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Understanding TMD
Treatment Failures | Part 2
A Peer-Reviewed Publication
Written by Jeff Burgess, DDS, MSD
Abstract
In addition to diagnostic factors that can contribute to
temporomandibular disorder (TMD) treatment failure,
there are many other confounding variables that can
impact the success or failure of treatment. Part 2 of this
course reviews some of these other contributors including biology, pain chronicity, comorbid pain or medical
problems, iatrogenic issues, the selection of therapy (e.g.
evidence based versus non-evidence based therapy), the
recognition of psychological and behavioral issues, and
other nonspecific considerations.
Educational Objectives
Author Profile
At the conclusion of this educational activity participants
will be able to:
1. Describe the many therapies used to treat TMD.
2. Discuss how biologic factors can predict treatment
failure.
3. Describe how pain chronicity and comorbid medical
problems can affect treatment.
4. Discuss the ramifications of failing to use evidence based
therapy.
Jeff Burgess, DDS, MSD, (Retired) Clinical Assistant Professor, Department of Oral Medicine, University of Washington
School of Dental Medicine; (Retired) Attending in Pain
Center, University of Washington Medical Center; (Retired)
Private Practice in Hawaii and Washington; Director, Oral Care
Research Associates. He can be reached at jeffreyaburgess@
hotmail.com .
Author Disclosure
Jeff Burgess, DDS, MSD, has no commercial ties
with the sponsors or providers of the unrestricted
educational grant for this course.
Go Green, Go Online to take your course
Publication date: Apr. 2014
Expiration date: Mar. 2017
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Educational Objectives
At the conclusion of this educational activity participants will
be able to:
1. Describe the many therapies used to treat TMD.
2. Discuss how biologic factors can predict treatment
failure.
3. Describe how pain chronicity and comorbid medical
problems can affect treatment.
4. Discuss the ramifications of failing to use evidence based
therapy.
Abstract
In addition to diagnostic factors that can contribute to temporomandibular disorder (TMD) treatment failure, there are
many other confounding variables that can impact the success
or failure of treatment. Part 2 of this course reviews some of
these other contributors including biology, pain chronicity,
comorbid pain or medical problems, iatrogenic issues, the selection of therapy (e.g. evidence based versus non-evidence
based therapy), the recognition of psychological and behavioral issues, and other nonspecific considerations.
Introduction
Treatment of the patient with a temporomandibular disorder
(TMD) can be a rewarding experience when the effect is a
reduction in facial pain and improvement in jaw joint function. It can be quite frustrating for both patient and clinician
when intervention has little or no effect on the patient’s subjective complaints or objective findings and worse yet when it
increases symptoms or functional problems. Treatment failure
can lead to loss of confidence in the provider, iatrogenic abnormality, discontinuation of intervention, and potential litigation. Thus, understanding the complexity associated with
treatment failure is an important pre-treatment consideration
that should guide the clinician prior to TMD intervention.
Current Therapeutic Interventions Used to
Treat Temporomandibular Disorders
Multiple single and multimodal therapeutic options are available for managing TMD. There is literature and research
associated with the use of the following treatment strategies:
assurance, patient education and self-care, activity modification, pharmacotherapy, various occlusal splints, hydrostatic
appliances, muscle and joint exercises, myofascial therapy, trigger point therapy, spray and stretch therapy, heat application,
massage, chiropractic therapy, arthroscopy, different surgeries,
and what has been termed ‘phase 2’ occlusal therapy (e.g. occlusal equilibration, full mouth reconstruction, orthodontic
treatment), among others.
The vast majority of the efficacy data from research looking at treatment outcomes suggests that regardless of the type
of intervention, a significant percentage of TMD patients will
demonstrate improvement in symptoms and dysfunctional
parameters over time.1 Up to 20 to 40 percent of patients either
stay the same or worsen following intervention. Intervention
studies indicate that some therapies are superior to others in
treating TMD. It also suggests that there are many confounding factors that can contribute to treatment failure.
