Al-Moraissi Essam Ahmed, Conti Paulo César Rodrigues, Alyahya Abdulmalik, Alkebsi Khaled, Elsharkawy Ahmed, Christidis Nikolaos
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Thamar University, Thamar, Yemen.
Department of Prosthodontics, Bauru School of Dentistry, University of São Paulo, São Paulo, Brazil.
Oral Maxillofac Surg. 2022 Dec;26(4):519-533. doi: 10.1007/s10006-021-01009-y. Epub 2021 Oct 21.
The best treatment modality for the management of painful temporomandibular disorders of muscular origin (M-TMD) with predictable outcomes based on solid evidence is still not well defined. Thus, the aim of this network meta-analysis (NMA) was to identify the best treatment for adult patients with M-TMD. An electronic search was undertaken from the inception of each database to August 2018, to identify randomized clinical trials (RCTs), which are comparing two or more of the following treatment modalities in patients with M-TMD: counseling therapy; occlusal appliances; manual therapy; laser therapy; dry needling; intramuscular injection of local anesthesia (LA) or botulinum toxin-A (BTX-A); muscle relaxants; hypnosis/relaxation therapy; oxidative ozone therapy; and placebo or no treatment. Primary outcome variables were the reduction of pain and mechanical sensitivity. The secondary outcome was the maximal mouth opening (MMO). The quality of evidence was rated according to Cochrane's tool for assessing risk of bias. Standardized mean difference was used to analyze via frequentist network meta-analysis (NMA), using STATA software. 52 RCTs were included in this NMA. At the most follow up moments, manual therapy, counseling therapy, occlusal splints therapy, and needling using BTX-A or LA as well as dry needling significantly decreased post-treatment pain intensity in M-TMDs, when compared to placebo. At short term (≤5 months), the four highest-ranked treatments for post-treatment pain reduction were manual therapy (83.5%, low quality evidence), ozone therapy (75.7%, very low quality evidence),counseling therapy (71.2%, moderate quality), and occlusal appliances (71.7%,moderate quality evidence). When intermediate term (≥6 months)was considered, BTX-A (85.8%, very low quality evidence) , counseling therapy(80%, low quality evidence), occlusal appliances (62.8%, low quality evidence) and hypnosis (50.6%, very low quality evidence) were the four highest-ranked treatments. This NMA reveals that manual therapy can be considered the most effective treatment for M-TMD, followed by counseling treatment, intramuscular injection of LA, and occlusal appliances . However, considering the limitations of the studies included, and the scarce of strong evidence, the present findings should be interpreted cautiously.
基于确凿证据且能带来可预测结果的、用于治疗肌肉源性颞下颌关节紊乱病（M-TMD）的最佳治疗方式仍未明确界定。因此，本网状Meta分析（NMA）的目的是确定治疗成年M-TMD患者的最佳方法。从每个数据库创建之初至2018年8月进行了电子检索，以识别随机临床试验（RCT），这些试验比较了以下两种或更多种治疗方式在M-TMD患者中的效果：咨询治疗；咬合器具；手法治疗；激光治疗；干针疗法；肌肉注射局部麻醉药（LA）或A型肉毒杆菌毒素（BTX-A）；肌肉松弛剂；催眠/放松疗法；氧化臭氧疗法；以及安慰剂或不治疗。主要结局变量是疼痛减轻和机械敏感性降低。次要结局是最大张口度（MMO）。根据Cochrane评估偏倚风险的工具对证据质量进行评级。使用标准化均数差值，通过频率学派网状Meta分析（NMA），采用STATA软件进行分析。本NMA纳入了52项RCT。在大多数随访时间点，与安慰剂相比，手法治疗、咨询治疗、咬合板治疗以及使用BTX-A或LA的针刺疗法和干针疗法在M-TMD中显著降低了治疗后的疼痛强度。在短期（≤5个月），治疗后疼痛减轻排名前四位的治疗方法是手法治疗（83.5%，低质量证据）、臭氧疗法（75.7%，极低质量证据）、咨询治疗（71.2%，中等质量）和咬合器具（71.7%，中等质量证据）。当考虑中期（≥6个月）时，BTX-A（85.8%，极低质量证据）、咨询治疗（80%，低质量证据）、咬合器具（62.8%，低质量证据）和催眠（50.6%，极低质量证据）是排名前四位的治疗方法。本NMA表明，手法治疗可被认为是治疗M-TMD最有效的方法，其次是咨询治疗、肌肉注射LA和咬合器具。然而，考虑到纳入研究的局限性以及有力证据的匮乏，对目前的研究结果应谨慎解读。
