al., 2007; Politi et al., 2007; Schiffman
eligibility. Throughout the review and an I2 statistic > 50% were considered et al., 2007; Diracoglu et al., 2009; Haketa
process, disagreements were resolved substantial heterogeneity et al., 2010; Yoshida et al., 2011; Craane
by consensus or, when necessary, by a (Deeks et al., 2011). Pooling of clinically et al., 2012; Sahlstrom et al., 2013).

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 vol. XX • issue X • suppl no. X JDR Clinical Research Supplement

Figure 1.
Study flow diagram.

Summary characteristics of included overall risk of bias. Of the 20 studies (2) minimally invasive, including
studies are available in Appendix 3. The included, 7 presented a priori sample arthrocentesis; or
list of excluded studies and reasons for size calculation, and 8 had inadequate (3) invasive (surgical), including
exclusion is available upon request. statistical power (< 80%) (Appendix 3). arthroscopic and open joint surgeries.
Risk of Bias Effects of Interventions Twenty-one comparisons were made
None of the included studies was The reviewed interventions varied among interventions. Data for the 21
at low risk of bias across all domains widely in invasiveness. For the purpose comparisons (between-group statistical
(Appendix 4). Eight were assessed as of this review, the interventions were analysis) are presented in the text, with
unclear overall risk of bias because of grouped into 3 modalities, based on their the primary outcomes described at short-
insufficient information in the trial report level of invasiveness (Appendix 5): and long-term follow-up time points in
and/or from the contacted authors, or the Table. Data examining within-group
because it was not possible to make (1) non-invasive (conservative), including differences from baseline for primary
a definite judgment in at least one education, self-management, splint outcomes (within-group statistical
domain of the bias assessment tool. The therapy, physiotherapy, and their analysis) at short- and long-term follow-
remaining studies were assessed as high combinations; ups are tabulated and presented in

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Table.
Summary of Findings for the Primary Outcomes (pain at jaw function and unassisted/active maximum mouth opening)
Follow-up
(short- p Value for
term & No. of Relative Between- Overall Outcome
Comparison Primary long- Patients Effect group Risk of Measurement
(Study) Outcome term) (Trials) (95% CI)a Differenceb Bias Tool/Scalec
1. MM vs. No treatment MMO 10 min (ST) 148 (1 RCT) RR 16.67 p < .0001 favors High MMO > 38 mm
(Yoshida et al., 2011) (5.44 to MM
51.06)
2. Jaw exercises vs. Paind 3 mo (ST) 42 (1 RCT) MD 3.81 NS Unclear VAS (0-100)
Education only (–6.15 to
(Craane et al., 2012) 13.77)
Paind 13 mo (LT) 42 (1 RCT) MD 0.62 NS Unclear VAS (0-100)
(–5.46 to
6.70)
MMO 3 mo (ST) 45 (1 RCT) MD -3.10 NS Unclear aMMO (mm)
(–6.96 to
0.76)
MMO 13 mo (LT) 42 (1 RCT) MD -3.80 NS (p = .05 Unclear aMMO (mm)
(–7.68 to toward Educ)
0.08)
3. Self-management vs. Pain 2 mo (ST) 44 (1 RCT) MD -4.40 NS Unclear VAS (0-100) on
Education only (–19.54 to chewing
(Minakuchi et al., 2001) 10.74)
MMO 2 mo (ST) 44 (1 RCT) MD -1.40 NS Unclear aMMO (mm)
(–6.90 to
4.10)
4. Self-management vs. No Pain & 1 mo (ST) 60 (1 RCT) RR 1.80 NS (p = .05 Unclear No. improved
treatment MMO (1.00 to toward SM) patients for: VAS
(Yuasa and Kurita, 2001) 3.23) pain & MMO
Subgroup 1 mo (ST) 15 Acute RR 1.05 NS
analysis (0.57 to
1.94)
45 Chronic RR 2.51 p < .05 favors SM
(1.06 to
5.95)
5. Self-management vs. Pain 2 mo (ST) 44 (1 RCT) MD -15.20 NS (p = .07 Unclear VAS (0-100)
Splint (–31.55 to toward SM)
(Haketa et al., 2010) 1.15)
MMO 2 mo (ST) 44 (1 RCT) MD 6.00 p < .001 favors Unclear MMO with pain
(2.67 to SM (mm)
9.33)
6. Splint vs. Control Pain 12 mo (LT) 51 (1 RCT) RR 0.49 p < .05 favors High No. reduced pain
(Lundh et al., 1992) (0.26 to Control
0.92)
7. Splint vs. TENS Pain 6 wk (ST) 31 (1 RCT) RR 8.53 p < .05 favors High Reduction in
(Linde et al., 1995) (1.21 to Splint pain ≥ 50%
60.33)
MMO 6 wk (ST) 31 (1 RCT) MD -0.16 NS High Change from
(–4.07 to baseline (mm)
3.75)
(continued)