Therapeutic Factors That Can Lead to
Treatment Failure
Biologic factors
Evidence that biologic factors can confound patient response
to TMD therapy is of relatively recent vintage in the scientific
literature. Gender appears to play a significant role in predicting treatment outcome2 due to physiology and more specifically
to genetic differences and genotypic variation.3 One example
of how gender confounds treatment is in subject response to
narcotic medication. Opioid medication is more effective in
controlling pain (generally) in women than in men; possibly because of differences related to the interaction of opioid receptor
complexes with estrogen and progesterone.4 The literature also
suggests that estrogen plays a significant role in pain associated
with TMD.5,6
Genetic differences may lead to different affective, neuroendocrine, and autonomic responses that could differentially
confound treatment efficacy.3,7 There are also reported gender
differences in terms of pain thresholds, temporal summation of
pain, pain expectations, and somatic awareness in patients with
chronic TMD and orofacial pain.5,8
Additional studies have assessed brain activity via functional MRI in patients with TMD. One study detected, following splint insertion, decreased activity in the somatosensory,
primary cortex, and insular cortex. There was also evidence
of activation of the parietal brain regions typically activated
during control of coordinated movements.9 In another study,
successful therapy for TMJ pain was found to change function
in the anterior insula and cerebellar region of the brain.10 While
the precise neurophysiologic and endocrine factors potentially
contributing to treatment effect have not been fully defined,
future research will help to clarify how they contribute to treatment failure as well as to the identification of TMD patient
subgroups that specific disease oriented treatments are most
likely to help.11
Finally, genetic research indicates that the reason some
TMD patients develop chronic pain is the result of specific molecular and genetic profiles inherent within each individual.12
While much research remains to be done, this emerging genetic
research may help to define patient genetic profiles that are predisposed to treatment failure.13
Persistent Pain (Chronicity)
The pain literature is replete with studies assessing the effect of
pain duration on central neural processes. As it is currently understood, the excitation of peripheral nociceptors (termed peripheral
sensitization) can lead to increased excitability of nociceptors in
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the spinal cord and brain. This is described as ’central sensitization’. Central sensitization can lead to increased sensitivity to
painful stimuli in normal peripheral tissue that is not associated
with the disease causing nociceptor insult. Other central changes
include the expression of new sodium channels that facilitate pain,
adrenergic receptors, and cholinergic receptors that may influence
the depolarization of nociceptors in the involved area.14
Studies specifically assessing pain in patients with TMD reveal that central processing is similar to that occurring in other
conditions when pain persists for a prolonged period.15 The
science indicates that these central changes are gender based;
for example, upregulation of nociceptors is more likely to contribute to persistent pain in women than men.16
Comorbid Pain or Medical Problems
Patients with TMD and pain may also experience other pain
problems including fibromyalgia, headache (HA), and neck pain.
Although it is not clear precisely how these other pain problems
interact with TMD, their presence may confound pain sensitivity
and subsequent TMD treatment.17 With respect to fibromyalgia,
in one study of associated oral symptoms, TMD was found to
be present in approximately 67 percent of fibromyalgia subjects
as compared to 20 percent of controls.18 Other studies support
an association between fibromyalgia and TMD even though they
may be separate diagnostic entities.19
TMD has also been associated with chronic fatigue syndrome20 and various types of HA including migraine,21 moderate
and severe headache,22,23 chronic tension-type HA, and episodic
tension-type HA.24 The association between HA and myofascial
pain appears to be the most common comorbidity. There also appears to be association between TMD and neck pain.25 TMD pain
in association with these other pain problems is potentially due
to underlying multisystem dysregulation.26 Thus, in the patient
with TMD with other conditions causing pain, co-management
would appear to be important to prevent treatment failure. Referring the patient for additional medical evaluation and treatment
should help to reduce this possibility.27
Additionally, TMD treatment outcome (success or failure)
may be influenced by comorbid medical conditions such as
autoimmune disease; sleep disturbance; cardiovascular, gastrointestinal, and reproductive system complaints and weight loss
or weight gain, among others.
Failure to Recognize the Potential for Iatrogenic
Problems
Almost any TMD therapy can produce unanticipated results
but the risk is greater for those that involve invasive intervention. For example, although removable soft splints are not
considered invasive, malocclusion has been reported following
their use.28,29 Bite change has also been associated with dental
appliances that do not have adequate occlusal coverage (which
can result in over-eruption of the posterior teeth)30 and the use
of dental repositioning appliances has been associated with posterior tooth intrusion.31 TMJ arthroscopy has been associated
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with the development of Horner’s syndrome and TMJ surgery
has resulted in vascular trauma and joint arthritis32 as well as
middle meningeal and superficial temporal artery hemorrhage
during joint replacement surgery.33,34 Medications used to treat
TMD can cause medical problems such as distorted sense of
taste (dysgeusia), stomatitis, and xerostomia,35 liver or kidney
disease (e.g. NSAIDs, acetaminophen and acetaminophen with
codeine preparations), addiction, mental confusion, bleeding
problems, and allergic reactions. Joint and muscle injections
can cause bruising and swelling in the applied area as well as
allergy. Metal allergy has also occurred with TMJ implants
leading to treatment failure.36
Ignoring Evidence Based Treatment Implications
A substantial body of literature exists evaluating the treatment
of TMD including research associated with specific therapies,
critical reviews of specific types of intervention, and systematic
meta-analyses of multiple randomized controlled trials. There
are also a large number of texts devoted specifically to the
treatment of orofacial pain and temporomandibular disorders.
