Non-pharmacological interventions for temporomandibular disorders: A systematic review and meta-analysis
非药物疗法干预颞下颌关节紊乱：一项系统评价和荟萃分析

Qiu-yi CHEN（陈秋怡）, Quan MIAO（苗荃）, Fei-yu FU（付飞羽）, Ying LIN（林颖）, Chen-xi ZENG（曾晨曦）, Pei-yue PENG（彭佩玥）, Yi-xin ZHANG（张艺馨）, Lu LIU(刘璐), Bin LI（李彬）

Department of Acupuncture and Moxibustion, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing 100010, China（首都医科大学附属北京中医医院针灸科，北京100010，中国）

Abstract

Background: A temporomandibular disorders (TMDs) is a musculoskeletal and neuromuscular condition that affects the temporomandibular joint, masticatory muscles, and associated tissues. Non-pharmacological interventions are currently considered as potential therapies for TMDs. However, high-quality systematic reviews and meta-analyses evaluating their clinical efficacy are lacking.

Objective: This study aimed to evaluate the clinical efficacy of non-pharmacological interventions for TMDs, focusing on their impact on pain relief, jaw mobility, and functional improvement. Specifically, we aimed to compare the effectiveness of four non-pharmacological interventions, including acupuncture, exercise, occlusal splinting, and laser therapy, for treating TMDs.

Methods: Comprehensive searches for randomized controlled trials (RCTs) were conducted in PubMed, Web of Science, Scopus, Embase, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, China Biomedical Literature Database (SinoMed), VIP, and Wanfang databases. The primary outcome was visual analog scale (VAS) score. The secondary outcomes included pain-free mouth opening, maximum assisted and unassisted mouth opening, and occurrence of adverse events. We used the Cochrane Risk of Bias tool and the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the risk of bias and the quality of evidence. The meta-analysis was performed using RevMan 5.4 software.

Results: A total of 22 RCTs involving 717 patients with TMDs were included. Non-pharmacological interventions significantly reduced VAS scores (n=19; mean difference [MD]= –1.86, 95% confidence interval [CI] –2.40 to –1.31; Z=6.68; P<0.05) and improved the pain-free mouth opening (n=6; MD=6.92, 95% CI 4.91 to 8.94; Z=6.73; P<0.05) and maximum unassisted mouth opening (n=10; MD=4.05, 95% CI 2.08 to 6.02; Z=4.04; P<0.05) in patients with TMDs. However, non-pharmacological interventions did not show a significant effect on maximum assisted mouth opening (n=2; MD=0.33, 95% CI –4.16 to 4.82; Z=0.15; P=0.88). Only one RCT reported the occurrence of adverse events. Subgroup analysis showed that acupuncture (n=6; MD= –1.52, 95% CI –2.86 to –0.18; Z=2.22; P=0.03), exercise (n=4; MD= –1.12, 95% CI –1.94 to –0.31, Z=2.70; P0.05), occlusal splint (n=5; MD= –2.00, 95% CI –2.67 to –1.33, Z=5.88; P0.05), and laser therapy (n=4; MD= –2.81, 95% CI –3.89 to –1.73, Z=5.10, P0.05) were significantly superior to control treatments in reducing VAS scores. In addition, acupuncture (n=2; MD=6.50, 95% CI 3.87 to 9.13; Z=4.85; P＜0.05), occlusal splint (n=2; MD=8.33, 95% CI 4.41 to 12.24; Z=4.17; P＜0.05), and laser therapy (n=2; MD=6.09, 95% CI 0.86 to 11.32; Z=2.28; P=0.02) significantly improved pain-free mouth opening, whereas exercise (n=2; MD=6.84, 95% CI 3.16 to 10.51; Z=3.65; P＜0.05) and occlusal splint (n=2; MD=4.93, 95% CI 1.66 to 8.19; Z=2.96; P＜0.05) increased maximum unassisted mouth opening.