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 vol. XX • issue X • suppl no. X JDR Clinical Research Supplement

Table. (continued)

Follow-up
(short- p Value for
term & No. of Relative Between- Overall Outcome
Comparison Primary long- Patients Effect group Risk of Measurement
(Study) Outcome term) (Trials) (95% CI)a Differenceb Bias Tool/Scalec
8. Combination therapye vs. Pain 2 mo (ST) 46 (1 RCT) MD -2.80 NS Unclear VAS (0-100) on
Education only (–16.12 to chewing
(Minakuchi et al., 2001) 10.52)
MMO 2 mo (ST) 46 (1 RCT) MD 1.40 NS Unclear aMMO (mm)
(–3.94 to
6.74)
9. Combination therapy vs. Pain 2-3 mo (ST) 97 (2 RCTs) SMD 0.22 NS Unclear VAS & SSI
Self-management (–0.19 to
(Minakuchi et al., 2001; 0.62)
Schiffman et al., 2007) Pain 60 mo (LT) 50 (1 RCT) MD 0.00 NS Unclear SSI (0-1)
(–0.13 to
0.13)
MMO 2 mo (ST) 48 (1 RCT) MD 2.80 NS Unclear aMMO (mm)
(–2.95 to
8.55)
10. Jaw exercise + splint vs. Pain 1-3 mo (ST) 50 (2 RCTs) MD 0.90 NS High VAS & NRS
Splintf (–12.28 to (0-100)
(Maloney et al., 2002; Ismail 14.07)
et al., 2007) MMO 1-3 mo (ST) 50 (2 RCTs) MD 4.67 p < .01 favors High aMMO (mm)
(1.80 to 7.55) Ex+Sp
11. Active PEMF vs. Placebo Paind 6 wk (ST) 31 (1 RCT) MD 0.23 NS Low VAS (0-100)
PEMF (–17.96 to
(Peroz et al., 2004) 18.42)
Paind 4 mo (LT) 30 (1 RCT) MD 19.49 p < .05 favors Unclear VAS (0-100)
(0.97 to placebo
38.01)
MMOd 6 wk (ST) 31 (1 RCT) MD -2.47 NS Low aMMO (mm)
(–8.23 to
3.29)
MMO 4 mo (LT) 30 (1 RCT) MD -1.00 NS Unclear aMMO (mm)
(–6.09 to
4.09)
12. Active iontophoresis vs. Pain 1 wk (ST) 18 (1 RCT) MD -0.03 NS Unclear SSI (0-1)
Placebo iontophoresisg (–0.21 to
(Schiffman et al., 1996) 0.15)
MMO 1 wk (ST) 18 (1 RCT) MD 1.90 NS Unclear aMMO (mm)
(–5.70 to
9.50)
13. Arthrocentesis vs. Painh 2 mo (ST) 33 (1 RCT) MD -16.02 NS (p = .09 High VAS (0-100) after
Arthrography only (–34.79 to toward AC) chewing
(Petersson et al., 1994) 2.75)
MMO 2 mo (ST) 33 (1 RCT) MD -3.00 NS High mm
(–9.54 to
3.54)
(continued)

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Table. (continued)