The most important studies for a clinician attempting to treat
TMD to be familiar with in terms of potential failure are those
that are longitudinal in nature, utilize accepted methodology
and involve treatment assessed by randomized controlled trials (RCTs). Another consideration regarding the efficacy of
treatment is the number of RCTs associated with a particular
intervention as the results of several studies have greater clinical
significance than that of a single study. Further, studies that are
not designed with a sufficient number of subjects, regardless of
inclusion of controls or randomization, may not be helpful in
predicting the effectiveness of therapy. An example of this is a
recent study assessing the value of botulinum toxin injection
as a means of managing TMJ anterior disk displacement (joint
clicking). While the results of this study apparently demonstrated that dysfunction could be altered by the procedure, only
7 patients were enrolled and there was no control group, thus
limiting the validity of the results.37
So what does the research suggest about temporomandibular disorders that can help the clinician navigate successful
intervention instead of treatment failure? In general, the science suggests that the pursuit of a single modality therapeutic
approach may not be as effective as multiple modalities. The
evidence also reveals that under-appreciating the cyclic fluctuations of some TMJ diagnoses may lead to overtreatment
and failure. It reveals that the vast majority of patients with
TMD achieve significant symptom reduction (with or without
improved function) through the use of non-invasive interventions.38 The science further indicates that there is a complex
relationship/interaction between pain experience and psychological, behavioral, and somatic complaints. Further scientific
inquiry will unravel the precise relationships; however, failing
to recognize that these interactions are present, particularly as
they relate to the chronic TMD patient, may lead to treatment
failure.
3
The Choice of Intervention
The research assessing various interventions in comparison
studies is extensive and wading through the literature takes a
significant amount of time. The most reliable evaluation of the
effectiveness of selected interventions is provided by systematic
meta-analyses of multiple studies meeting strict inclusion criteria. Much of this literature can be found in the Journal of Evidence
Based Dentistry, the Cochrane Database Systematic Reviews and
other peer reviewed journals.
An example of one such systematic review is the report
assessing whether multimodal therapy is superior to simple
intervention in the treatment of patients with temporomandibular disorders.39 To perform this review, multiple databases
were assessed including Ovid Medicine, the Cochrane Library,
and the Science Citation Index. After reading the literature the
studies were divided into three subsections based on presenting symptoms. Eleven articles representing nine different
clinical studies were ultimately identified as having the appropriate inclusion criteria. Based on this extensive review it
is concluded by the author that “(1) in the disc displacement
group with pain, multimodal therapy was not superior to explanation and advice and (2) a combination of occlusal appliance and biofeedback-assisted relaxation/stress management
was not significantly superior to either of these therapies after
6 months. Furthermore, brief information alone or combined
with relaxation training or occlusal appliance, respectively,
were equally efficacious at the 6 month follow-up. There was
no superiority of multimodal therapy including splints as compared with simple care. A slightly better outcome was reported
for a combination of education and home physical therapy regimen than for patient education alone. In temporomandibular
pain patients with major psychological disturbances, patients
benefited more from a combined therapeutic approach compared with simple care”. Systematic studies related to other
TMD diagnoses are also available to help in clinical decision
making.
