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. 2020 Feb;24(7):1–224. doi: 10.3310/hta24070

Oral splints for patients with temporomandibular disorders or bruxism: a systematic review and economic evaluation.

Philip Riley, Anne-Marie Glenny, Helen V Worthington, Elisabet Jacobsen, Clare Robertson, Justin Durham, Stephen Davies, Helen Petersen, Dwayne Boyers
PMCID: PMC7049908  PMID: 32065109

Abstract

BACKGROUND

Splints are a non-invasive, reversible management option for temporomandibular disorders or bruxism. The clinical effectiveness and cost-effectiveness of splints remain uncertain.

OBJECTIVES

The objectives were to evaluate the clinical effectiveness and cost-effectiveness of splints for patients with temporomandibular disorders or bruxism. This evidence synthesis compared (1) all types of splint versus no/minimal treatment/control splints and (2) prefabricated versus custom-made splints, for the primary outcomes, which were pain (temporomandibular disorders) and tooth wear (bruxism).

REVIEW METHODS

Four databases, including MEDLINE and EMBASE, were searched from inception until 1 October 2018 for randomised clinical trials. The searches were conducted on 1 October 2018. Cochrane review methods (including risk of bias) were used for the systematic review. Standardised mean differences were pooled for the primary outcome of pain, using random-effects models in temporomandibular disorder patients. A Markov cohort, state-transition model, populated using current pain and Characteristic Pain Intensity data, was used to estimate the incremental cost-effectiveness ratio for splints compared with no splint, from an NHS perspective over a lifetime horizon. A value-of-information analysis identified future research priorities.

RESULTS

Fifty-two trials were included in the systematic review. The evidence identified was of very low quality with unclear reporting by temporomandibular disorder subtype. When all subtypes were pooled into one global temporomandibular disorder group, there was no evidence that splints reduced pain [standardised mean difference (at up to 3 months) -0.18, 95% confidence interval -0.42 to 0.06; substantial heterogeneity] when compared with no splints or a minimal intervention. There was no evidence that other outcomes, including temporomandibular joint noises, decreased mouth-opening, and quality of life, improved when using splints. Adverse events were generally not reported, but seemed infrequent when reported. The most plausible base-case incremental cost-effectiveness ratio was uncertain and driven by the lack of clinical effectiveness evidence. The cost-effectiveness acceptability curve showed splints becoming more cost-effective at a willingness-to-pay threshold of ≈£6000, but the probability never exceeded 60% at higher levels of willingness to pay. Results were sensitive to longer-term extrapolation assumptions. A value-of-information analysis indicated that further research is required. There were no studies measuring tooth wear in patients with bruxism. One small study looked at pain and found a reduction in the splint group [mean difference (0-10 scale) -2.01, 95% CI -1.40 to -2.62; very low-quality evidence]. As there was no evidence of a difference between splints and no splints, the second objective became irrelevant.

LIMITATIONS

There was a large variation in the diagnostic criteria, splint types and outcome measures used and reported. Sensitivity analyses based on these limitations did not indicate a reduction in pain.

CONCLUSIONS

The very low-quality evidence identified did not demonstrate that splints reduced pain in temporomandibular disorders as a group of conditions. There is insufficient evidence to determine whether or not splints reduce tooth wear in patients with bruxism. There remains substantial uncertainty surrounding the most plausible incremental cost-effectiveness ratio.

FUTURE WORK

There is a need for well-conducted trials to determine the clinical effectiveness and cost-effectiveness of splints in patients with carefully diagnosed and subtyped temporomandibular disorders, and patients with bruxism, using agreed measures of pain and tooth wear.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017068512.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 7. See the NIHR Journals Library website for further project information.

Plain language summary

Treatment options for people experiencing temporomandibular disorders (pain and/or restricted movement in and around the jaw joint) include splints, which are removable appliances, often similar to a mouthguard. They are provided to patients to help ease pain in the mouth, face or jaws. They are also used to manage the symptoms of temporomandibular disorders, such as frequent headaches/migraines, clicking jaws, restricted mouth-opening or tooth wear from the grinding of teeth (bruxism). There are many types of splints. This research looked at the evidence addressing the primary question of whether or not splints work (regardless of type of splint) in reducing the pain associated with temporomandibular disorders and/or tooth wear, and if they offered value for money. Patients were involved in the research to ensure that the question and the outcomes that were measured were appropriate. A systematic review of the literature was undertaken to find all randomised controlled trials including patients with temporomandibular disorders or bruxism. Online databases of research publications were searched, and these searches were checked, to identify relevant trials. All stages of the review process were undertaken to the highest standards by two people, independently and in duplicate, using well-respected and recognised Cochrane methods. We conducted a value-for-money assessment, comparing the trial data with the costs of splints to see if splints are a cost-effective use of NHS funding. There was no evidence that splints reduced pain when compared with not wearing a splint or when compared with a minimal treatment (like jaw exercises, advice or education) in patients with temporomandibular disorders. The evidence was assessed as being of very low quality; therefore, it remains unclear whether or not splints are good value for money, or if they should be paid for by the NHS. This research showed that more well-conducted trials on temporomandibular disorder patients are needed.