Follow-up
(short- p Value for
term & No. of Relative Between- Overall Outcome
Comparison Primary long- Patients Effect group Risk of Measurement
(Study) Outcome term) (Trials) (95% CI)a Differenceb Bias Tool/Scalec
14. Arthrocentesis vs. ATN LA Paind 3 mo (ST) 37 (1 RCT) MD 24.60 p < .01 favors LA Unclear VAS (0-100) at
block (no ITT) (6.06 to movements
(Sahlstrom et al., 2013) 43.14)
Pain 3 mo (ST) 45 (1 RCT) RR 0.72 (0.46 NS Unclear Reduced pain
(ITT) to 1.14) ≥ 30%
MMO d
3 mo (ST) 37 (1 RCT) MD -4.90 NS (p = .06 Unclear aMMO (mm)
(–10.00 to toward LA)
0.20)
15. Arthrocentesis vs. Pain 3 mo (ST) 110 (1 qRCT) MD -19.3 p < .0001 favors High VAS (0-100)
Combination therapy (–28.54 to AC
(Diracoglu et al., 2009) –10.06)
Pain 6 mo (LT) 110 (1 qRCT) MD -28.80 p < .0001 favors High VAS (0-100)
(–36.56 to AC
–21.04)
MMO 3 mo (ST) 110 (1 qRCT) MD 1.93 NS High mm
(–0.75 to
4.61)
MMO 6 mo (LT) 110 (1 qRCT) MD 2.35 NS (p = .06 High mm
(–0.07 to toward AC)
4.77)
16. Arthroscopy vs. Self- Pain 3 mo (ST) 50 (1 RCT) MD 0.01 NS Unclear SSI (0-1)
management (–0.12 to
(Schiffman et al., 2007) 0.14)
Pain 60 mo (LT) 51 (1 RCT) MD 0.03 NS Unclear SSI (0-1)
(–0.09 to
0.15)
17. Arthroscopy vs. Pain 3 mo (ST) 43 (1 RCT) MD -0.08 NS Unclear SSI (0-1)
Combination therapy (–0.24 to
(Schiffman et al., 2007) 0.08)
Pain 60 mo (LT) 47 (1 RCT) MD 0.03 NS Unclear SSI (0-1)
(–0.09 to
0.15)
18. Open surgery vs. Self- Pain 3 mo (ST) 48 (1 RCT) MD -0.07 NS Unclear SSI (0-1)
management (–0.20 to
(Schiffman et al., 2007) 0.06)
Pain 60 mo (LT) 50 (1 RCT) MD 0.05 NS Unclear SSI (0-1)
(–0.09 to
0.19)
19. Open surgery vs. Pain 3 mo (ST) 41 (1 RCT) MD -0.16 p < .05 favors OS Unclear SSI (0-1)
Combination therapy (–0.32 to
(Schiffman et al., 2007) –0.00)
Pain 60 mo (LT) 46 (1 RCT) MD 0.05 NS Unclear SSI (0-1)
(–0.09 to
0.19)
(continued)

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Table. (continued)

Follow-up
(short- p Value for
term & No. of Relative Between- Overall Outcome
Comparison Primary long- Patients Effect group Risk of Measurement
(Study) Outcome term) (Trials) (95% CI)a Differenceb Bias Tool/Scalec
20. Arthroscopy vs. Pain 12 mo (LT) 62 (1 RCT) MD 10.00 NS (p = .08 High VAS (0-100)
Arthrocentesis (–1.20 to toward AC)
(Fridrich et al., 1996; Goudot 21.20)
et al., 2000) MMO 6-24 mo (LT) 81 (2 RCTs) MD 5.13 p < .0001 favors High mm
(3.20 to AS
7.06)
21. Open surgery vs. Pain 3 mo (ST) 42 (1 RCT) MD -0.08 NS Unclear SSI (0-1)
Arthroscopy (–0.23 to
(Holmlund et al., 2001; Politi 0.07)
et al., 2007; Schiffman et al., Pain 12 mo (LT) 81 (3 RCTs) SMD -0.50 p < .05 favors OS High VAS & SSI
2007) (–0.95 to
–0.06)
Sensitivity 12 mo (LT) 61 (2 RCTs) SMD -0.43 NS High VAS & SSI
analysis (–0.93 to
0.08)
MMO 12 mo (LT) 40 (2 RCTs) RR 1.07 NS High MMO > 35 mm
(0.76 to
1.49)

