X. Konstantakis1,2, I. Grigoriadis3, H. Syrgiamiotis4
1Physio Clinic Konstantakis, Athens, Greece, 2Panathinaikos Football Club, Athens, Greece, 3Orthopaedic Manual Therapy-Greece, Athens, Greece, 4HS Physiotherapy, Athens, Greece
Background: Temporomandibular disorders (TMD) are considered as a collective term describing various clinical symptoms involving the temporomandibular joint (TMJ), the masticatory system and the associated structures. Numerous treatment interventions have been proposed for the management of TMD. Among them, dental splint therapy is considered as the primary treatment approach for TMD patients. At the same time, physiotherapy including manual therapy techniques (MT) and therapeutic exercise (TE), is also regarded as an effective therapeutic intervention which may have superior effects compared to occlusal splint in improving pain and mouth opening in patients with TMD. However, the evidence is still inconclusive. A limitation of the existing systematic reviews is the heterogeneity of the included TMD interventions. Evidence report that the collective analysis of treatment methods may lead to inaccurate estimation of treatment effect for particular treatments. Accordingly it was considered appropriate to conduct a systematic review focusing on these two specific therapeutic interventions with the aim of highlighting whether the dental or the aforementioned physiotherapy treatment approach is superior for TMD management and thus inform clinical practice.
Purpose: To investigate whether MT and TE are more effective than dental occlusal splint in improving pain and mouth opening in patients with TMD.
Methods: A systematic review was designed in accordance to published guidelines and reported in line with PRISMA. Key databases were searched until June 2020. Studies were included if they were RCT study designs, comparing MT techniques and TE compared to dental occlusal splint and included measures of pain and mouth opening. The Cochrane risk of bias tool was used to evaluate the quality of the included studies. Searching, data extraction and quality assessment was undertaken by 2 independent reviewers. Outcomes of interest were measures of pain and mouth opening. Heterogeneity in key characteristics precluded meta-analysis.
Results: From 1.104 articles, 10 full text articles were evaluated, resulting in 5 included RCTs. Methodological deficits found in the majority of the studies, conduct of the studies; unclear randomisation methods; inadequate allocation concealment, raising doubts for the accuracy of the results. Thus 1 study was classified as having high risk of bias while 3 had unclear risk of bias. Only one study (n=38) had low risk of bias, in which, the intervention (physiotherapy) group reported statistical significant increase of mouth-opening range (11,3mm without pain and 8,8mm with pain-subjects) compared to the splint group (5,9mm without pain and 4,7mm with pain-subjects) at eight weeks, but the maximum daily pain intensity rated by the visual numeric rating scale, significantly decreased in both treatment groups.
Conclusion(s): Limited evidence suggests that physiotherapy, including MT and TE may have superior effects over dental occlusal splint in the short term, thus it may be regarded as the primary treatment approach for TMD. However, poor quality coupled with heterogeneity of both interventions precludes strong conclusions to be drawn.
Implications: More methodologically high quality studies are required to evaluate further the physiotherapy approach and establish the optimal TE and MT regimen thus allowing clinicians to take an evidence based practice approach when treating patients with TMD.
Funding, acknowledgements: No funding
Keywords: Temporomandibular disorders, Manual therapy and Therapeutic exercise, Dental occlusal splint
Topic: Musculoskeletal
Did this work require ethics approval? No
Institution: Orthopaedic Manual Therapy - Greece
Committee: Orthopaedic Manual Therapy - Greece
Reason: its a systematic review
All authors, affiliations and abstracts have been published as submitted.