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References

  1. Riley P, Glenny AM, Worthington HV, Jacobsen E, Robertson C, Durham J, et al. Oral splints for temporomandibular disorder or bruxism: a systematic review. Br Dent J 2020;228:191–7. doi: 10.1038/s41415-020-1250-2. [DOI] [PMC free article] [PubMed]
  2. National Institute of Dental and Craniofacial Research. Prevalence of TMJD and Its Signs and Symptoms. 2014. URL: www.nidcr.nih.gov/datastatistics/finddatabytopic/facialpain/prevalencetmjd.htm (accessed March 2019).
  3. Aggarwal VR, Joughin A, Zakrzewska J, Appelbe P, Tickle M. Dentists’ preferences for diagnosis, management and referral of chronic oro-facial pain: results from a national survey. Health Educ J 2012;71:662–9. https://doi.org/10.1177/0017896911419350 doi: 10.1177/0017896911419350. [DOI]
  4. Lobbezoo F, Ahlberg J, Glaros AG, Kato T, Koyano K, Lavigne GJ, et al. Bruxism defined and graded: an international consensus. J Oral Rehabil 2013;40:2–4. https://doi.org/10.1111/joor.12011 doi: 10.1111/joor.12011. [DOI] [PubMed]
  5. Manfredini D, Winocur E, Guarda-Nardini L, Paesani D, Lobbezoo F. Epidemiology of bruxism in adults: a systematic review of the literature. J Orofac Pain 2013;27:99–110. https://doi.org/10.11607/jop.921 doi: 10.11607/jop.921. [DOI] [PubMed]
  6. Lobbezoo F, Ahlberg J, Manfredini D, Winocur E. Are bruxism and the bite causally related? J Oral Rehabil 2012;39:489–501. https://doi.org/10.1111/j.1365-2842.2012.02298.x doi: 10.1111/j.1365-2842.2012.02298.x. [DOI] [PubMed]
  7. Marbach JJ, Raphael KG, Janal MN, Hirschkorn-Roth R. Reliability of clinician judgements of bruxism. J Oral Rehabil 2003;30:113–18. https://doi.org/10.1046/j.1365-2842.2003.01146.x doi: 10.1046/j.1365-2842.2003.01146.x. [DOI] [PubMed]
  8. Klasser GD, Greene CS. Oral appliances in the management of temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:212–23. https://doi.org/10.1016/j.tripleo.2008.10.007 doi: 10.1016/j.tripleo.2008.10.007. [DOI] [PubMed]
  9. Clark GT, Minakuchi H. Oral Appliances. In Laskin DM, Greene CS, Hylander WL, editors. Temporomandibular Disorders: An Evidence-based Approach to Diagnosis and Treatment. Hanover Park, IL: Quintessence Publishing Co. Inc.; 2006. pp. 377–390.
  10. Wright EF. Occlusal Appliance Therapy. In Wright EF, editor. Manual of Temporomandibular Disorders. Ames, IA: Wiley-Blackwell; 2014. pp. 149–222.
  11. Wassell RW, Verhees L, Lawrence K, Davies S, Lobbezoo F. Over-the-counter (OTC) bruxism splints available on the Internet. Br Dent J 2014;216:E24. https://doi.org/10.1038/sj.bdj.2014.452 doi: 10.1038/sj.bdj.2014.452. [DOI] [PubMed]
  12. Lickteig R, Lotze M, Kordass B. Successful therapy for temporomandibular pain alters anterior insula and cerebellar representations of occlusion. Cephalalgia 2013;33:1248–57. https://doi.org/10.1177/0333102413491028 doi: 10.1177/0333102413491028. [DOI] [PubMed]
  13. American Academy of Dental Sleep Medicine. About Dental Sleep Medicine. URL: https://aadsm.org (accessed 9 October 2019).
  14. Abstract Archives. Welcome to the IADR Abstract Archive. URL: https://iadr.abstractarchives.com/home (accessed 9 October 2019).
  15. The Cochrane Collaboration. Cochrane Handbook for Systematic Reviews of Interventions. URL: https://training.cochrane.org/handbook (accessed 24 October 2019).
  16. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997;315:629–34. https://doi.org/10.1136/bmj.315.7109.629 doi: 10.1136/bmj.315.7109.629. [DOI] [PMC free article] [PubMed]
  17. Dworkin SF, LeResche L. Research diagnostic criteria for temporomandibular disorders: review, criteria, examinations and specifications, critique. J Craniomandib Disord 1992;6:301–55. [PubMed]