Abbreviations: AC, arthrocentesis; aMMO, active (unassisted) maximum mouth opening; AS, arthroscopy; ATN LA block, auriculotemporal nerve local anesthesia block;
CI, confidence interval; Educ, education; Ex+Sp, exercises plus splint; ITT, intention-to-treat analysis; LT, long-term; MD, mean difference; min, minutes; MM, mandibular
manipulation; mm, millimeters; MMO, maximum mouth opening; mo, months; No., number of patients; NRS, numerical rating scale; NS, non-significant; OS, open surgery;
PEMF, pulsed electromagnetic fields; qRCT, quasi-randomized clinical trial; RCT, randomized clinical trial; RR, risk ratio; SM, self-management; SMD, standardized mean
difference; SSI, symptoms severity index; ST, short-term; TENS, transcutaneous electric nerve stimulation; VAS, visual analog scale; wk, weeks.
a
The risk ratio (RR) is the ratio of the chance of experiencing a particular event that occurs with use of the intervention that occurs with the use of control. The mean
difference (MD) is the difference in the values of means between 2 groups in a clinical trial. It estimates the amount by which an 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 standardized mean difference (SMD) is used as a summary statistic in meta-analysis when the studies all assess the same outcome but measure it
on different scales. It expresses the size of the intervention effect in each study relative to its variance (SD). Further details about the statistical analysis used to
measure the relative effects of interventions in clinical trials are available in the Cochrane handbook for systematic reviews of interventions, which is accessible
online at: http://handbook.cochrane.org/.
b
Statistical significance (p value < .05) for between-group statistical differences.
c
For uniformity, data were analyzed and presented by rescaling pain scales (VAS and NRS) on 0-10 cm (Goudot et al., 2000; Holmlund et al., 2001; Maloney et al.,
2002; Politi et al., 2007; Diracoglu et al., 2009) to a 0-100 mm scale.
d
Unpublished statistical data provided by the contacted authors (personal e-mail communication).
e
Combination therapy of splint plus jaw exercises (± self-care/education/medication ± cognitive behavioral therapy [CBT]) conservative interventions.
f
In Maloney et al. (2002), Therabite device + splint group and wooden tongue depressors (WTDs) + splint group were merged as one group: jaw exercises plus splint.
g
In Schiffman et al. (1996), three groups were compared (active iontophoresis by dexamethasone + lidocaine, control iontophoresis by lidocaine only, and placebo
iontophoresis by normal saline). In this review, however, only the comparison between active and placebo iontophoresis was considered and reported.
h
Estimated from Fig. 2 in the published trial.

Appendix 6 to allow readers to assess with the main difference being the delivery DDwoR. In Yoshida et al. (2011), the
the potential clinical significance of of manipulation: by clinicians (Yoshida number of patients with MMO > 38 mm
the differences. Data on all secondary et al., 2005) or by patients (Yoshida was significantly greater 10 min after
outcomes are available upon request. et al., 2011). No extractable numerical data self-MM, and these ‘improvers’ also had a
were available from the former study, but short duration of locking (mean = 35 days)
Comparisons of Non-
invasive Interventions the authors reported that 172 out of 204 (Table, Comparison 1).
(84%) patients in the MM group showed
Mandibular Manipulation vs. Control Jaw Exercises vs. Education
reduced pain and increased opening at
Mandibular manipulation (MM) was 1 wk. Of 172 improvers, 170 had ‘acute’ Craane et al. (2012) compared jaw
compared against the control in 2 studies (≤ 4 wk) and 2 had ‘chronic’ (> 4 wk) manipulation by physiotherapists

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 JDR Clinical Research Supplement Month XXXX

