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

Dear Editor

We read with interest the recent publication by Busse et al [1] concerning the management of chronic pain associated with temporomandibular disorders (TMDs). We note that among the recommendations, were conditional recommendations against arthrocentesis, botulinum toxin and steroid injections and strong recommendations against discectomy, these being included in a total of 59 interventions examined. We furthermore note that the specialty of Oral and Maxillofacial Surgery is under represented in the authorship of the article, arguably the specialty most concerned with the diagnosis and management of TMDs, some clinicians having a dedicated subspecialty interest in this regard.

We have recently been guest editors for a special edition of the British Journal of Oral and Maxillofacial Surgery [2], collating a series of papers on the growing evidence base for interventions in temporomandibular joint (TMJ) surgery including advanced arthroscopy, open arthroplasty (including discectomy) and botulinum toxin. Many of the assertions in the paper by Busse et al [1] fail to resonate with our clinical experience of such surgery (and that of our colleagues) and simultaneously do not acknowledge a growing evidence base that suggests that appropriately selected patients will yield a significant therapeutic benefit to such interventions.

The authors have based their systematic review on patients with “chronic pain associated with temporomandibular disorders”, but we would argue that not all TMDs are created equal. For instance, intra-articular pain and dysfunction from early degenerative joint disease can be attributable to demonstrable synovitis and a cascade of molecular events including the generation of free radicals and cytokines, with eventual progression to more advanced degenerative changes. In this cohort, arthroscopy or arthrocentesis may benefit up to 95% of patients with improvements in pain reduction and range of motion [3]. To assert that this can be recommended against in a published guideline is potentially short-changing patients who would significantly benefit, by creating a heterogenous group of TMDs and attempting to generate a “one size fits all” approach that is doomed to failure.

We would agree that a majority of TMD patients, including even those presenting to a tertiary referral service, can benefit from physiotherapy and/or psychological support such as cognitive behavioural therapy (CBT) due to not infrequently co-existing mental health issues and chronic pain conditions that can worsen outcomes to surgical interventions (although interestingly the authors of the current study chose to exclude patients with mental illness and fibromyalgia).

As such, we would not advocate for interventional treatment in the vast majority of patients, but would respectfully argue that surgical interventions (including those recommended against by Busse et al [1]) have an essential role to play in the management of a minority of TMD patients with a growing evidence base in the scientific literature to support their use, with an increasingly nuanced approach that should be encouraged rather than quashed in the modern era of TMJ surgery. We acknowledge that the scientific rigour of such research can be improved and welcome the advent of randomised controlled trials where possible, such as the upcoming MiTiGate [4] trial, but we would welcome a dialogue from our specialty in developing such guidelines5 to ensure that surgical candidates do not fall by the wayside.

References

1. Busse JW, et al. Management of chronic pain associated with temporomandibular disorders: a clinical practice guideline. BMJ 2023;383:e076227
2. Elledge ROC, Speculand B. Current thinking in temporomandibular disorders: the science and art behind contemporary management. Br J Oral Maxillofac Surg 2024 [published online ahead of print]
3. Boloux GF, Chou J, DiFabio V, et al. The contemporary management of temporomandibular joint intra-articular pain and dysfunction. J Oral Maxillofac Surg 2024;82(6):623-631
4. National Institute for Health and Care Research (NIHR). Award ID NIHR15388. Managing chronic Myalgia Temporomandibular Disorder (M-TMD): a pragmatic randomized controlled trial of botulinum toxin type A, lidocaine, and amitriptyline/gabapentin, with internal pilot and cost-effectiveness analysis (MiTiGate trial). Available online at https://dev.fundingawards.nihr.ac.uk/award/NIHR153888 [last accessed 9 June 2024]
5. Beecroft E, Palmer J, Penlington C, et al. Management of painful temporomandibular disorder in adults NHS England Getting it Right First Time (GIRFT) and Royal College of Surgeons of England’s Faculty of Dental Surgery. Available online at https://www.rcseng.ac.uk/-/media/FDS/Comprehensive-guideline-Management- of-painful-Temporomandibular-disorder-in-adults-March-2024.pdf [last accessed 7 June 2024]