Knowledge of such findings can help the clinician reduce
the potential for treatment failure. Another article reviews
multiple TMD management strategies. It is published in the
Journal of Oral Rehabilitation, 2010. The authors, List and
Axelsson, conclude from their systematic review that the accumulated evidence supports the effectiveness of a number of
interventions for managing TMD including the use of occlusal
appliances, acupuncture, behavioral therapy, jaw exercises,
postural training, and some pharmacological treatments. They
further conclude that the evidence for the impact of electrophysical modalities and surgery is insufficient, and that occlusal adjustment is not an effective intervention.40
Several systematic literature reviews are available that cover
multiple therapeutic approaches including arthroscopy,41 orthodontic TMD therapy,42 acupuncture,43 occlusal adjustment,44,45
intraoral appliances,46 palliative and anti-inflammatory medication,47 psychosocial interventions,48 counseling and self-management49 and low-level laser therapy.50
Systematic reviews also indicate that the evidence supporting intra-articular steroid injection for TMJ arthritis in juvenile
idiopathic arthritis is inconclusive.51 Furthermore, treatment
of degenerative joint disease with intra-articular injection of
hyaluronate is as effective as injection of corticosteroid and that
glucosamine may be as effective as ibuprofen for managing TMJ
osteoarthritis.52 Systematic reviews also reveal that stabilization
splint therapy coupled with counseling and masticatory muscle
exercises may be more beneficial than counseling and masticatory muscle exercises used without splint therapy.53 Another
consideration with respect to intervention and treatment failure
may be gained from the US Headache Consortium Guidelines for
Treatment of HA which recommends the use of ‘stratified care’:
the selection of initial therapy based on patient characteristics at
the time of pre-presentation, including headache related disability’.54,55 Treatment of TMD should be approached in the same
manner to reduce the possibility of therapeutic failure.
Failure to Consider the Impact of Psychological and
Behavioral Factors in Managing the Patient with Chronic
Pain
An interesting TMD treatment study included two groups;
one receiving cognitive-behavioral therapy coupled with standard
conservative care for TMD and another receiving the same intervention coupled with additional coping skills training. The factor
that identified non-responders (16 percent of the two groups at
the one year therapy end point) was not the difference in TMJ
pathology but rather the absence of coping skills training. Nonresponders demonstrated more catastrophizing, poorer coping
skills, and more psychiatric symptoms.56 Additional reports have
suggested that the addition of cognitive-behavioral intervention
may improve TMD treatment efficacy.57-59 The 2005 study by
Turner et al, discussed above, also indicates that a patient’s sense
of control over his/her pain has a significant impact on treatment
outcome. The authors note, “patients who reported more pain
sites, depressive symptoms, non-specific physical problems,
rumination, catastrophizing, and stress before treatment had
higher activity interference at one year” (the conclusion of the
study). Somatization and depression appear to be associated with
chronic TMD to a greater degree than acute TMD conditions,
regardless of the diagnostic complexity.60 These psychosocial factors may also need to be considered in the acute patient group to
avoid subsequent treatment failure.
In addition to depression and somatization, other disorders such as generalized anxiety and psychological distress
are common features of patients with chronic TMD and may
contribute to a poor response to treatment.61,62 Ohrbach et
al conclude that the presence of a psychiatric disorder could
be connected to an increased ‘vulnerability to maladaptive
cognitive, affective, and behavioral response’ to pain.63 Other
researchers have shown that elevated somatization, which is
characterized by a history of pain complaints related to multiple
sites that are all different as well as other non-specific physical
symptoms is a predictor of poor TMD treatment outcome.64
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Thus it is important for the clinician treating patients with
TMD to assess the potential presence of these confounding
variables. The RDC/TMD Axis II has been designed for
clinical use as a means of measuring not only depression but
non-specific physical symptoms and the grade of chronic pain.
It has demonstrated reasonable reliability and validity when
compared to other measurement instruments used clinically.65
Another instrument that can be used is the MPI (multidimensional pain inventory). The MPI has demonstrated clinical reliability and validity. It measures the impact of pain on a person’s
life and helps to identify psychosocial profiles or patterns. With
this instrument patients are defined as either dysfunctional,
interpersonally distressed, or adaptive copers.66 MPI was used
to assess whether TMD subgroups might have different
psychosocial profiles, with the results suggesting that the
location of TMD pain is not associated with specific behavioral or psychological variables.67
Other potential confounding factors that could contribute to
treatment failure include; doctor-patient or staff-patient interaction, failure to educate the patient about treatment alternatives
prior to intervention and failure to gain ‘knowledgeable’ consent,
the patient’s perception of the level of expertise of the treating
clinician, unrealistic expectations with respect to treatment outcome, patient compliance, and even the general office environment. While research assessing these specific factors and their
effect on treatment success or failure is virtually non-existent,
clinical experience suggests they should also be considered in
managing the patient with TMD.
