Self-care, education, and awareness of the patient with temporomandibular disorder: a systematic review

Giovanna Pimentel Daniel Bonotto Priscila Brenner Hilgenberg-Sydney About the authors

ABSTRACT

BACKGROUND AND OBJECTIVES:

Temporomandibular disorder consists of a variety of conditions associated with pain and dysfunction of the temporomandibular joint, masticatory muscles and associated structures. Self-care clinical protocols are commonly used as initial therapy for temporomandibular disorder patients after diagnosis as a conservative and non-invasive approach. This review aimed to study the self-care techniques in the literature and its efficacy.

CONTENTS:

This was a systematic review of the literature, with a survey in the databases Science Direct and Pubmed, in addition to the gray literature, Google Scholar. The following descriptors were used: “self-care”, “temporomandibular dysfunction” and “counseling”. Articles in English and Portuguese published between 2010 and 2018 were included. Twenty-one articles were selected based on a series of inclusion and exclusion criteria.

CONCLUSION:

There are two main objectives in the treatment of temporomandibular disorder patients, the reduction of pain and improvement of function. It was concluded that self-care therapies are effective in achieving these goals, in addition to being low-tech and non-invasive. Patients who actively participate in their healing process present faster improvements, by altering their general perception of pain.

Keywords:
Conservative treatment; Protocols; Temporomandibular joint disorders

RESUMO

JUSTIFICATIVA E OBJETIVOS:

Disfunção temporomandibu lar consiste em uma variedade de condições associadas com dor e disfunção da articulação temporomandibular, músculos da masti gação e estruturas associadas. Os protocolos clínicos de autocuidado são comumente usados como terapia inicial do paciente com disfun ção temporomandibular, após o diagnóstico, como uma abordagem conservadora e não invasiva. O objetivo deste estudo foi estudar as técnicas de autocuidado presentes na literatura e sua eficácia.

CONTEÚDO:

Foi realizada uma revisão sistemática da litera tura, com um levantamento nas bases de dados Science Direct e Pubmed, além da literatura cinzenta, Google Acadêmico. Os seguintes descritores foram utilizados: “autocuidado”, “disfunção temporomandibular” e “aconselhamento”. Artigos em inglês e português, publicados entre 2010 e 2018, foram incluídos. Vin te e um artigos foram selecionados com base em uma série de critérios de inclusão e exclusão.

CONCLUSÃO:

Há dois objetivos principais no tratamento do paciente com disfunção temporomandibular, sendo a redução da dor e a melhora da função. Concluiu-se que terapias de au tocuidado são efetivas em atingir estes objetivos, além de não -invasivas e de baixo custo tecnológico. Pacientes que participam ativamente no próprio processo de cura apresentam melhorias mais rapidamente, alterando sua percepção geral da dor.

Descritores:
Protocolos; Transtornos da articulação temporo mandibular; Tratamento conservador

INTRODUCTION

Self-management clinical protocols are commonly used as initial treatment for patients with temporomandibular disorders (TMD), after adequate diagnosis, as a conservative and non-invasive approach11 Durham J, Al-Baghdadi M, Baad-Hansen L, Breckons M, Goulet JP, Lobbezoo F, et al. Self-management programmes in temporomandibular disorders: results from an international Delphi process. J Oral Rehabil. 2016;43(12):929-36.. They should be simple enough to allow the patient’s control over the execution and enable healing and/or prevention of more injuries to the musculoskeletal system. The main objectives of any treatment for chronic pain consist in reducing pain and improving quality of life22 De Laat A, Stappaerts K, Papy S. Counseling and physical therapy as treatment for myofascial pain of the masticatory system. J Orofac Pain. 2003;17(1):42-9..

The variety of self-care techniques include education; jaw exercises (such as stretching and relaxation); massage; thermal therapy; dietary advice and nutrition; and parafunctional behavior identification, monitoring, and avoidance11 Durham J, Al-Baghdadi M, Baad-Hansen L, Breckons M, Goulet JP, Lobbezoo F, et al. Self-management programmes in temporomandibular disorders: results from an international Delphi process. J Oral Rehabil. 2016;43(12):929-36..

