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

May combine two claims.

Of the five most recently published temporomandibular disorder guidelines, four do not report the methodology used for their development and provide lists of available treatments without information on comparative effectiveness or certainty of evidence.

“Of the five most recently published guidelines, four do not report the methodology used for their development, and they provide lists of available conservative and invasive treatments for TMD without information on comparative effectiveness or certainty of evidence.”

• cites [20] sourceCould not verify

  The Methods (Sensitivity analysis; page unavailable) mention TMD diagnostic guidelines, while the Discussion (Alternative treatment options for TMD; page unavailable) lists treatments. Neither assesses five recently published treatment guidelines or says that four omit development methods, comparative effectiveness, or certainty of evidence. Searches for those specific guideline claims found no passage addressing them. (LLM, conf=0.75)

  Experimental — accuracy not yet measured
• cites [21] sourceNot checked — no full text of the source
• cites [25] Royal College of Dental Surgeons of Ontario. Diagnosis and management of temporomandibular disorders. 2019. https://az184419.vo.msecnd.net/rcdso/pdf/guidelines/RCDSO_Guidelines_Diagnosis_and_Management_of_TMD.pdf.Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

The linked systematic review included 210 studies (233 publications), of which 153 trials (8713 participants) were included in network meta-analyses.

“The linked systematic review included 210 studies (in 233 publications), of which 153 trials (8713 participants) were included in network meta-analyses.”

• cites [1] sourcePartly supported

  The Results report 233 publications covering 210 eligible trials, and 153 studies enrolling 8713 patients in the meta-analyses. However, the study-selection figure labels the quantitative synthesis as including both network and conventional meta-analysis; the copy does not establish that all 153 trials were included in network meta-analyses specifically. (LLM, conf=0.85)

  Experimental — accuracy not yet measured

May combine two claims.

The 2018 guideline from the Korea Standard CPG Development Agency conducted systematic reviews to identify evidence but only considered Korean medicine treatments.

“The exception, the 2018 guideline from the Korea Standard CPG Development Agency, conducted systematic reviews of the literature to identify evidence to inform their recommendations, but only considered Korean medicine treatments.”

• cites [26] sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The guideline followed the BMJ Rapid Recommendations procedures for creating trustworthy guidance, including using the GRADE approach to critically appraise the evidence and create recommendations.

“We followed the BMJ Rapid Recommendations procedures for creating trustworthy guidance, 41 including using the GRADE approach to critically appraise the evidence and create recommendations (appendix 2 on bmj.com).42”

• cites [41] sourceNot checked — no full text of the source
• cites [42] sourceSupported

Classified as probably not a substantial claim.

The recommendations are based on a linked systematic review and network meta-analysis.

“Our recommendations are based on a linked systematic review and network meta-analysis (see box 1). 1”

• cites [1] sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The draft summary of findings was prepared prior to the panel meetings, following GRADE guidance from the accompanying network meta-analysis.

“The draft summary of findings were prepared prior to the panel meetings, following GRADE guidance from the accompanying network meta-analysis. 1”

• cites [1] sourcePartly supported

  The Certainty of evidence section says the network meta-analysis followed GRADE guidance for communicating its findings, and the Additional analysis section identifies a summary of findings. Neither section, nor the Guideline panel involvement section, says a draft summary was prepared before panel meetings. (LLM, conf=0.82)

  Experimental — accuracy not yet measured

May combine two claims.

Access to CBT may be facilitated by therapist-supported remote delivery, which is less costly than and likely similarly effective to in-person CBT.

“Access to cognitive behavioural therapy (CBT) may be facilitated by therapist-supported remote delivery, which is less costly than and likely similarly effective to in-person CBT 38 39 44”

• cites [38] Zandieh S Abdollahzadeh M Inness BE . Remote versus in-person cognitive behavioural therapy: a systematic review and meta-analysis of randomized trials. CMAJ forthcoming.Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites [39] sourceNot checked — no full text of the source
• cites [44] sourcePartly supported

  The Introduction says therapist-guided internet CBT can improve access, and the Cost-effectiveness Analysis reports substantially lower costs than face-to-face CBT. But the Results (Primary Outcome; page not provided) say noninferiority at three months was inconclusive, so the claim of likely similar effectiveness is stronger than this trial establishes. The findings concern adults with OCD. (LLM, conf=0.86)

  Experimental — accuracy not yet measured

May combine two claims.

Serious adverse events are unlikely with exercise and CBT.