Conclusion
Important factors that can contribute to treatment failure
include; biologic considerations, pain chronicity, comorbid
pain or medical problems, iatrogenic issues, the failure to use
evidence based therapies and the choice of intervention. Additionally, failure to recognize the importance of confounding
psychological and behavioral issues and other non-specific
factors can impact treatment failure. While there is a reasonable volume of literature supporting the information presented
in this course, more research involving longitudinal RCTs or
other studies that tease out the specific factors that contribute to
treatment failure is needed.
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2003;(1):CD003812
46. Fricton J, Look JO, Wright E, Alencar FG Jr, Chen H, Lang M, Ouyang
W, Velly AM. Systematic review and meta-analysis of randomized
controlled trials evaluating intraoral orthopedic appliances for
temporomandibular disorders. J Orofac Pain. 2010 Summer;24(3):237-5
47. Januzzi E, Nasri-Heir C, Grossmann E, Leite FM, Heir GM, Melnik
T.Combined palliative and anti-inflammatory medications as treatment
of temporomandibular joint disc displacement without reduction: a
systematic review. Cranio. 2013 Jul;31(3):211-25
48. Aggarwal VR, Lovell K, Peters S, Javidi H, Joughin A, Goldthorpe
J.Psychosocial interventions for the management of chronic orofacial
pain. Cochrane Database Syst Rev. 2011 Nov 9;(11):CD008456
49. de Freitas RF, Ferreira MÂ, Barbosa GA, Calderon PSCounselling
and self-management therapies for temporomandibular disorders: a
systematic review. J Oral Rehabil. 2013 Nov;40(11):864-74
50. Maia ML, Bonjardim LR, Quintans Jde S, Ribeiro MA, Maia LG,
Conti PC.Effect of low-level laser therapy on pain levels in patients with
temporomandibular disorders: a systematic review. J Appl Oral Sci.
2012 Nov-Dec;20(6):594-602
51. Stoustrup P, Kristensen KD, Verna C, Küseler A, Pedersen TK, Herlin
T. Intra-articular steroid injection for temporomandibular joint arthritis
in juvenile idiopathic arthritis: A systematic review on efficacy and
safety. Semin Arthritis Rheum. 2013 Aug;43(1):63-70
52. Patel DN, Manfredini D.Two commentaries on interventions for the
management of temporomandibular joint osteoarthritis. Evid Based
Dent. 2013 Mar;14(1):5-7
53. Niemelä K, Korpela M, Raustia A, Ylöstalo P, Sipilä K. Efficacy of
stabilisation splint treatment on temporomandibular disorders. J Oral
Rehabil. 2012 Nov;39(11):799-804)
54. Silberstein SD, Rosenberg J. Multispecialty consensus on diagnosis and
treatment of headache. Neurology 2000;54:1553)(Lipton RB Silberstein
SD. The role of headache-related disability in migraine management:
implications for headache treatment guidelines. Neurology
2001;56(suppl 1):35–42
55. Lipton RB Silberstein SD. The role of headache-related disability in
migraine management: implications for headache treatment guidelines.
Neurology 2001;56(suppl 1):35–42
56. Litt MD, Porto FBDeterminants of Pain Treatment Response and
Nonresponse: Identification of TMD Patient Subgroups. J Pain. 2013
Nov;14(11):1502-13
57. Litt MD, Shafer DM, Kreutzer DL.Brief cognitive-behavioral treatment
for TMD pain: long-term outcomes and moderators of treatment. Pain.
2010 Oct;151(1):110-6
58. Turner JA, Mancl L, Aaron LA. Brief cognitive-behavioral therapy for
temporomandibular disorder pain: effects on daily electronic outcome
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of therapeutic change in cognitive-behavioral therapy for chronic pain.
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on acute and chronic orofacial pain in patients with single or multiple
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Author Profile
Jeff Burgess, DDS, MSD, (Retired) Clinical Assistant
Professor, Department of Oral Medicine, University of
Washington School of Dental Medicine; (Retired) Attending
in Pain Center, University of Washington Medical Center;
(Retired) Private Practice in Hawaii and Washington; Director, Oral Care Research Associates. He can be reached at [email protected] .
Author Disclosure
Jeff Burgess, DDS, MSD, has no commercial ties with the
sponsors or providers of the unrestricted educational grant for
this course.