  18. Schiffman E, Ohrbach R, Truelove E, Look J, Anderson G, Goulet JP, et al. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: recommendations of the International RDC/TMD Consortium Network* and Orofacial Pain Special Interest Group†. J Oral Facial Pain Headache 2014;28:6–27. https://doi.org/10.11607/jop.1151 doi: 10.11607/jop.1151. [DOI] [PMC free article] [PubMed]
  19. De Leeuw R, Klasser GD, editors. Orofacial Pain: Guidelines for Assessment, Diagnosis, and Management. 5th edn. Hanover Park, IL: Quintessence Publishing Co. Inc.; 2013.
  20. Atkins D, Best D, Briss PA, Eccles M, Falck-Ytter Y, Flottorp S, et al. Grading quality of evidence and strength of recommendations. BMJ 2004;328:1490. https://doi.org/10.1136/bmj.328.7454.1490 doi: 10.1136/bmj.328.7454.1490. [DOI] [PMC free article] [PubMed]
  21. GRADEPro. GRADE your Evidence and Improve your Guideline Development in Health Care. URL: www.guidelinedevelopment.org (accessed 9 October 2019).
  22. Wassell RW, Adams N, Kelly PJ. Treatment of temporomandibular disorders by stabilising splints in general dental practice: results after initial treatment. Br Dent J 2004;197:35–41. https://doi.org/10.1038/sj.bdj.4811420 doi: 10.1038/sj.bdj.4811420. [DOI] [PubMed]
  23. Tavera AT, Montoya MC, Calderón EF, Gorodezky G, Wixtrom RN. Approaching temporomandibular disorders from a new direction: a randomized controlled clinical trial of the TMDes ear system. Cranio 2012;30:172–82. https://doi.org/10.1179/crn.2012.027 doi: 10.1179/crn.2012.027. [DOI] [PubMed]
  24. Alencar F, Becker A. Evaluation of different occlusal splints and counselling in the management of myofascial pain dysfunction. J Oral Rehabil 2009;36:79–85. https://doi.org/10.1111/j.1365-2842.2008.01913.x doi: 10.1111/j.1365-2842.2008.01913.x. [DOI] [PubMed]
  25. Conti PC, Miranda JE, Conti AC, Pegoraro LF, Araújo Cdos R. Partial time use of anterior repositioning splints in the management of TMJ pain and dysfunction: a one-year controlled study. J Appl Oral Sci 2005;13:345–50. https://doi.org/10.1590/S1678-77572005000400006 doi: 10.1590/S1678-77572005000400006. [DOI] [PubMed]
  26. Conti PC, dos Santos CN, Kogawa EM, de Castro Ferreira Conti AC, de Araujo Cdos R. The treatment of painful temporomandibular joint clicking with oral splints: a randomized clinical trial. J Am Dent Assoc 2006;137:1108–14. https://doi.org/10.14219/jada.archive.2006.0349 doi: 10.14219/jada.archive.2006.0349. [DOI] [PubMed]
  27. Conti PC, de Alencar EN, da Mota Corrêa AS, Lauris JR, Porporatti AL, Costa YM. Behavioural changes and occlusal splints are effective in the management of masticatory myofascial pain: a short-term evaluation. J Oral Rehabil 2012;39:754–60. https://doi.org/10.1111/j.1365-2842.2012.02327.x doi: 10.1111/j.1365-2842.2012.02327.x. [DOI] [PubMed]
  28. Conti PC, Corrêa AS, Lauris JR, Stuginski-Barbosa J. Management of painful temporomandibular joint clicking with different intraoral devices and counseling: a controlled study. J Appl Oral Sci 2015;23:529–35. https://doi.org/10.1590/1678-775720140438 doi: 10.1590/1678-775720140438. [DOI] [PMC free article] [PubMed]
  29. Costa YM, Porporatti AL, Stuginski-Barbosa J, Bonjardim LR, Conti PC. Additional effect of occlusal splints on the improvement of psychological aspects in temporomandibular disorder subjects: a randomized controlled trial. Arch Oral Biol 2015;60:738–44. https://doi.org/10.1016/j.archoralbio.2015.02.005 doi: 10.1016/j.archoralbio.2015.02.005. [DOI] [PubMed]
  30. de Felício CM, Mazzetto MO, de Silva MA, Bataglion C, Hotta TH. A preliminary protocol for multi-professional centers for the determination of signs and symptoms of temporomandibular disorders. Cranio 2006;24:258–64. https://doi.org/10.1179/crn.2006.041 doi: 10.1179/crn.2006.041. [DOI] [PubMed]
  31. de Felício CM, de Oliveira MM, da Silva MA. Effects of orofacial myofunctional therapy on temporomandibular disorders. Cranio 2010;28:249–59. https://doi.org/10.1179/crn.2010.033 doi: 10.1179/crn.2010.033. [DOI] [PubMed]