“Serious adverse events are unlikely with exercise 45 and CBT 46”

• cites [45] sourceSupported
• cites [46] sourcePartly supported

  The Discussion reports that clients did not mention severe adverse events, such as suicidality or hospitalization, in emails to their therapists. That supports an absence of reported events in this internet-delivered CBT sample, but it does not establish that serious adverse events are generally unlikely with CBT. The exercise portion is attached to a different citation and is not judged here. (LLM, conf=0.83)

  Experimental — accuracy not yet measured

Classified as probably not a substantial claim.

The 59 interventions were classified into four sets of recommendations according to strength and direction relative to placebo or sham procedures.

“The 59 interventions summarised in the associated network meta-analysis were classified into four sets of recommendations, according to their strength and direction, relative to placebo or sham procedures.”

May combine two claims.

Studies typically enrolled small numbers of patients with short follow-up, predominantly women aged 30-39 years with longstanding chronic temporomandibular disorder pain of moderate severity.

“Studies typically enrolled small numbers of patients with short follow-up, and predominantly included women aged 30-39 years with longstanding chronic TMD pain of moderate severity.”

Classified as probably not a substantial claim. May combine two claims.

The experts felt that most invasive procedures, such as arthrocentesis and trigger point injections, were associated with the possibility of moderate harm, and that discectomy and irreversible splints may result in serious harms.

“Our experts felt that most invasive procedures, such as arthrocentesis and trigger point injections, were associated with the possibility of moderate harm (such as local infection), and that discectomy and irreversible splints may result in serious harms (such as permanent change in range of motion, facial nerve weakness).”

May combine two claims.

The panel found moderate to high certainty evidence for important benefits on pain relief for cognitive behavioural therapy (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.

“As we found moderate to high certainty evidence for important benefits on pain relief (our critical outcome), and the guideline panel was confident that the interventions were not associated with serious harms”

The quote only partly states this claim.

Relative to placebo or sham procedures, cognitive behavioural therapy augmented with relaxation therapy or biofeedback, therapist-assisted jaw mobilisation, and manual trigger point therapy provide the largest reduction in chronic pain severity associated with temporomandibular disorders, approximating twice the minimally important difference (GRADE moderate certainty evidence).

“Cognitive behavioural therapy (CBT) augmented with relaxation therapy or biofeedback, therapist-assisted jaw mobilisation, and manual trigger point therapy provide the largest reduction in chronic pain severity associated with TMD, approximating twice the minimally important difference (MID) (GRADE moderate certainty evidence).”

• AssumptionRests on an assumption: The minimally important difference for chronic pain associated with temporomandibular disorders is 1 cm on a 10 cm visual analogue scale.

May combine two claims.

Many trials eligible for the review excluded temporomandibular disorder patients with comorbid mental illness, fibromyalgia, or rheumatoid arthritis, or those who had previously undergone temporomandibular disorder surgery, and did not report representation of veterans or individuals receiving disability benefits or engaged in litigation.

“Many trials eligible for our review excluded TMD patients with comorbid mental illness, fibromyalgia, or rheumatoid arthritis, or those who had previously undergone TMD surgery, and did not report the representation of veterans (who seem to be more prone to developing TMD 33 ) or of individuals receiving disability benefits or engaged in litigation.”

Classified as probably not a substantial claim.

Due to the greater risk of moderate or serious harms, patients would likely require an improvement in pain approximating three times the minimally important difference with invasive or irreversible procedures.

“However, due to the greater risk of moderate or serious harms, patients would likely require an improvement in pain approximating three times the MID with invasive or irreversible procedures.”

• AssumptionRests on an assumption: The minimally important difference for chronic pain associated with temporomandibular disorders is 1 cm on a 10 cm visual analogue scale.

May combine two claims.

Most trials enrolled mixed types of temporomandibular disorders or did not specify subtypes; of those providing details, the most commonly enrolled subtype was myalgia.

“Most trials enrolled mixed types of TMD or did not specify which subtypes were included; of those that did provide details, the most commonly enrolled subtype of TMD was myalgia (table 2).”

May combine two claims.

Trials for most interventions did not report effects on adverse events, and of the 32% (19 of 59) of interventions that did report data on harms, the evidence was almost entirely very low certainty.

“Trials for most interventions did not report effects on adverse events, and of the 32% (19 of 59) of interventions that did report data on harms, the evidence was almost entirely very low certainty.”

May combine two claims.

The network meta-analysis included 153 eligible randomised clinical trials with 8713 patients.

“Table 2 | Characteristics of 153 eligible randomised clinical trials (8713 patients) included in the network meta-analysis of interventions for chronic pain associated with temporomandibular disorders (TMD).”

Classified as probably not a substantial claim.

Aside from usual care, seven interventions have strong recommendations in favour.

“Aside from usual care, there are seven interventions with strong recommendations in favour; however, they all require active participation by patients.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Several conservative interventions showed important net benefits for pain relief and/or functional improvement.