It is important for the professional to acknowledge such techniques because the adoption of a self-care protocol may be sufficient therapy for the adaptive and motivated patients, or it may be an essential part of a more complex and multidisciplinary treatment plan33 Türp JC, Jokstad A, Motschall E, Schindler HJ, Windecker-Gétaz I, Ettlin DA. Is there a superiority of multimodal as opposed to simple therapy in patients with temporomandibular disorders? A qualitative systematic review of the literature. Clin Oral Implants Res. 2007;18(Suppl 3):138-50..

The objectives of this present study were to systematically review the literature about the efficacy and applicability of self-management therapies to TMD patients, as well as orientations, education, and awareness of these patients, and to propose a clinical protocol.

CONTENTS

The included articles in this review were those concerning conservative and self-care therapies for the treatment of TMD patients. A period filter was applied to only select articles published between 2010 and 2018. There was also a filter for language and articles were accepted only in English and Portuguese.

Furthermore, the following exclusion criteria were applied: 1) Irreversible or more invasive treatments; 2) Pharmacotherapy; 3) Studies with children; and 4) Studies with patients with special needs.

Searches were performed in two databases: 1. Science Direct; 2. Pubmed; and the gray literature, Google Scholar. The last electronic database search was performed on February 27th, 2017.

The selected keywords were: I. Self-management, II. Temporomandibular disorders, and III. Counseling. The first search included only self-management (I); followed by temporomandibular disorders (II) alone. The searched combinations were: self-management and temporomandibular disorders (I and II); and self-management, temporomandibular disorders and counseling (I, II and III).

The elected search was the one that joined the keywords: self-management, temporomandibular disorders and counseling (I, II and III), with 209 results.

From the elected survey, these articles were pooled for a series of inclusion and exclusion steps, as shown in figure 1. The research presented many results not related specifically to the theme, so the first step aimed to reduce the total number of articles. First exclusion step consisted of reading the titles, and the unrelated ones were excluded. The second step was the pdf download of the results, selecting only those that were available at the Federal University of Paraná database. The third step consisted of removing the duplicate articles from the three databases. As a fourth and final step, the abstracts of the 33 remaining articles were read, and those concerning conservative and self-care therapies were selected, reaching a total of 21 articles.

Figure 1
Flowchart of the selection of the articles.

DISCUSSION

The scope of this systematic review was to synthesize the literature regarding conservative therapies and self-management guidelines, aiming at a biopsychosocial approach in the treatment of TMD patients.

TMD treatment is not standardized due to the different etiologies and distinct structures that might be affected44 Martins AP, Aquino LM, Meloto CB, Barbosa CM. Counseling and oral splint for conservative treatment of temporomandibular dysfunction: preliminary study. Rev Odontol UNESP. 2016;45(4):207-13.. However, the indication of self-care protocols, in addition to education and awareness of the patient’s own dysfunction, are powerful tools to relieve symptoms. Self-care new habits may be all that is required for those patients that are adaptive and self-motivated, and/or it also may be part of a more complex multi-modal treatment plan11 Durham J, Al-Baghdadi M, Baad-Hansen L, Breckons M, Goulet JP, Lobbezoo F, et al. Self-management programmes in temporomandibular disorders: results from an international Delphi process. J Oral Rehabil. 2016;43(12):929-36..

According to Heiskanen, Roine e Kalso55 Heiskanen T, Roine RP, Kalso E. Multidisciplinary pain treatment - which patients do benefit? Scand J Pain. 2012;3(4):201-7. health-related quality of life of chronic pain patients improved during a multi-disciplinary treatment, whereas the factors explaining poor response were not treatment-related, such as occupation and degree of education.

