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

CLINICAL QUESTION: What is the comparative effectiveness of available therapies for chronic pain associated with temporomandibular disorders (TMD)? CURRENT PRACTICE: TMD are the second most common musculoskeletal chronic pain disorder after low back pain, affecting 6-9% of adults globally. TMD are associated with pain affecting the jaw and associated structures and may present with headaches, earache, clicking, popping, or crackling sounds in the temporomandibular joint, and impaired mandibular function. Current clinical practice guidelines are largely consensus-based and provide inconsistent recommendations. RECOMMENDATIONS: For patients living with chronic pain (≥3 months) associated with TMD, and compared with placebo or sham procedures, the guideline panel issued: (1) strong recommendations in favour of cognitive behavioural therapy (CBT) with or without biofeedback or relaxation therapy, therapist-assisted mobilisation, manual trigger point therapy, supervised postural exercise, supervised jaw exercise and stretching with or without manual trigger point therapy, and usual care (such as home exercises, stretching, reassurance, and education); (2) conditional recommendations in favour of manipulation, supervised jaw exercise with mobilisation, CBT with non-steroidal anti-inflammatory drugs (NSAIDS), manipulation with postural exercise, and acupuncture; (3) conditional recommendations against reversible occlusal splints (alone or in combination with other interventions), arthrocentesis (alone or in combination with other interventions), cartilage supplement with or without hyaluronic acid injection, low level laser therapy (alone or in combination with other interventions), transcutaneous electrical nerve stimulation, gabapentin, botulinum toxin injection, hyaluronic acid injection, relaxation therapy, trigger point injection, acetaminophen (with or without muscle relaxants or NSAIDS), topical capsaicin, biofeedback, corticosteroid injection (with or without NSAIDS), benzodiazepines, and ß blockers; and (4) strong recommendations against irreversible oral splints, discectomy, and NSAIDS with opioids. HOW THIS GUIDELINE WAS CREATED: An international guideline development panel including patients, clinicians with content expertise, and methodologists produced these recommendations in adherence with standards for trustworthy guidelines using the GRADE approach. The MAGIC Evidence Ecosystem Foundation (MAGIC) provided methodological support. The panel approached the formulation of recommendations from the perspective of patients, rather than a population or health system perspective. THE EVIDENCE: Recommendations are informed by a linked systematic review and network meta-analysis summarising the current body of evidence for benefits and harms of conservative, pharmacologic, and invasive interventions for chronic pain secondary to TMD. UNDERSTANDING THE RECOMMENDATION: These recommendations apply to patients living with chronic pain (≥3 months duration) associated with TMD as a group of conditions, and do not apply to the management of acute TMD pain. When considering management options, clinicians and patients should first consider strongly recommended interventions, then those conditionally recommended in favour, then conditionally against. In doing so, shared decision making is essential to ensure patients make choices that reflect their values and preference, availability of interventions, and what they may have already tried. Further research is warranted and may alter recommendations in the future.

Evidence-based clinical practice guideline for the pharmacologic management of acute dental pain in children: A report from the American Dental Association Science and Research Institute, the University of Pittsburgh School of Dental Medicine, and the Center for Integrative Global Oral Health at the University of Pennsylvania.

BACKGROUND: A guideline panel convened by the American Dental Association Council on Scientific Affairs, American Dental Association Science and Research Institute, University of Pittsburgh School of Dental Medicine, and Center for Integrative Global Oral Health at the University of Pennsylvania conducted a systematic review and meta-analyses and formulated evidence-based recommendations for the pharmacologic management of acute dental pain after 1 or more simple and surgical tooth extractions and the temporary management of toothache (that is, when definitive dental treatment not immediately available) associated with pulp and furcation or periapical diseases in children (< 12 years). TYPES OF STUDIES REVIEWED: The authors conducted a systematic review to determine the effect of analgesics and corticosteroids in managing acute dental pain. They used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty of the evidence and the Grading of Recommendations Assessment, Development and Evaluation Evidence to Decision framework to formulate recommendations. RESULTS: The panel formulated 7 recommendations and 5 good practice statements across conditions. There is a small beneficial net balance favoring the use of nonsteroidal anti-inflammatory drugs alone or in combination with acetaminophen compared with not providing analgesic therapy. There is no available evidence regarding the effect of corticosteroids on acute pain after surgical tooth extractions in children. CONCLUSIONS AND PRACTICAL IMPLICATIONS: Nonopioid medications, specifically nonsteroidal anti-inflammatory drugs like ibuprofen and naproxen alone or in combination with acetaminophen, are recommended for managing acute dental pain after 1 or more tooth extractions (that is, simple and surgical) and the temporary management of toothache in children (conditional recommendation, very low certainty). According to the US Food and Drug Administration, the use of codeine and tramadol in children for managing acute pain is contraindicated.