  32. Gomes CA, El Hage Y, Amaral AP, Politti F, Biasotto-Gonzalez DA. Effects of massage therapy and occlusal splint therapy on electromyographic activity and the intensity of signs and symptoms in individuals with temporomandibular disorder and sleep bruxism: a randomized clinical trial. Chiropr Man Therap 2014;22:43. https://doi.org/10.1186/s12998-014-0043-6 doi: 10.1186/s12998-014-0043-6. [DOI] [PMC free article] [PubMed]
  33. Gomes CA, El-Hage Y, Amaral AP, Herpich CM, Politti F, Kalil-Bussadori S, et al. Effects of massage therapy and occlusal splint usage on quality of life and pain in individuals with sleep bruxism: a randomized controlled trial. J Jpn Phys Ther Assoc 2015;18:1–6. https://doi.org/10.1298/jjpta.18.1 doi: 10.1298/jjpta.18.1. [DOI] [PMC free article] [PubMed]
  34. Zuim PR, Garcia AR, Turcio KH, Hamata MM. Evaluation of microcurrent electrical nerve stimulation (MENS) effectiveness on muscle pain in temporomandibular disorders patients. J Appl Oral Sci 2006;14:61–6. https://doi.org/10.1590/S1678-77572006000100012 doi: 10.1590/S1678-77572006000100012. [DOI] [PMC free article] [PubMed]
  35. Ekberg EC, Vallon D, Nilner M. Occlusal appliance therapy in patients with temporomandibular disorders. A double-blind controlled study in a short-term perspective. Acta Odontol Scand 1998;56:122–8. https://doi.org/10.1080/00016359850136102 doi: 10.1080/00016359850136102. [DOI] [PubMed]
  36. Ekberg E, Vallon D, Nilner M. The efficacy of appliance therapy in patients with temporomandibular disorders of mainly myogenous origin. A randomized, controlled, short-term trial. J Orofac Pain 2003;17:133–9. [PubMed]
  37. Johansson A, Wenneberg B, Wagersten C, Haraldson T. Acupuncture in treatment of facial muscular pain. Acta Odontol Scand 1991;49:153–8. https://doi.org/10.3109/00016359109005900 doi: 10.3109/00016359109005900. [DOI] [PubMed]
  38. List T, Helkimo M, Andersson S, Carlsson GE. Acupuncture and occlusal splint therapy in the treatment of craniomandibular disorders. Part I. A comparative study. Swed Dent J 1992;16:125–41. [PubMed]
  39. Lundh H, Westesson PL, Kopp S, Tillström B. Anterior repositioning splint in the treatment of temporomandibular joints with reciprocal clicking: comparison with a flat occlusal splint and an untreated control group. Oral Surg Oral Med Oral Pathol 1985;60:131–6. https://doi.org/10.1016/0030-4220(85)90280-4 doi: 10.1016/0030-4220(85)90280-4. [DOI] [PubMed]
  40. Lundh H, Westesson PL, Jisander S, Eriksson L. Disk-repositioning onlays in the treatment of temporomandibular joint disk displacement: comparison with a flat occlusal splint and with no treatment. Oral Surg Oral Med Oral Pathol 1988;66:155–62. https://doi.org/10.1016/0030-4220(88)90084-9 doi: 10.1016/0030-4220(88)90084-9. [DOI] [PubMed]
  41. Lundh H, Westesson PL, Eriksson L, Brooks SL. Temporomandibular joint disk displacement without reduction. Treatment with flat occlusal splint versus no treatment. Oral Surg Oral Med Oral Pathol 1992;73:655–8. https://doi.org/10.1016/0030-4220(92)90003-9 doi: 10.1016/0030-4220(92)90003-9. [DOI] [PubMed]
  42. Magnusson T, Syrén M. Therapeutic jaw exercises and interocclusal appliance therapy. A comparison between two common treatments of temporomandibular disorders. Swed Dent J 1999;23:27–37. [PubMed]
  43. Nilsson H, Limchaichana N, Nilner M, Ekberg EC. Short-term treatment of a resilient appliance in TMD pain patients: a randomized controlled trial. J Oral Rehabil 2009;36:547–55. https://doi.org/10.1111/j.1365-2842.2009.01973.x doi: 10.1111/j.1365-2842.2009.01973.x. [DOI] [PubMed]
  44. Wahlund K, List T, Larsson B. Treatment of temporomandibular disorders among adolescents: a comparison between occlusal appliance, relaxation training, and brief information. Acta Odontol Scand 2003;61:203–11. https://doi.org/10.1080/00016350310003891 doi: 10.1080/00016350310003891. [DOI] [PubMed]