The main factors that might influence the outcome of a self-care program are self-efficacy, depression, pain catastrophizing and physical activity66 Miles CL, Pincus T, Carnes D, Homer KE, Taylor SJ, Bremner SA, Rahman A, et al. Can we identify how programmes aimed at promoting self-management in musculoskeletal pain work and who benefits? A systematic review of sub-group analysis within RCTs. Eur J Pain. 2011;15(8):775-e1-11.. These programs rely on a therapeutic alliance between clinician and patient, which requires patient cooperation and clinician commitment, such as monitoring and constant evaluation of the dysfunction’s progression, in order to readapt the therapeutic alternatives11 Durham J, Al-Baghdadi M, Baad-Hansen L, Breckons M, Goulet JP, Lobbezoo F, et al. Self-management programmes in temporomandibular disorders: results from an international Delphi process. J Oral Rehabil. 2016;43(12):929-36.. Other important measures include chronic pain being recognized as a disease and the adoption of a patient-centered and personalized treatment approach77 Kress HG, Aldington D, Alon E, Coaccioli S, Collett B, Coluzzi F, et al. A holistic approach to chronic pain management that involves all stakeholders: change is needed. Curr Med Res Opin. 2015;31(9):1743-54..

Schiffman et al.88 Schiffman EL, Velly AM, Look JO, Hodges JS, Swift JQ, Decker KL, et al. Effects of four treatment strategies for temporomandibular joint closed lock. Int J Oral Maxillofac Surg. 2014;43(2):217-26. compared four therapeutic approaches for the temporomandibular joint closed lock (two of them non-invasive, and the other two invasives), and found that there was no clinically significant difference. Therefore, educating and providing the patient with self-care techniques is the proper strategy for initial care. It empowers the patient to know that they have the innate ability to heal - and the clinician’s engagement, training them to do so, is a great facilitating factor11 Durham J, Al-Baghdadi M, Baad-Hansen L, Breckons M, Goulet JP, Lobbezoo F, et al. Self-management programmes in temporomandibular disorders: results from an international Delphi process. J Oral Rehabil. 2016;43(12):929-36..

The conservative therapy for TMD success rate can reach values above 90 percent, so there is no need for invasive, irreversible and high-tech treatments for most of the patients99 Martins-Júnior RL, Palma AJ, Marquardt EJ, Gondin TM, Kerber Fde C. Temporomandibular disorders: a report of 124 patients. J Contemp Dent Pract. 2010;11(5):71-8.. Conti, Corrêa and Lauris1010 Conti PC, Corrêa AS, Lauris JR, Stuginski-Barbosa J. Management of painful temporomandibular joint clicking with different intraoral devices and counseling: a controlled study. J Appl Oral Sci. 2015;23(5):529-35. found that all management strategies were effective in reducing the reported pain intensity, but patients improved faster when wearing occlusal devices associated with counseling and behavior changes. It is unlikely that self-care acts as a unique therapeutic strategy, however, this kind of self-regulatory behavior influences the overall pain perception11 Durham J, Al-Baghdadi M, Baad-Hansen L, Breckons M, Goulet JP, Lobbezoo F, et al. Self-management programmes in temporomandibular disorders: results from an international Delphi process. J Oral Rehabil. 2016;43(12):929-36..

The highest evidence of benefit in the treatment of a TMD patient points out to psychological interventions, more specifically cognitive behavioral therapy - especially when associated with biofeedback, reducing pain intensity, activity interference, and depression levels1111 Peters S, Goldthorpe J, McElroy C, King E, Javidi H, Tickle M, et al. Managing chronic orofacial pain: A qualitative study of patients', doctors', and dentists' experiences. Br J Health Psychol. 2015;20(4):777-91..

Orientations from the revised literature are shown in table 1. Based on that, a proposed self-management clinical protocol is shown in table 2. The intention is to distribute these orientations to TMD patients.