Injectable and topical local anesthetics for acute dental pain: 2 systematic reviews.

BACKGROUND: Local anesthesia is essential for pain control in dentistry. The authors assessed the comparative effect of local anesthetics on acute dental pain after tooth extraction and in patients with symptomatic irreversible pulpitis. TYPES OF STUDIES REVIEWED: The authors searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and the US Clinical Trials registry through November 21, 2020. The authors included randomized controlled trials (RCTs) comparing long- vs short-acting injectable anesthetics to reduce pain after tooth extraction (systematic review 1) and evaluated the effect of topical anesthetics in patients with symptomatic pulpitis (systematic review 2). Pairs of reviewers screened articles, abstracted data, and assessed risk of bias using a modified version of the Cochrane risk of bias 2.0 tool. The authors assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS: Fourteen RCTs comparing long- vs short-acting local anesthetics suggest that bupivacaine may decrease the use of rescue analgesia and may not result in additional adverse effects (low certainty evidence). Bupivacaine probably reduces the amount of analgesic consumption compared with lidocaine with epinephrine (mean difference, -1.91 doses; 95% CI, -3.35 to -0.46; moderate certainty) and mepivacaine (mean difference, -1.58 doses; 95% CI, -2.21 to -0.95; moderate certainty). Five RCTs suggest that both benzocaine 10% and 20% may increase the number of people experiencing pain reduction compared with placebo when managing acute irreversible pulpitis (low certainty). PRACTICAL IMPLICATIONS: Bupivacaine may be superior to lidocaine with epinephrine and mepivacaine with regard to time to and amount of analgesic consumption. Benzocaine may be superior to placebo in reducing pain for 20 through 30 minutes after application.

Efficacy of adjuvant laser therapy in reducing postsurgical complications after the removal of impacted mandibular third molars: A systematic review update and meta-analysis.

BACKGROUND: The authors updated a previously published systematic review to assess the effects of low-level laser therapy (LLLT) on reducing complications after the removal of impacted mandibular third molars. TYPES OF STUDIES REVIEWED: The authors searched for randomized clinical trials in which the investigators evaluated the efficacy of LLLT compared with that of placebo or no treatment. Two reviewers independently screened studies, extracted data, and assessed risk of bias. The authors used random effects model meta-analysis and the Grading of Recommendations Assessment, Development and Evaluation approach to rate the certainty of evidence. RESULTS: The authors included 21 studies. There was low-certainty evidence that LLLT results in less pain at 2 days after surgery (mean difference [MD], -1.42 on a 10 point scale; 95% confidence interval [CI], -2.18 to -0.67) and moderate certainty that it results in negligibly less pain at 7 days (MD, -0.59; 95% CI, -0.96 to -0.22); moderate-certainty evidence that LLLT has a negligible benefit on reducing trismus at 2 days (MD, -3.42 millimeters; 95% CI, -5.34 to -1.50) and at 7 days after surgery (MD, -2.30 mm; 95% CI, -3.96 to -0.64); lastly, there was moderate-certainty evidence that LLLT results in less postoperative swelling at 2 days (standardized MD, -0.82; 95% CI, -1.28 to -0.35) and low-certainty evidence that LLLT results in negligibly less postoperative swelling at 7 days after surgery (standardized MD, -0.17; 95% CI, -0.4 to 0.07). Low-quality evidence suggests that LLLT will not cause adverse effects. CONCLUSIONS AND PRACTICAL IMPLICATIONS: LLLT probably has negligible benefits but may not result in adverse events. Evidence does not support the use of LLLT in clinical practice to reduce complications after impacted mandibular third-molar surgical extractions.

Hypnosis/Relaxation therapy for temporomandibular disorders: a systematic review and meta-analysis of randomized controlled trials.