  45. DeVocht JW, Goertz CM, Hondras MA, Long CR, Schaeffer W, Thomann L, et al. A pilot study of a chiropractic intervention for management of chronic myofascial temporomandibular disorder. J Am Dent Assoc 2013;144:1154–63. https://doi.org/10.14219/jada.archive.2013.0034 doi: 10.14219/jada.archive.2013.0034. [DOI] [PMC free article] [PubMed]
  46. Pierce CJ, Gale EN. A comparison of different treatments for nocturnal bruxism. J Dent Res 1988;67:597–601. https://doi.org/10.1177/00220345880670031501 doi: 10.1177/00220345880670031501. [DOI] [PubMed]
  47. Raphael KG, Marbach JJ. Widespread pain and the effectiveness of oral splints in myofascial face pain. J Am Dent Assoc 2001;132:305–16. https://doi.org/10.14219/jada.archive.2001.0173 doi: 10.14219/jada.archive.2001.0173. [DOI] [PubMed]
  48. Rubinoff MS, Gross A, McCall WD. Conventional and nonoccluding splint therapy compared for patients with myofascial pain dysfunction syndrome. Gen Dent 1987;35:502–6. [PubMed]
  49. Sharma AR. Short Term Efficacy of Appliance and Physical Therapy for the Treatment of Bilateral Masseter Myalgia: a Double Blinded Randomized Clinical Trial. PhD thesis. Buffalo, NY: University at Buffalo; 2016.
  50. Truelove E, Huggins KH, Mancl L, Dworkin SF. The efficacy of traditional, low-cost and nonsplint therapies for temporomandibular disorder: a randomized controlled trial. J Am Dent Assoc 2006;137:1099–107. https://doi.org/10.14219/jada.archive.2006.0348 doi: 10.14219/jada.archive.2006.0348. [DOI] [PubMed]
  51. Wright E, Anderson G, Schulte J. A randomized clinical trial of intraoral soft splints and palliative treatment for masticatory muscle pain. J Orofac Pain 1995;9:192–9. [PubMed]
  52. Hasanoglu Erbasar GN, Alpaslan C, Eroglu Inan G. Can an NTI-tss device be effective as a first-line therapy in patients with TMD myofascial pain? J Oral Rehabil 2017;44:589–93. https://doi.org/10.1111/joor.12524 doi: 10.1111/joor.12524. [DOI] [PubMed]
  53. Karakis D, Dogan A, Bek B. Evaluation of the effect of two different occlusal splints on maximum occlusal force in patients with sleep bruxism: a pilot study. J Adv Prosthodont 2014;6:103–8. https://doi.org/10.4047/jap.2014.6.2.103 doi: 10.4047/jap.2014.6.2.103. [DOI] [PMC free article] [PubMed]
  54. Tatli U, Benlidayi ME, Ekren O, Salimov F. Comparison of the effectiveness of three different treatment methods for temporomandibular joint disc displacement without reduction. Int J Oral Maxillofac Surg 2017;46:603–9. https://doi.org/10.1016/j.ijom.2017.01.018 doi: 10.1016/j.ijom.2017.01.018. [DOI] [PubMed]
  55. Amin A, Meshramkar R, Lekha K. Comparative evaluation of clinical performance of different kind of occlusal splint in management of myofascial pain. J Indian Prosthodont Soc 2016;16:176–81. https://doi.org/10.4103/0972-4052.176521 doi: 10.4103/0972-4052.176521. [DOI] [PMC free article] [PubMed]
  56. Katyayan PA, Katyayan MK, Shah RJ, Patel G. Efficacy of appliance therapy on temporomandibular disorder related facial pain and mandibular mobility: a randomized controlled study. J Indian Prosthodont Soc 2014;14:251–61. https://doi.org/10.1007/s13191-013-0320-4 doi: 10.1007/s13191-013-0320-4. [DOI] [PMC free article] [PubMed]
  57. Daif ET. Correlation of splint therapy outcome with the electromyography of masticatory muscles in temporomandibular disorder with myofascial pain. Acta Odontol Scand 2012;70:72–7. https://doi.org/10.3109/00016357.2011.597776 doi: 10.3109/00016357.2011.597776. [DOI] [PubMed]
  58. Elsharkawy TM, Ali NM. Evaluation of acupuncture and occlusal splint therapy in the treatment of temporomandibular joint disorders. Egypt Dent J 1995;41:1227–32. [PubMed]
  59. Yu CH, Qian HX. Evaluation of short term efficacy of the stabilized splint and the combination of manipulative and physical therapies for temporomandibular joint disc displacement without reduction. [Chinese.] J Shanghai Jiaotong Univ (Sci) 2016;36:850–5.