Table 1
Orientations for the clinician, regarding conservative therapies for the treatment of the temporomandibular disorders patient
Table 2
Self-management clinical protocol for the patient, including techniques and education with the purpose of awareness

DIFFICULTIES

There is a recognized difficulty in the establishment of a reference standard clinical protocol, or some type of guidelines for specific interventions, due to a lack of evidence of the efficacy of one treatment over another11 Durham J, Al-Baghdadi M, Baad-Hansen L, Breckons M, Goulet JP, Lobbezoo F, et al. Self-management programmes in temporomandibular disorders: results from an international Delphi process. J Oral Rehabil. 2016;43(12):929-36. and also because there are a great variety of methods used in clinical trials.

Moreover, it is known that having a confirmed diagnosis is a necessary step towards effective clinical management, which is particularly difficult for TMD’s, due to the multifactorial etiology of the TMD1111 Peters S, Goldthorpe J, McElroy C, King E, Javidi H, Tickle M, et al. Managing chronic orofacial pain: A qualitative study of patients', doctors', and dentists' experiences. Br J Health Psychol. 2015;20(4):777-91.. Several patients seek treatment for symptoms of diverse origins, or comorbidities, emphasizing the importance of differential diagnosis99 Martins-Júnior RL, Palma AJ, Marquardt EJ, Gondin TM, Kerber Fde C. Temporomandibular disorders: a report of 124 patients. J Contemp Dent Pract. 2010;11(5):71-8.. Orofacial pain management can be immensely challenging, so the clinician must be well aware of the variety of etiological factors and characteristics of these conditions1212 Mukherjee S, Sen S, Sinha S. Orofacial pain: a critical appraisal in management. Indian J Pain. 2015;29(3):127-34..

Another barrier is the impact of a wide range of demographic, clinical, psychological and social factors in the treatment outcome66 Miles CL, Pincus T, Carnes D, Homer KE, Taylor SJ, Bremner SA, Rahman A, et al. Can we identify how programmes aimed at promoting self-management in musculoskeletal pain work and who benefits? A systematic review of sub-group analysis within RCTs. Eur J Pain. 2011;15(8):775-e1-11.. Parafunctional habits, neuromuscular and psychosocial factors are involved in the development and maintenance of TMD’s signs and symptoms. Hence treatments that take into account only biomedical factors are often insufficient to promote long-term improvement1313 Giro G, Policastro VB, Scavassin PM, Leite AR, Mendoza Marin DO, Gonçalves DA, et al. Mandibular kinesiographic pattern of women with chronic TMD after management with educational and self-care therapies: a double-blind, randomized clinical trial. J Prosthet Dent. 2016;116(5):749-55..

CONCLUSION

There are two main objectives established for the treatment of the TMD patient: the control of pain severity and improvement of function. Current literature indicates that non-invasive and conservative therapies, with a good level of scientific evidence, are effective and more prudent.

Patients present better results when the professional is willing to inform them completely about their condition. This contributes to reducing the fear, depression and anxiety that are characteristic of the patient with chronic pain. It becomes the clinician responsibility to study the self-management therapies in the literature, in order to guide the patient in his individuality and in the particularities of his clinical case, enabling him in the light of his own dysfunction.

  • Sponsoring sources: none.

REFERENCES

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    De Laat A, Stappaerts K, Papy S. Counseling and physical therapy as treatment for myofascial pain of the masticatory system. J Orofac Pain. 2003;17(1):42-9.
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    Türp JC, Jokstad A, Motschall E, Schindler HJ, Windecker-Gétaz I, Ettlin DA. Is there a superiority of multimodal as opposed to simple therapy in patients with temporomandibular disorders? A qualitative systematic review of the literature. Clin Oral Implants Res. 2007;18(Suppl 3):138-50.
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    Martins AP, Aquino LM, Meloto CB, Barbosa CM. Counseling and oral splint for conservative treatment of temporomandibular dysfunction: preliminary study. Rev Odontol UNESP. 2016;45(4):207-13.
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Publication Dates

  • Publication in this collection
    Jul-Sep 2018

History

  • Received
    20 Feb 2018
  • Accepted
    01 Aug 2018
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