Is there a superiority of multimodal as opposed to simple therapy in patients with temporomandibular disorders? A qualitative systematic review of the literature.

BACKGROUND Pain is the most common motivation for patients with temporomandibular disorders (TMDs) to seek care. Therapeutic options range from patient education to joint surgery. OBJECTIVES To conduct a systematic review of articles reporting on simple and multimodal management strategies in TMD patients. 'Simple therapy' was defined as care provided by a dentist, without using technical dental interventions, whereas 'multimodal' refers to at least two different modalities. We followed the null hypothesis of no difference between these two approaches. MATERIAL AND METHODS A systematic search was carried out in the following databases: Ovid Medline (1966-2006), Cochrane Library (Issue 3/2006), and Science Citation Index (1945-2006). Subsequently, the reference lists of the identified articles were searched to find additional pertinent publications. We divided the study reports according to the main presenting symptom: (1) disc displacement without reduction, with pain; (2) TMD pain, without major psychological symptoms; and (3) TMD pain, with major psychological symptoms. RESULTS Eleven articles representing nine different clinical studies were identified. (1) In the disc displacement group with pain, multimodal therapy was not superior to explanation and advice. (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. (3) In temporomandibular pain patients with major psychological disturbances, patients benefited more from a combined therapeutic approach compared with simple care. CONCLUSION Current research suggests that individuals without major psychological symptoms do not require more than simple therapy. In contrast, patients with major psychological involvement need multimodal, interdisciplinary therapeutic strategies. The clinician's acceptance of the importance of psychological factors in TMD pain forms the platform for convincingly educating patients about the need for multimodal management.