  60. Zhang FY, Wang XG, Dong J, Zhang JF, Lü YL. Effect of occlusal splints for the management of patients with myofascial pain: a randomized, controlled, double-blind study. Chin Med J 2013;126:2270–5. [PubMed]
  61. Ficnar T, Middelberg C, Rademacher B, Hessling S, Koch R, Figgener L. Evaluation of the effectiveness of a semi-finished occlusal appliance – a randomized, controlled clinical trial. Head Face Med 2013;9:5. https://doi.org/10.1186/1746-160X-9-5 doi: 10.1186/1746-160X-9-5. [DOI] [PMC free article] [PubMed]
  62. Giannakopoulos NN, Katsikogianni EN, Hellmann D, Eberhard L, Leckel M, Schindler HJ, Schmitter M. Comparison of three different options for immediate treatment of painful temporomandibular disorders: a randomized, controlled pilot trial. Acta Odontol Scand 2016;74:480–6. https://doi.org/10.1080/00016357.2016.1204558 doi: 10.1080/00016357.2016.1204558. [DOI] [PubMed]
  63. Leeson RMA. A Comparison of Medical and Physical Therapies in the Management of Facial Arthromyalgia (Temporomandibular Joint Dysfunction). PhD thesis. London: University of London; 2007.
  64. Michelotti A, Iodice G, Vollaro S, Steenks MH, Farella M. Evaluation of the short-term effectiveness of education versus an occlusal splint for the treatment of myofascial pain of the jaw muscles. J Am Dent Assoc 2012;143:47–53. https://doi.org/10.14219/jada.archive.2012.0018 doi: 10.14219/jada.archive.2012.0018. [DOI] [PubMed]
  65. Rampello A, Saccucci M, Falisi G, Panti F, Polimeni A, Di Paolo C. A new aid in temporomandibular joint disorders’ therapy: the universal neuromuscular immediate relaxing appliance. J Biol Regul Homeost Agents 2013;27:1011–19. [PubMed]
  66. Haketa T, Kino K, Sugisaki M, Takaoka M, Ohta T. Randomized clinical trial of treatment for TMJ disc displacement. J Dent Res 2010;89:1259–63. https://doi.org/10.1177/0022034510378424 doi: 10.1177/0022034510378424. [DOI] [PubMed]
  67. Nagata K, Maruyama H, Mizuhashi R, Morita S, Hori S, Yokoe T, Sugawara Y. Efficacy of stabilisation splint therapy combined with non-splint multimodal therapy for treating RDC/TMD axis I patients: a randomised controlled trial. J Oral Rehabil 2015;42:890–9. https://doi.org/10.1111/joor.12332 doi: 10.1111/joor.12332. [DOI] [PubMed]
  68. Dao TT, Lavigne GJ, Charbonneau A, Feine JS, Lund JP. The efficacy of oral splints in the treatment of myofascial pain of the jaw muscles: a controlled clinical trial. Pain 1994;56:85–94. https://doi.org/10.1016/0304-3959(94)90153-8 doi: 10.1016/0304-3959(94)90153-8. [DOI] [PubMed]
  69. van der Zaag J, Lobbezoo F, Wicks DJ, Visscher CM, Hamburger HL, Naeije M. Controlled assessment of the efficacy of occlusal stabilization splints on sleep bruxism. J Orofac Pain 2005;19:151–8. [PubMed]
  70. Nitecka-Buchta A, Marek B, Baron S. CGRP plasma level changes in patients with temporomandibular disorders treated with occlusal splints – a randomised clinical trial. Endokrynol Pol 2014;65:217–23. https://doi.org/10.5603/EP.2014.0030 doi: 10.5603/EP.2014.0030. [DOI] [PubMed]
  71. Niemelä K, Korpela M, Raustia A, Ylöstalo P, Sipilä K. Efficacy of stabilisation splint treatment on temporomandibular disorders. J Oral Rehabil 2012;39:799–804. https://doi.org/10.1111/j.1365-2842.2012.02335.x doi: 10.1111/j.1365-2842.2012.02335.x. [DOI] [PubMed]
  72. Christidis N, Doepel M, Ekberg E, Ernberg M, Le Bell Y, Nilner M. Effectiveness of a prefabricated occlusal appliance in patients with temporomandibular joint pain: a randomized controlled multicenter study. J Oral Facial Pain Headache 2014;28:128–37. https://doi.org/10.11607/ofph.1216 doi: 10.11607/ofph.1216. [DOI] [PubMed]
  73. Nilner M, Ekberg E, Doepel M, Andersson J, Selovuo K, Le Bell Y. Short-term effectiveness of a prefabricated occlusal appliance in patients with myofascial pain. J Orofac Pain 2008;22:209–18. [PubMed]