with education in DDwoR with/ than in the transcutaneous electric nerve the combined treatment (MD = 4.67 mm;
without limited opening. Jaw exercises stimulation (TENS) group, but there 95%CI, 1.80 to 7.55; p = .001) (Fig. 3 and
demonstrated no additional effect was no statistically significant difference Table, Comparison 10).
over education alone on all measured between the interventions on MMO
Active Pulsed Electromagnetic
outcomes over the short or long term over the short term (Table, Comparison Fields (PEMF) vs. Placebo PEMF
(Table, Comparison 2). 7). TENS caused mild transient
hypersensitivity pre-auricular skin reaction. In Peroz et al. (2004), active PEMF
Self-management vs. Control did not demonstrate an additional
Combination Therapy vs. Education effect over placebo on all measured
Two studies compared self-management
(self-exercises + self-care/medication) Minakuchi et al. (2001) compared the outcomes in DDwoR patients over
with no active treatment over the short short-term effect of combined splint both the short and longer terms (Table,
term (Minakuchi et al., 2001; Yuasa and plus exercises (+ self-care/medication/ Comparison 11).
Kurita, 2001). No statistically significant education) with education only, with no
Active Iontophoresis vs.
differences in all measured outcomes statistically significant differences in
Placebo Iontophoresis
between self-management and education effect between the interventions on
were demonstrated by Minakuchi et al. all measured outcomes (Table, In Schiffman et al. (1996), active
(2001) (Table, Comparison 3). In Yuasa Comparison 8). iontophoresis by dexamethasone +
and Kurita (2001), a greater number of lidocaine demonstrated greater short-term
Combination Therapy vs. Self-management effects over placebo iontophoresis by
patients experienced decreased pain and
increased opening in the self-management Two studies compared combination normal saline on all measured outcomes,
group, but the difference was not therapy including splint plus exercises but the differences were not statistically
statistically significant. In a subgroup- (+ self-care/medication/education ± significant (Table, Comparison 12).
analysis, however, self-management cognitive behavioral therapy [CBT]) with Iontophoresis caused 2 types of mild
demonstrated a statistically significant self-management (self-care/medication/ transient adverse events (skin erythema
difference over no treatment with ‘chronic’ education ± self-exercises) (Minakuchi and dizziness).
(> 4 wk) DDwoR (Table, Comparison 4). et al., 2001; Schiffman et al., 2007), with
no statistically significant differences Comparisons of Minimally Invasive
Self-management vs. Splint vs. Non-invasive Interventions
between the effects of the interventions
Haketa et al. (2010) compared self- on all measured outcomes over the Arthrocentesis vs. Control
management involving self-exercises (+ longest follow-up (Table, Comparison Two studies evaluated the short-
self-care/NSAIDs) with splint (+ self- 9). Pooling the data demonstrated
term effect of arthrocentesis
care/NSAIDs). Although there was no statistically significant differences
with a control group: diagnostic
greater reduction in pain intensity in the between the short-term effects of
arthrography (Petersson et al., 1994)
self-management group over the short the interventions on pain intensity
and auriculotemporal nerve (ATN)
term, the difference was not statistically [standardized mean differences
block as sham treatment (Sahlstrom
significant. For MMO, however, self- (SMD) = 0.22; 95% CI, -0.19 to 0.62;
et al., 2013). In both, arthrocentesis
management demonstrated a statistically p = .29] (Fig. 2). did not demonstrate a statistically
significant difference in effect over splint
Combination of Splint Plus significant effect over the control
(Table, Comparison 5). Jaw Exercises vs. Splint groups on all measured outcomes
Splint vs. Control Two studies made this comparison (Table, Comparisons 13 & 14). Pooling
on patients with “disc displacement” or the data to evaluate the overall effect of
Lundh et al. (1992) made this
osteoarthritis with the main difference arthrocentesis was not possible because
comparison on patients diagnosed by
being the delivery of jaw exercises: of clinical (incomparable ‘controls’) and
arthrography and given information
by clinicians (Ismail et al., 2007) or statistical (chi-square < .05; I2 > 50%)
and pain medication as needed. The
by patients using either a mechanical heterogeneity.
number of patients with reduced pain
was significantly greater in untreated device (Therabite) or wooden tongue
Arthrocentesis vs. Combination Therapy
individuals than in those treated with depressors (WTDs) (Maloney et al.,
splints over the long term (Table, 2002). Pooling the data showed no Diracoglu et al. (2009) compared
Comparison 6). statistically significant difference in arthrocentesis with a combination of
effects between the combined splint + splint plus self-care/self-exercises in
Splint vs. Transcutaneous exercises vs. splint alone on pain over patients with ‘acute’ DDwoR (≤ 4 wk).
Electric Nerve Stimulation the short term (MD = 0.90; 95%CI, -12.28 In this q-RCT, arthrocentesis
In Linde et al. (1995), the number of to 14.07; p = .89). For MMO, however, demonstrated a statistically significant
patients with ≥ 50% pain reduction was the meta-analysis showed a statistically difference in effect over the combined
significantly greater in the splint group significant difference in effect in favor of treatment on pain over both the short

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 vol. XX • issue X • suppl no. X JDR Clinical Research Supplement

Figure 2.
Forest plot of pooled data regarding pain outcome for combination therapy vs. self-management. Guidance for interpreting forest plots
can be found in Lewis and Clarke (2001).

Figure 3.
Forest plot of pooled data regarding pain and mandibular movements outcomes for combination of splint plus jaw exercises vs. splint only.

and longer terms, but there was no conservative treatment strategies: self- Open Surgery vs. Conservative Treatments
statistically significant difference between management (self-care/medication/ Schiffman et al. (2007) also compared
the interventions on MMO (Table, education) and combination of splint open surgery with the same conservative
Comparison 15). plus exercises (+ self-care/medication/ interventions: self-management and
education + CBT). Arthroscopy did combination therapy. Open surgery
Comparisons of Invasive vs.
Non-invasive Interventions not demonstrate statistically significant did not demonstrate statistically
differences in effect over conservative significant differences in effect over self-
Arthroscopy vs. Conservative Treatments interventions on all measured outcomes management on all measured outcomes
Schiffman et al. (2007) compared over the short or long term (Table, over the short or long term (Table,
arthroscopic surgery with 2 Comparisons 16 & 17). Comparison 18). When compared with

