Intended for healthcare professionals

Practice Rapid Recommendations

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

BMJ 2023; 383 doi: https://doi.org/10.1136/bmj-2023-076227 (Published 15 December 2023) Cite this as: BMJ 2023;383:e076227 © 2023 BMJ Publishing Group Limited Disclaimer: This infographic is not a validated clinical decision aid. This information is provided without any representations, conditions or warranties that it is accurate or up to date. BMJ and its licensors assume no responsibility for any aspect of treatment administered with the aid of this information. Any reliance placed on this information is strictly at the user's own risk. For the full disclaimer wording see BMJ's terms and conditions: https://www.bmj.com/company/legal-information/ Visual summary of recommendation Population These recommendations apply only to people with these characteristics: Summary of recommendations People with temporomandibular disorder Evidence profiles Practical issues Values and preferences https://bit.ly/rr-tmd-cif Conditionalin favour Strongin favour https://bit.ly/rr-tmd-sif Strongagainst https://bit.ly/rr-tmd-sa Conditionalagainst https://bit.ly/rr-tmd-ca Use the interactive MATCH-IT multiple comparison tool to compare the effects of treatments across outcomes, and view the certainty of effect estimates Expense may be a barrier to accessing care delivered by therapists unless patients have private coverage Adverseeffects Serious adverse events are unlikely with exercise and cognitive behavioural therapy Long-term opioids, NSAIDs, and invasive or irreversible procedures are associated with a small risk of serious, potentially catastrophic, harms Both costs and access to cognitive behavioural therapy may be facilitated by remote delivery supported by therapists, which is less costly and likely similarly effective to in-person cognitive behavioural therapy Patientengagement Patient adherence is required for active interventions such as cognitive behavioural therapy and supervised exercise. Both feasibility and patient preference should be considered when initiating a trial of active therapy Cost and access Chronic painPatients who live with chronic pain associated with temporomandibular disorder place high value on small improvements in pain relief Acceptable risks - conservative and pharmacological therapies Patients were willing to accept the typical risks associated with conservative and most pharmacological therapies for an improvement in pain relief approximating the minimally important difference of 1 cm on a 10 cm visual analogue scale Acceptable risks - surgical therapies Patients were willing to accept the typical risks associated with surgical therapies for an improvement in pain approximating 3 times the minimally important difference Contextual differencesIn making recommendations, the panel recognised that values and preferences were likely to vary between patients and between different socio-cultural and health service contexts globally Additional areas of uncertainty There may be differential effects based on subtypes of temporomandibular disorder Research is needed into the many available interventions for chronic temporomandibular disorder that are currently supported by low or very low certainty evidence Evidence is required about how the interventions affect outcomes other than pain, including adverse events, which are important to patients ? Find recommendations, evidence summaries and consultation decision aids for use in your practice Does not apply to: May not apply to: Including: <3 months duration Acute temporomandibular disorder pain Adult patients with: Moderate severity chronic pain (4-6 out of 10 on visual pain scale) ≥3 monthsduration Associated with any type of temporomandibular disorder Myofascial Degenerative joint disease Mixed Internal derangement of the joint Patients with comorbidities Mental illness Fibromyalgia Rheumatoid arthritis Those who have previously undergone surgery for temporomandibular disorder Military veterans Individuals receiving disability benefits or engaged in litigation Start with interventions that are available and supported by a strong recommendation in favour, then conditional in favour, then conditional against. Do not offer interventions for which there is a strong recommendation against Strong recommendations in favour Conditional recommendations against Strong recommendations against Shared decision making is key in ensuring patients are offered treatments in line with: their values and preferences what they have already tried accessibility of treatments in their context NSAIDs + Opioid * details on specific co-interventions that have been evaluated can be found in the MATCH-IT tool All or nearly all informed people would likely want an intervention in this category. Benefits on pain relief or function are very likely to outweigh harms or burden Most people would likely not want an intervention in this category. Benefits on pain relief and function are uncertain, and they are associated with harms or burden All or nearly all informed people would likely not want an intervention in this category. Benefits on pain relief and function are uncertain, and they are associated with important harms Conditional recommendations in favour Most, but not all, informed people would likely want an intervention in this category. Benefits on pain relief or function are likely to outweigh harms or burden Cognitive behavioural therapy + NSAIDs Jaw exercise + jaw stretching + trigger point therapy Jaw exercise + jaw mobilisation Augmented cognitive behavioural therapy Cognitive behavioural therapy Jaw mobilisation Postural exercise Jaw exercise + jaw stretching Trigger point therapy Usual care Acupuncture Manipulation Manipulation + postural exercise Acetaminophen with or without muscle relaxants or NSAIDS Arthrocentesis with or without co-interventions* Benzodiazepine Beta-blockers Biofeedback Botulinum toxin injection Capsaicin cream Cartilage supplement with or without hyaluronic acid injection Gabapentin Hyaluronic acid injection Low-level laser therapy with or without co-interventions* NSAIDs with or without steroids Relaxation therapy Removable occlusal splint with or without co-interventions* Steroid injection Transcutaneous electrical nerve stimulation Trigger point injection Ultrasound-guided arthrocentesis Discectomy Irreversible oral splint

Linked Editorial

Chronic pain associated with temporomandibular disorders

Linked Research

Management of chronic pain secondary to temporomandibular disorders: a systematic review and network meta-analysis of randomised trials