  74. Helkimo M. Studies on function and dysfunction of the masticatory system. II. Index for anamnestic and clinical dysfunction and occlusal state. Sven Tandlak Tidskr 1974;67:101–21. [PubMed]
  75. Fonseca DM, Bonfante G, Valle AL, de Freitas SFT. Diagnóstico pela anamnese da disfunção craniomandibular. Rev Gauch de Odontol 1994;4:23–32.
  76. Castroflorio T, Bargellini A, Lucchese A, Manuelli M, Casasco F, Cugliari G, et al. Effects of clear aligners on sleep bruxism: randomized controlled trial. J Biol Regul Homeost Agents 2018;32(2 Suppl. 2):21–9. [PubMed]
  77. Al Quran FA, Kamal MS. Anterior midline point stop device (AMPS) in the treatment of myogenous TMDs: comparison with the stabilization splint and control group. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:741–7. https://doi.org/10.1016/j.tripleo.2005.04.021 doi: 10.1016/j.tripleo.2005.04.021. [DOI] [PubMed]
  78. Alpaslan C, Kahraman S, Guner B, Cula S. Does the use of soft or hard splints affect the short-term outcome of temporomandibular joint arthrocentesis? Int J Oral Maxillofac Surg 2008;37:424–7. https://doi.org/10.1016/j.ijom.2008.01.022 doi: 10.1016/j.ijom.2008.01.022. [DOI] [PubMed]
  79. Gavish A, Winocur E, Ventura YS, Halachmi M, Gazit E. Effect of stabilization splint therapy on pain during chewing in patients suffering from myofascial pain. J Oral Rehabil 2002;29:1181–6. https://doi.org/10.1046/j.1365-2842.2002.00994.x doi: 10.1046/j.1365-2842.2002.00994.x. [DOI] [PubMed]
  80. Madani AS, Mirmortazavi A. Comparison of three treatment options for painful temporomandibular joint clicking. J Oral Sci 2011;53:349–54. https://doi.org/10.2334/josnusd.53.349 doi: 10.2334/josnusd.53.349. [DOI] [PubMed]
  81. Manfredini D, Favero L, Cocilovo F, Monici M, Guarda-Nardini L. A comparison trial between three treatment modalities for the management of myofascial pain of jaw muscles: a preliminary study. Cranio 2018;36:327–31. https://doi.org/10.1080/08869634.2017.1349571 doi: 10.1080/08869634.2017.1349571. [DOI] [PubMed]
  82. Drummond MF, Jefferson TO. Guidelines for authors and peer reviewers of economic submissions to the BMJ. The BMJ Economic Evaluation Working Party. BMJ 1996;313:275–83. https://doi.org/10.1136/bmj.313.7052.275 doi: 10.1136/bmj.313.7052.275. [DOI] [PMC free article] [PubMed]
  83. Philips Z, Ginnelly L, Sculpher M, Claxton K, Golder S, Riemsma R, et al. Review of guidelines for good practice in decision-analytic modelling in health technology assessment. Health Technol Assess 2004;8(36). https://doi.org/10.3310/hta8360 doi: 10.3310/hta8360. [DOI] [PubMed]
  84. Lincoff NS. Treatment of chronic facial pain. Curr Treat Options neurol 2006;8:69–79. https://doi.org/10.1007/s11940-996-0025-7 doi: 10.1007/s11940-996-0025-7. [DOI] [PubMed]
  85. Patel K, Hemmings KW, Vaughan S. The provision of occlusal splints in primary dental care. Prim Dent Care 2000;7:109–13. https://doi.org/10.1308/135576100322694196 doi: 10.1308/135576100322694196. [DOI] [PubMed]
  86. Banhiran W, Kittiphumwong P, Assanasen P, Chongkolwatana C, Metheetrairut C. Adjustable thermoplastic mandibular advancement device for obstructive sleep apnea: outcomes and practicability. Laryngoscope 2014;124:2427–32. https://doi.org/10.1002/lary.24607 doi: 10.1002/lary.24607. [DOI] [PubMed]
  87. Wiedel AP. Fixed or removable appliance for early orthodontic treatment of functional anterior crossbite. Swed Dent J Suppl 2015;238:10–72. [PubMed]
  88. Yekkalam N, Wänman A. Factors associated with clinical decision-making in relation to treatment need for temporomandibular disorders. Acta Odontol Scand 2016;74:134–41. https://doi.org/10.3109/00016357.2015.1063159 doi: 10.3109/00016357.2015.1063159. [DOI] [PubMed]
  89. Vos LM, Stant AD, Quik EH, Huddleston Slater JJR, Stegenga B. Cost effectiveness of arthrocentesis as initial treatment for temporomandibular joint arthralgia: a randomized controlled trial. Int J Oral Maxillofac Surg 2013;42:1369. https://doi.org/10.1016/j.ijom.2013.07.710 doi: 10.1016/j.ijom.2013.07.710. [DOI]