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 JDR Clinical Research Supplement Month XXXX

Figure 4.
Forest plot of pooled data regarding maximum mouth opening outcome for arthroscopy vs. arthrocentesis.

the combination therapy, open surgery When combined in meta-analysis, a other (between groups), the least invasive
demonstrated a statistically significant significant overall effect for open surgery conservative interventions, including
difference in effect on pain over the short over arthroscopy on reducing the patient education and self-management,
term, but not over the long term (Table, pain intensity over the long term was seemed to exert effects comparable with
Comparison 19). demonstrated (SMD = -0.50; 95%CI, -0.95 those of more ‘active’ (combined splint
to -0.06; p = .03). However, sensitivity plus physiotherapy) or ‘invasive’ (TMJ
Comparison of Invasive vs.
Minimally Invasive Interventions analysis by excluding the study without surgery) treatment approaches. Splints as
confirmatory diagnostic imaging a solitary treatment approach, however,
Arthroscopy vs. Arthrocentesis (Holmlund et al., 2001) showed no seemed to have no additional effect over
Two studies made this comparison statistically significant difference between other active interventions or no treatment,
on patients with disc displacement the surgical procedures (SMD = although as an adjunct to others, they
with/without reduction (Fridrich et al., -0.43; 95%CI, -0.93 to 0.08; p = .10). may help to alleviate symptoms.
1996; Goudot et al., 2000). In Goudot Furthermore, pooling the data from 2 Among the physiotherapeutic
et al. (2000), no statistically significant studies (Holmlund et al., 2001; Politi interventions, early mandibular
difference in effects between the et al., 2007) showed no statistically manipulation seemed to exert an
interventions on pain over the long term significant difference between the long- immediate effect, increasing MMO
was demonstrated. For MMO, pooling the term effects of surgeries on the number in patients with ‘acute’ DDwoR. Jaw
data resulted in a statistically significant of patients with MMO > 35 mm (RR = ‘stretching’ exercises, either alone or in
difference in favor of arthroscopy 1.07; 95%CI, 0.76 to 1.49; p = .71) (Fig. combination with others, also increased
over the long term (MD = 5.13 mm; 5 and Table, Comparison 21). Open MMO, but their effects were inconsistent
95%CI, 3.20 to 7.06; p < .0001) (Fig. surgery caused one transient motor between studies, while the electro-
4 and Table, Comparison 20). Four nerve injury (Schiffman et al., 2007) and physical modalities had, in general, no
surgical complications were reported by several transient sensory nerve injuries significant effect over placebo treatment
Goudot et al. (2000): 2 intra-operative (Holmlund et al., 2001; Politi et al., 2007). or splints and could be associated with
complications in the arthrocentesis group transient adverse events.
Discussion Minimally invasive arthrocentesis and
(2 severe reversible bradycardias) and
2 post-operative complications in the Summary of Main Findings invasive arthroscopic and open joint
arthroscopic group (transient frontal There was high clinical heterogeneity surgical interventions did not, in general,
palsy and prolonged cervico-facial among the studies included, which demonstrate significant differences in
edema). was unsurprising given the differing effects over non-invasive conservative
interventions used, and the considerable interventions and could be associated with
Comparison of Invasive Interventions variations in techniques applied and complications. Nevertheless, in one study,
Open Surgery vs. Arthroscopy combinations and/or delivery of arthrocentesis reduced pain intensity more
interventions. In most comparisons, than did conservative treatment in ‘acute’
Three studies made this comparison therefore, there was only 1 trial, and only DDwoR (Diracoglu et al., 2009). That study,
with no statistically significant differences 4 meta-analyses could be performed on however, used quasi-randomization based
between the effects of the 2 surgeries on trials of homogenous comparable groups. on alternate allocation to intervention
all measured outcomes over the longest In this review, analysis was conducted groups, and, if excluded from this review,
follow-up (Holmlund et al., 2001; between and within groups. When the arthrocentesis has not been proven to
Politi et al., 2007; Schiffman et al., 2007). interventions were compared with each have additional effects over conservative

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 vol. XX • issue X • suppl no. X JDR Clinical Research Supplement

Figure 5.
Forest plot of pooled data regarding pain, mandibular movements, and function outcomes for open joint surgery vs. arthroscopic surgery.

interventions. When compared with finding, suggesting that the result is 400 mL) (Zardeneta et al., 1997; Kaneyama
each other, arthroscopy increased MMO unstable and the evidence is not robust. et al., 2004), surgical techniques, intra-
more than arthrocentesis, and open The surgical procedures also suffered articular medications injected, and intra-
surgery reduced pain intensity more than from clinical heterogeneity – in anesthetic and/or post-operative jaw manipulation –
arthroscopy. In the latter comparison, modality, lavage volumes (50-150 mL) making circumstances incomparable and
sensitivity analysis did not confirm this sometimes less than recommended (100- any direct comparison difficult.