“Our patient partners agreed that, while several conservative interventions showed important net benefits for pain relief and/or functional improvement, individual patients may prefer some types of interventions over others.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

No panel member had financial conflicts of interest; intellectual and professional conflicts were minimised and managed.

“No panel member had financial conflicts of interest; intellectual and professional conflicts were minimised and managed (see appendix 1 on bmj.com for details).”

May combine two claims.

Some treatment effects were rated down due to substantial unexplained heterogeneity, and different subtypes of temporomandibular disorders may benefit more or less from certain interventions.

“Some treatment effects were rated down due to substantial unexplained heterogeneity, and we cannot rule out the possibility that different subtypes of TMD may benefit more or less from certain interventions.”

May combine two claims.

Current clinical practice guidelines for temporomandibular disorders are largely consensus-based and provide inconsistent recommendations.

“Current clinical practice guidelines are largely consensus-based and provide inconsistent recommendations.”

• Also stated in: § Current practice · plain

  “Clinical practice guidelines have emerged to support decision making for TMD, but with inconsistent recommendations (table 1) and important limitations in their development.”

Probably not a substantial claim: may not pass S3 (load-bearing).

It is unlikely that new information will change interpretation for outcomes supported by high to moderate certainty of evidence.

“It is unlikely that new information will change interpretation for outcomes that are supported by high to moderate certainty of evidence.”

May combine two claims.

A systematic assessment of all temporomandibular disorder clinical practice guidelines published up to May 2020 found considerable deficits in development and reporting and concluded there was a need for rigorously developed guidelines.

“A systematic assessment of all clinical practice guidelines on diagnosis and management of TMD published up to May 2020, found considerable deficits in the development and reporting among each of them and concluded there was a need for rigorously developed guidelines.”

• cites [28] sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

The panel recognised that values and preferences were likely to vary between patients.

“The panel recognised that values and preferences were likely to vary between patients, further highlighting the importance of shared decision.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

Expense may be a barrier to accessing therapist-delivered care unless patients have private health coverage or reside in a jurisdiction where these services are included in public health care.

“Expense may be a barrier to accessing therapists-delivered care unless patients have private health coverage or reside in a jurisdiction where these services are included in public health care”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

Patient adherence is required for active interventions such as CBT and supervised exercise.

“Patient adherence is required for active interventions (such as CBT, supervised exercise): both feasibility and patient preference should be considered when starting a trial of therapy”

Probably not a substantial claim: may not pass S3 (load-bearing).

Individual patients may prefer some types of interventions for chronic pain associated with TMD over others.

“Our patient partners agreed that, while several conservative interventions showed important net benefits for pain relief and/or functional improvement, individual patients may prefer some types of interventions over others.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Three patients with lived experience of chronic pain associated with TMD were full members of the guideline panel.

“Three patients with lived experience of chronic pain associated with TMD were full members of our guideline panel.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The executive team and The BMJ judged that no panel member had any financial conflict of interest.

“As with all BMJ Rapid Recommendations, the executive team and The BMJ judged that no panel member had any financial conflict of interest.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The guideline required 80% consensus among panel members for strong recommendations, and a majority consensus for conditional recommendations.

“We required 80% consensus among panel members for strong recommendations, and a majority consensus for conditional recommendations.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The patient panel members participated in the teleconferences and email discussions and met all authorship criteria.

“These panel members participated in the teleconferences and email discussions and met all authorship criteria.”

Probably not a substantial claim: may not pass S3 (load-bearing).

When formulating the recommendations, the guideline panel focused on patients' perspectives rather than that of society.

“When formulating the recommendations, the guideline panel focused on patients' perspectives rather than that of society.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

“The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Each intervention recommended in this guideline requires clinician administration and depends on access and patient participation.

“Each recommended intervention requires clinician administration and depends on access and patient participation, and may entail costs that are borne by patients.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Personal, professional, and academic interests were minimised as much as possible while maintaining necessary expertise on the panel to make fully informed decisions.

“Personal, professional, and academic interests were minimised as much as possible, while maintaining necessary expertise on the panel to make fully informed decisions.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The patient panel members identified important outcomes and informed the discussion on values and preferences.

“These panel members identified important outcomes and informed the discussion on values and preferences.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The recommended interventions may entail costs that are borne by patients.

“Each recommended intervention requires clinician administration and depends on access and patient participation, and may entail costs that are borne by patients.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The consensus process was overseen by two experienced guideline methodologists.

“The consensus process was overseen by two experienced guideline methodologists (JWB, TA).”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

Both availability and costs of interventions for chronic pain associated with TMD may influence decision making.

“However, both availability and costs of interventions for chronic pain associated with TMD may influence decision making.”