6www.ineedce.com
Online Completion
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Questions
1. Which of the following is supported by the
literature to treat TMD?
a. Hydrostatic appliances
b.Pharmacotherapy
c. Hydrostatic appliances
d. All of the above
2. What is the relative percentage of patients that
stay the same or worsen post TMD therapy?
a. 10-15 %
b. 30-50 %
c. 20-40 %
d. 50-60 %
3. Which of the following biologic factors is
known to play a significant role in predicting
treatment outcome?
a.Gender
b. Physical stature
c.Occlusion
d. Periodontal status
4. Which of the following is an accurate statement?
a. Opioid medication is more effective in men than
women
b. Opioid medication is not effective in women
c. Opioid medication effectiveness is not associated with
gender
d. Opioid medication is more effective in women than
men
5. Which of the following statements is accurate?
a. Genetic differences may lead to different affective,
neuroendocrine and autonomic responses
b. Gender differences exist for pain thresholds, temporal
summation of pain and pain expectation
c. Both a and b
d. Neither a or b
6. Studies suggest that there is an association
between TMD pain and:
a. Serotonin receptors
b. Adrenergic receptor Beta 2
c. Both a and b
d. Neither a or b
7. As currently understood, persistent excitation
of peripheral nociceptors can lead to:
a. Increased excitability of nociceptors in the spinal cord
b. Increased excitability of nociceptors in the brain
c. Both a and b
d. Neither a or b
8. The result of central sensitization is:
a. Severe pain in a non-head region
b. Increased sensitivity to painful stimuli in normal
tissue
c. Both a and b
d. Neither a or b
9. Which of the following central cellular changes
are known to occur with chronic pain?
a. The expression of new sodium channels
b. The expression of adrenergic receptors
c. The expression of cholinergic receptors
d. All of the above
10. In a study of fibromyalgia which of the following percentage of patients had TMD?
a. 27 %
b. 37 %
c. 57 %
d. 67 %
11. Which of the following headache (HA)
conditions has not found to be associated with
TMD?
a. Episodic tension-type HA
b. Paroxysmal hemicrania
c. Chronic tension-type HA
d.Migraine
12. The research indicates that TMD is most
likely to be associated with which of the following conditions?
a. Neck pain
b. Shoulder pain
c. Thoracic pain
d. Hand pain
13. The association between HA and which of
the following TMD conditions occurs most
commonly?
a. TMJ degenerative disease
b. TMJ non-reducing disc displacement
c. Myofascial pain
d. TMJ disk displacement with reduction
14. Which of the following statements is
accurate?
a. TMD treatment outcome may be influenced by
comorbid medical conditions
b. TMD treatment outcome is not influenced by other
head pain problems
c. Both a and b
d. Neither a or b
15. Comorbid medical conditions that can affect
TMD treatment outcome include:
a. Autoimmune disease
b. Gastrointestinal problems
c.Numbness
d. All of the above
16. Iatrogenic bite change has been associated
with which of the following TMD interventions?
a. Physical therapy
b. TMJ arthroscopy
c. TMJ implant surgery
d. Appliance therapy
17. TMJ arthroscopy has caused which of the
following iatrogenic conditions?
a. TMJ arthritis
b. Horner’s syndrome
c. TMJ dysfunction
d.Malocclusion
18. Which of the following statements is accurate
with respect to potential TMD treatment
failure?
a. Treatment failure can result from unplanned side
effects of intervention
b. Treatment failure is the always the fault of the
provider
c. Both a and b
d. Neither a or b
19. The most important studies for a clinician
attempting to treat TMD are those that are:
a. Longitudinal in nature
b. Utilize accepted methodology
c. Involve randomized controlled trials
d. All of the above
20. A recent study assessed the value of botulinum
toxin injection as a means of managing TMJ
disc displacement. It had 7 patients and no
controls. Which best describes this study?
a. The results strongly support the value of the
procedure
b. The validity of the study is questionable because of
the limited number of subjects and lack of controls
c. The results clearly indicate that botulinum toxin
injection is useful in managing TMJ clicking
d. Studies like this are the most useful form of clinical
research.
Notes
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ANSWER SHEET
Understanding TMD Treatment Failures | Part 2
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If not taking online, mail completed answer sheet to
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1. Describe the many therapies used to treat TMD.
A Division of PennWell Corp.
2. Discuss how biologic factors can predict treatment failure.
P.O. Box 116, Chesterland, OH 44026
or fax to: (440) 845-3447
3. Describe how pain chronicity and comorbid medical problems can affect treatment.
4. Discuss the ramifications of failing to use evidence based therapy.
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