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 JDR Clinical Research Supplement Month XXXX

Previous Cochrane reviews for can confirm the minimal therapeutic unassisted and assisted MMO for DDwoR
arthrocentesis (Guo et al., 2009) or difference between interventions’ effects patients (Hesse et al., 1996) due to joint
arthroscopy (Rigon et al., 2011) included – for example, Holmlund et al. (2001) laxity and passive stretch force]. The
7 studies which were either included would have needed a very large, and suggested values can be used as an
in the present review (5 studies) or unrealistic, sample size (~132 patients approximate to help readers interpret
did not meet our inclusion criteria (2 in each treatment group) to achieve the clinical significance of change from
studies). The current review’s findings adequate power. This would have been baseline reported in Appendix 6.
concur with these reviews in that: non- highly impractical in a single-center study The study samples included in this
invasive conservative interventions need of a low-incidence condition (DDwoR). review also had limitations. Most
to be applied first; there is insufficient Third: Despite the absence of individuals included were female (87%)
evidence to support or refute the use of statistically significant differences with a mean age of 35 yr, thereby
minimally invasive and invasive surgical between interventions, most interventions mirroring ‘closed lock’ reviews (Al-Belasy
interventions; and there is a need for caused statistically significant and Dolwick, 2007; Monje-Gil et al.,
higher quality RCTs. improvement from baseline, thereby 2012), but they were recruited mostly
Overall, the between-group analysis posing the question: Is this improvement from specialized university clinics/
showed no statistically significant clinically meaningful? To answer such hospitals as opposed to other first-point-
differences in effects between and among a question, we must understand the contact clinical settings; differed in the
most of the compared interventions. The minimal clinically important difference presence/absence of co-morbid disorders;
differences in effect seemed to be minimal, (MCID) determined from the patient’s and differed in duration of DDwoR
thereby replicating/confirming results from perspective (Copay et al., 2007) for the symptoms (1 day to several yr). All these
a previous review (Kropmans et al., 1999). primary outcomes. For pain intensity, the factors may have affected the magnitude
In contrast, the within-group analysis of MCID has been defined as a reduction of treatment effect because of possible
differences from baseline caused by each from baseline of approximately one- variations in the level of pathologic
individual intervention showed that most third (~30%): 2 points on an 11-point changes in the intra-articular tissues
interventions caused a statistically significant numerical rating scale (Farrar et al., 2001) (Stiesch-Scholz et al., 2002; Emshoff and
improvement in primary outcomes over or 20 mm on a 100-mm visual analog Rudisch, 2004; Machon et al., 2012),
the short and long terms. Most analyzed scale (Jensen et al., 2003). In this review, among other variables. To investigate
interventions, therefore, seemed to be however, pain intensity was measured by this, we estimated a threshold of four-
effective in alleviating DDwoR symptoms different instruments (tools/scales), which week locking duration for acute/
(decreased pain and increased opening) to may not be directly comparable. For chronic DDwoR subgroup analysis. Few
a greater or lesser degree. These findings, MMO, Kropmans et al. (2000) suggested analyses could be conducted based on
however, highlight 3 issues: an increase of at least 9 mm to this threshold, and the effect of locking
First: The improvement in patients’ demonstrate a statistical and clinical duration on effectiveness of interventions
symptoms regardless of treatment- improvement in MMO. The study by could not be established.
specific effects could be due to placebo those authors had several methodologic Most included studies had methodologic
effects (Greene et al., 2009) or the flaws, and the 9-mm threshold was flaws in their design and used different
‘favorable’ natural course of DDwoR based on the smallest detectable methods to assess subjective outcomes.
(Sato et al., 1997; Kurita et al., 1998; difference in measurements for assisted/ This made comparisons of the effect size
Yura, 2012). In this review, most studies passive MMO in untreated patients with of interventions difficult. Furthermore,
did not have a ‘true’ untreated control “painfully restricted TMJ disorders.” none of them captured the broad
group, and therefore the estimate of the This is as opposed to a MCID in MMO, multidimensional nature of patients’
intervention’s effect should be interpreted which would require assessment from quality of life (Locker and Allen, 2007),
with caution, since it may be due to the patient’s perspective as a result and only one evaluated the cost of
placebo effects and/or adaptation over of therapeutic intervention (Dworkin therapy (Schiffman et al., 2014). Future
time. et al., 2008). There is, therefore, no trials need to address these outcomes
Second: Some included studies were currently agreed MCID for MMO, and and should follow the Initiative on
found to be underpowered to detect further studies in biopsychosocially Methods, Measurement, and Pain
statistically significant differences representative samples of individuals Assessment in Clinical Trials (IMMPACT)
between the compared interventions. with DDwoR are needed to address this. recommendations for outcomes
Insufficient power usually indicates ‘poor’ Nevertheless, if the 9 mm for assisted/ assessment in pain clinical trials
methodologic quality – for example, passive MMO improvement is taken as (Dworkin et al., 2005) and CONSORT
Petersson et al. (1994) would have perhaps indicative of MCID, one could guidelines for RCT conduct and reporting
needed a reasonable sample size (~48 estimate an increase from baseline of (Schulz et al., 2011).
patients in each treatment group) to about 6.5 mm or more for unassisted/ Despite the aforementioned limitations,
achieve adequate power. It also, however, active MMO [~2.5 mm difference between one issue has become apparent from the