Conclusion: Nonpharmacological interventions have significant efficacy in relieving pain and enhancing pain-free mouth opening and maximum unassisted mouth opening in patients with TMDs. Specifically, acupuncture, exercise, occlusal splinting, and laser therapy significantly alleviate pain in patients with TMDs. Occlusal splinting showed good effects in improving pain-free mouth opening and maximum unassisted mouth opening, while acupuncture and laser therapy helped improve pain-free mouth opening. Exercise significantly improved maximum unassisted mouth opening. These findings support the application of these treatments in clinical practice and provide evidence to inform future conservative management guidelines for TMDs.

【摘要】

背景：颞下颌关节紊乱(temporomandibular disorders, TMDs) 是一类影响颞下颌关节、咀嚼肌及相关组织的肌肉骨骼和神经肌肉疾病。目前非药物治疗已被视为TMD的潜在疗法。然而，这些疗法的临床效果尚缺乏高质量的系统评价和荟萃分析。

目的：本研究旨在评价非药物疗法治疗TMD的临床疗效，重点评估其在缓解疼痛和改善下颌运动方面的影响。本研究以针刺、运动、咬合夹板和激光这4种在治疗TMD中应用最为广泛的疗法为非药物疗法的代表进行研究。同时比较这4种非药物疗法在TMD治疗中的临床疗效差异。

方法：检索PubMed、Web of Science、Scopus、Embase、Cochrane对照试验注册中心，中国知网，中国生物医学数据库，维普以及万方数据库上对随机对照试验进行了全面检索。主要疗效指标为视觉模拟量表（Visual Analog Scale, VAS）。次要疗效指标为无痛开口度、最大主动开口度、最大被动开口度，以及不良事件。使用Cochrane偏倚风险工具和GRADE方法评估偏倚风险和证据质量。使用RevMan 5.4软件进行meta分析。

结果：22项研究符合纳入标准，共涉及717例TMD患者。非药物疗法降低了TMD患者的VAS评分（n=19; mean difference [MD]= –1.86, 95% confidence interval [CI] –2.40 to –1.31; Z=6.68; P＜0.05），并改善了无痛开口度（n=6; MD=6.92, 95% CI 4.91 to 8.94; Z=6.73; P＜0.05）和最大主动开口度（n=10; MD=4.05, 95% CI 2.08 to 6.02; Z=4.04; P＜0.05），然而，非药物疗法对最大被动开口度无显著影响（n=2; MD=0.33, 95% CI –4.16 to 4.82; Z=0.15; P=0.88）。仅有一项研究报告了不良事件的发生。亚组分析结果显示，针刺（n=6; MD= –1.52, 95% CI –2.86 to –0.18; Z=2.22; P=0.03）、运动（n=4; MD= –1.12, 95% CI –1.94 to –0.31, Z=2.70; P0.05）、咬合夹板（n=5; MD= –2.00, 95% CI –2.67 to –1.33, Z=5.88; P0.05）和激光治疗（n=4; MD= –2.81, 95% CI –3.89 to –1.73, Z=5.10, P0.05）在减少VAS评分方面均显著优于对照组。此外，针刺（n=2; MD=6.50, 95% CI 3.87 to 9.13; Z=4.85; P＜0.05）、咬合夹板（n=2; MD=8.33, 95% CI 4.41 to 12.24; Z=4.17; P＜0.05）和激光治疗（n=2; MD=6.09, 95% CI 0.86 to 11.32; Z=2.28; P=0.02）显著改善了无痛开口度，而运动（n=2; MD=6.84, 95% CI 3.16 to 10.51; Z=3.65; P＜0.05）和咬合夹板治疗（n=2; MD=4.93, 95% CI 1.66 to 8.19; Z=2.96; P＜0.05）增加了最大主动开口度。

结论：非药物疗法在改善TMD患者的疼痛、无痛开口度和最大主动开口度方面具有显著疗效。具体而言，针刺、运动、咬合夹板和激光治疗均能显著缓解TMD患者的疼痛。咬合夹板在改善无痛开口度和最大主动开口度方面均表现出良好效果，而针刺和激光治疗有助于改善无痛开口度，运动则能显著提升最大主动开口度。这些结果支持在临床实践中应用这些治疗方法，并可能为未来的TMD保守治疗指南提供依据。