AIMS: To conduct a systematic review and meta-analysis to evaluate the effectiveness of hypnosis/relaxation therapy compared to no/minimal treatment in patients with temporomandibular disorders (TMD). METHODS: Studies reviewed included randomized controlled trials (RCTs) where investigators randomized patients with TMD or an equivalent condition to an intervention arm receiving hypnosis, relaxation training, or hyporelaxation therapy, and a control group receiving no/minimal treatment. The systematic search was conducted without language restrictions, in Medline, EMBASE, CENTRAL, and PsycINFO, from inception to June 30, 2014. Studies were pooled using weighted mean differences and pooled risk ratios (RRs) for continuous outcomes and dichotomous outcomes, respectively, and their associated 95% confidence intervals (CI). RESULTS: Of 3,098 identified citations, 3 studies including 159 patients proved eligible, although none of these described their method of randomization. The results suggested limited or no benefit of hypnosis/relaxation therapy on pain (risk difference in important pain -0.06; 95% CI: -0.18 to 0.05; P = .28), or on pressure pain thresholds on the skin surface over the temporomandibular joint (TMJ) and masticatory muscles. Low-quality evidence suggested some benefit of hypnosis/relaxation therapy on maximal pain (mean difference on 100-mm scale = -28.33; 95% CI: -44.67 to -11.99; P =.007) and active maximal mouth opening (mean difference on 100-mm scale = -2.63 mm; 95% CI: -3.30 mm to -1.96 mm; P < .001) compared to no/minimal treatment. CONCLUSION: Three RCTs were eligible for the systematic review, but they were with high risk of bias and provided low-quality evidence, suggesting that hypnosis/relaxation therapy may have a beneficial effect on maximal pain and active maximal mouth opening but not on pain and pressure pain threshold. Larger RCTs with low risk of bias are required to confirm or refute these findings and to inform other important patient outcomes.

Oral health care for patients with epidermolysis bullosa--best clinical practice guidelines.

OBJECTIVE: To provide the users with information on the current best practices for managing the oral health care of people living with EB. METHODS: A systematic literature search, in which the main topic is dental care in patients with Epidermolysis Bullosa, was performed. Consulted sources, ranging from 1970 to 2010, included MEDLINE, EMBASE, CINAHL, The Cochrane Library, DARE, and the Cochrane controlled trials register (CENTRAL). In order to formulate the recommendations of the selected studies the SIGN system was used. The first draft was analysed and discussed by clinical experts, methodologists and patients representatives on a two days consensus meeting. The resulting document went through an external review process by a panel of experts, other health care professionals, patient representatives and lay reviewers. The final document was piloted in three different centres in United Kingdom, Czech Republic and Argentina. RESULTS: The guideline is composed of 93 recommendations divided into 3 main areas: 1) Oral Care--access issues, early referral, preventative strategies, management of microstomia, prescriptions and review appointments 2) Dental treatment: general treatment modifications, radiographs, restorations, endodontics, oral rehabilitation, periodontal treatment, oral surgery and orthodontics, and 3) Anaesthetic management of dental treatment. CONCLUSIONS: A preventive protocol is today's dental management approach of choice.

Is adjuvant laser therapy effective for preventing pain, swelling, and trismus after surgical removal of impacted mandibular third molars? A systematic review and meta-analysis.

PURPOSE: To assess the efficacy and safety of low-level laser energy irradiation (LLEI) for decreasing pain, swelling, and trismus after surgical removal of impacted mandibular third molars (IMTMs). MATERIALS AND METHODS: MEDLINE, EMBASE, and the Central Register of Controlled Trials of the Cochrane Library were searched from their inception, and conference proceedings, cross-references, and gray literature were searched for the last 5 years for randomized and quasi-randomized controlled trials that evaluated the effects of any type of LLEI, compared with active or inactive treatments, in patients undergoing surgical removal of IMTMs. Risk of bias in included studies was assessed by 2 independent evaluators using the Cochrane Risk of Bias tool. A random-effects model meta-analysis was used to estimate the mean difference of trismus between the groups. Heterogeneity was assessed using Cochran χ(2) and I(2). RESULTS: Ten eligible trials were included in this systematic review. The included studies overall had a moderate risk of bias. Because of heterogeneity in the intervention and outcomes assessments, pain and swelling outcomes were only qualitatively summarized and indicated no beneficial effects of LLEI over placebo. Patients receiving LLEI had an average of 4.2 mm (95% confidence interval, 1.2 to 7.2) and 5.2 mm (95% confidence interval, 1.8 to 8.2) less trismus than patients receiving no active treatment on the second and seventh day after the surgery, respectively. CONCLUSIONS: There was no benefit of LLEI on pain or swelling and a moderate benefit on trismus after removal of IMTMs. It is necessary to standardize the intervention and outcomes assessment and to conduct adequately powered, well-designed trials to evaluate the efficacy of LLEI.