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© International & American Associations for Dental Research

 vol. XX • issue X • suppl no. X JDR Clinical Research Supplement

results of this review: Most interventions pragmatic RCTs are required to compare Deeks JJ, Higgins JPT, Altman DG (2011).
appear to alleviate DDwoR symptoms, the effects of arthrocentesis with those of Chapter 9: Analysing data and undertaking
meta-analyses. In: Cochrane Handbook
with no significant differences between conservative interventions.
for Systematic Reviews of Interventions
non-invasive conservative interventions Detailed descriptions about Version 5.1.0 (updated March 2011).
and minimally invasive or invasive surgical recommended research design are Higgins JP, Green S, editors. The Cochrane
interventions. Given the paucity of available upon request. Collaboration, 2011. Accessed on 2/21/2014
evidence and the difficulty in interpreting at: www.cochrane-handbook.org.
the minimal clinically important difference, Acknowledgments Diracoglu D, Saral IB, Keklik B, Kurt H, Emekli
this finding suggests that patients with U, Ozcakar L, et al. (2009). Arthrocentesis
The review authors thank Prof. versus nonsurgical methods in the treatment
DDwoR probably should be initially
Frank Lobbezoo (ACTA Amsterdam, of temporomandibular disc displacement
managed with the most minimal and
Netherlands) and Dr. Stephen Davies without reduction. Oral Surg Oral Med Oral
least invasive intervention. Escalation to Pathol Oral Radiol Endod 108:3-8.
(Manchester Dental School, UK) for their
more invasive treatment should occur
critical review of the study protocol. The Durham J, Exley C, Wassell R, Steele JG
only in the face of objective clinical need. (2007). ‘Management is a black art’—
review authors also thank the responding
This, however, should be interpreted in professional ideologies with respect to
authors of included studies and the four
the context of a review based mostly on temporomandibular disorders. Br Dent J
anonymous manuscript reviewers for 202:E29.
single studies of unclear to high risk of
their constructive and helpful critique.
bias. Future well-conducted research may Dworkin RH, Turk DC, Farrar JT,
This study is funded by the higher
change or confirm this. Haythornthwaite JA, Jensen MP, Katz NP,
committee for education development et al. (2005). Core outcome measures
in Iraq (HCED) and was undertaken as for chronic pain clinical trials: IMMPACT
Conclusion a part of a postgraduate PhD clinical recommendations. Pain 113:9-19.
Implications for Practice program in the Department of Oral and Dworkin RH, Turk DC, Wyrwich KW, Beaton
The comparable therapeutic effects of Maxillofacial Surgery, School of Dental D, Cleeland CS, Farrar JT, et al. (2008).
reviewed interventions suggest using the Sciences, Newcastle University, UK. The Interpreting the clinical importance of
simplest, least costly, and least invasive treatment outcomes in chronic pain clinical
authors declare no potential conflicts of
interventions for the initial management trials: IMMPACT recommendations. J Pain
interest with respect to the authorship 9:105-121.
of DDwoR. Of the variety of non- and/or publication of this article.
invasive conservative interventions Egger M, Davey Smith G, Schneider M, Minder C
(1997). Bias in meta-analysis detected by a
reviewed, the least invasive were patient
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