Decision-making in the management of TMJ disc displacement without reduction: A qualitative study.

OBJECTIVE: Patients with disc displacement without reduction (DDwoR) may suffer sudden-onset painful/limited mouth opening and immediately seek care from clinicians at the frontline. Currently, there is a lack of understanding of frontline, and specialist, clinicians' decision-making processes when encounter DDwoR patients. Understanding these processes and what influences them is an essential first-step towards the development of an evidence-informed behavioural intervention to improve first-line care of DDwoR patients. The objective of this study was to examine clinicians' decision-making processes in managing DDwoR and influences upon them. METHODS: A qualitative study informed by the Theoretical behaviour change Domains Framework (TDF) was conducted. The TDF-based topic guide was utilised in semi-structured interviews with a purposive sample of medical and dental frontline and specialist clinicians who might encounter patients with DDwoR. Interviews continued until data saturation across the theoretical domains was achieved (n = 21) and were analysed using the TDF to structure coding alongside framework analysis. RESULTS: The results highlighted the complexity of decision-making process and demonstrated the influences of all the domains on clinicians' decisions. Of the influential factors identified, the frontline clinicians placed most emphasis on their lack of: 'knowledge', 'skills', and 'experience' with DDwoR management. CONCLUSION: The clinicians at the frontline showed high degree of diagnostic and management uncertainty and preferred to refer DDwoR patients early. The frontline clinicians displayed lack of knowledge, experience, and training to diagnose and treat DDwoR. There is a need to enhance the clinicians' knowledge and skills in managing DDwoR at the first-point of contact. CLINICAL SIGNIFICANCE: The frontline clinicians showed unfamiliarity with DDwoR presentation and inability to diagnose and, consequently, treat DDwoR. This indicates that DDwoR patients may, currently, receive sub-optimal first-line care in the UK. Designing a behaviour change intervention informed by the identified theoretical domains can support the clinicians' decisions and improve patients' care.

Self-management programmes in temporomandibular disorders: results from an international Delphi process.

Self-management (SM) programmes are commonly used for initial treatment of patients with temporomandibular disorders (TMD). The programmes described in the literature, however, vary widely with no consistency in terminology used, components of care or their definitions. The aims of this study were therefore to construct an operationalised definition of self-management appropriate for the treatment of patients with TMD, identify the components of that self-management currently being used and create sufficiently clear and non-overlapping standardised definitions for each of those components. A four-round Delphi process with eleven international experts in the field of TMD was conducted to achieve these aims. In the first round, the participants agreed upon six principal concepts of self-management. In the remaining three rounds, consensus was achieved upon the definition and the six components of self-management. The main components identified and agreed upon by the participants to constitute the core of a SM programme for TMD were as follows: education; jaw exercises; massage; thermal therapy; dietary advice and nutrition; and parafunctional behaviour identification, monitoring and avoidance. This Delphi process has established the principal concepts of self-management, and a standardised definition has been agreed with the following components for use in clinical practice: education; self-exercise; self-massage; thermal therapy; dietary advice and nutrition; and parafunctional behaviour identification, monitoring and avoidance. The consensus-derived concepts, definitions and components of SM offer a starting point for further research to advance the evidence base for, and clinical utility of, TMD SM.

Self-management in temporomandibular disorders: a systematic review of behavioural components.

The aim of this qualitative systematic review was to identify the behaviour change techniques most frequently employed in published temporomandibular disorder (TMD) self-management (SM) programmes. The reviewers matched the components of SM programmes into the relevant behaviour change technique domains according to the definitions of the behaviour change taxonomy (version 1). Electronic databases were searched for randomised controlled trials assessing an SM programme for TMD. Manual searches were also conducted for potentially important journals. Eligibility criteria for the review included: the type of study, the participants, the intervention utilised and the comparators/control. Fifteen randomised controlled trials with 554 patients were included in this review. The review concludes a minority of the available behaviour change techniques are currently employed in SM programmes. Other behaviour change techniques should be examined to see whether there is a theoretical underpinning that might support their inclusion in self-management programmes in TMD. Further trials are required to conclude that SM programmes are more effective than no treatment at all and or placebo. With more structured SM programmes, greater therapeutic benefits might be achieved, and certainly if SM programmes published in the literature define their components through use of the behaviour change taxonomy, it would be easier for clinicians to replicate efficacious programmes.

TMJ Disc Displacement without Reduction Management: A Systematic Review.

Various interventions have been used for the management of patients with temporomandibular joint (TMJ) disc displacement without reduction (DDwoR), but their clinical effectiveness remains unclear. This systematic review investigated the effects of these interventions and is reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Electronic and manual searches up to November 1, 2013, were conducted for English-language, peer-reviewed, publications of randomized clinical trials comparing any form of conservative or surgical interventions for patients with clinical and/or radiologic diagnosis of acute or chronic DDwoR. Two primary outcomes (TMJ pain intensity and maximum mouth opening) and a number of secondary outcomes were examined. Two reviewers performed data extraction and risk of bias assessment. Data collection and analysis were performed according to Cochrane recommendations. Twenty studies involving 1,305 patients were included. Data analysis involved 21 comparisons between a variety of interventions, either between interventions, or between intervention and placebo or no intervention. Meta-analysis on homogenous groups was conducted in 4 comparisons. In most comparisons made, there were no statistically significant differences between interventions relative to primary outcomes at short- or long-term follow-up (p > .05). In a separate analysis, however, the majority of reviewed interventions reported significantly improved primary outcome measures from their baseline levels over time (p < .05). Evidence levels, however, are currently insufficient for definitive conclusions, because the included studies were too heterogeneous and at an unclear to high risk of bias. In view of the comparable therapeutic effects, paucity of high-quality evidence, and the greater risks and costs associated with more complex interventions, patients with symptomatic DDwoR should be initially treated by the simplest and least invasive intervention.

Timing interventions in relation to temporomandibular joint closed lock duration: a systematic review of 'locking duration'.

Temporomandibular joint (TMJ) 'closed lock' (CL) is a clinical condition causing TMJ pain and limited mouth opening (painful locking) that is mostly attributed to disc displacement without reduction (DDwoR), or less commonly to anchored disc phenomenon (ADP). Both conditions are described clinically as CL that can be 'acute' or 'chronic' depending on the duration of locking. There is, however, no consensus about the duration of locking that defines the acute state and its effect on the success of interventions. This review paper, therefore, aims to provide: (i) a narrative review of the pathophysiological need for early intervention in DDwoR and the clinical implications of acute/chronic CL stages on the management pathway; (ii) a systematic review investigating the effects of locking duration on the success of interventions for CL management. Electronic and manual searches until mid-August 2013 were conducted for English-language studies of any design investigating the effects of non-surgical and surgical interventions for acute or chronic CL (DDwoR or ADP). A total of 626 records were identified, and 113 studies were included. Data extraction and quality assessment were completed for all included studies. Included studies were, however, heterogeneous and mostly of poor-quality leading to contradictory and inconsistent evidence on the effect of the duration of locking on treatment outcomes. Future high-quality trials investigating the effect of CL duration on treatment outcome are needed. At present, early intervention by 'unlock' mandibular manipulation seems to be the most practical and realistic approach that can be attempted first in every CL patient as an initial diagnostic/therapeutic approach.