  90. Koyano K, Tsukiyama Y, Ichiki R, Kuwata T. Assessment of bruxism in the clinic. J Oral Rehabil 2008;35:495–508. https://doi.org/10.1111/j.1365-2842.2008.01880.x doi: 10.1111/j.1365-2842.2008.01880.x. [DOI] [PubMed]
  91. Korthals-de Bos IB, Hoving JL, van Tulder MW, Rutten-van Mölken MP, Adèr HJ, de Vet HC, et al. Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial. BMJ 2003;326:911. https://doi.org/10.1136/bmj.326.7395.911 doi: 10.1136/bmj.326.7395.911. [DOI] [PMC free article] [PubMed]
  92. Aggarwal VR, Macfarlane GJ, Farragher TM, McBeth J. Risk factors for onset of chronic oro-facial pain – results of the North Cheshire oro-facial pain prospective population study. Pain 2010;149:354–9. https://doi.org/10.1016/j.pain.2010.02.040 doi: 10.1016/j.pain.2010.02.040. [DOI] [PMC free article] [PubMed]
  93. Macfarlane TV, Glenny AM, Worthington HV. Systematic review of population-based epidemiological studies of oro-facial pain. J Dent 2001;29:451–67. https://doi.org/10.1016/S0300-5712(01)00041-0 doi: 10.1016/S0300-5712(01)00041-0. [DOI] [PubMed]
  94. Durham J, Steele JG, Breckons M, Story W, Vale L. DEEP Study: does EQ-5D-5L measure the impacts of persistent oro-facial pain? J Oral Rehabil 2015;42:643–50. https://doi.org/10.1111/joor.12296 doi: 10.1111/joor.12296. [DOI] [PMC free article] [PubMed]
  95. Von Korff M, Ormel J, Keefe FJ, Dworkin SF. Grading the severity of chronic pain. Pain 1992;50:133–49. https://doi.org/10.1016/0304-3959(92)90154-4 doi: 10.1016/0304-3959(92)90154-4. [DOI] [PubMed]
  96. Office for National Statistics. National Life Tables, UK: 2013 to 2015. URL: www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectancies/bulletins/nationallifetablesunitedkingdom/20132015 (accessed 10 October 2018).
  97. National Institute for Health and Care Excellence. Guide to the Methods of Technology Appraisal 2013. London: NICE; 2013. [PubMed]
  98. Durham J, Breckons M, Araujo-Soares V, Exley C, Steele J, Vale L. Developing Effective and Efficient care pathways in chronic Pain: DEEP study protocol. BMC Oral Health 2014;14:6. https://doi.org/10.1186/1472-6831-14-6 doi: 10.1186/1472-6831-14-6. [DOI] [PMC free article] [PubMed]
  99. Durham J, Shen J, Breckons M, Steele JG, Araujo-Soares V, Exley C, Vale L. Healthcare cost and impact of persistent orofacial pain: the DEEP study cohort. J Dent Res 2016;95:1147–54. https://doi.org/10.1177/0022034516648088 doi: 10.1177/0022034516648088. [DOI] [PubMed]
  100. Briggs A, Claxton K, Sculpher M. Decision Modelling for Health Economic Evaluation. Oxford: Oxford University Press, 2006.
  101. Welton NJ, Ades AE. Estimation of Markov chain transition probabilities and rates from fully and partially observed data: uncertainty propagation, evidence synthesis, and model calibration. Med Decis Making 2005;25:633–45. https://doi.org/10.1177/0272989X05282637 doi: 10.1177/0272989X05282637. [DOI] [PubMed]
  102. van Hout B, Janssen MF, Feng YS, Kohlmann T, Busschbach J, Golicki D, et al. Interim scoring for the EQ-5D-5L: mapping the EQ-5D-5L to EQ-5D-3L value sets. Value Health 2012;15:708–15. https://doi.org/10.1016/j.jval.2012.02.008 doi: 10.1016/j.jval.2012.02.008. [DOI] [PubMed]
  103. Ara R, Brazier JE. Populating an economic model with health state utility values: moving toward better practice. Value Health 2010;13:509–18. https://doi.org/10.1111/j.1524-4733.2010.00700 doi: 10.1111/j.1524-4733.2010.00700. [DOI] [PubMed]
  104. Steele J. NHS Dental Services in England: An Independent Review Led by Professor Jimmy Steele. 2009. URL: www.sigwales.org/wp-content/uploads/dh_101180.pdf (accessed October 2018).
  105. Lord J, Longworth L, Singh J, Onyimadu O, Fricke J, Bayliss S, Meads C. Oral Health Guidance – Economic Analysis of Oral Health Promotion Approaches for Dental Teams. Birmingham & Brunel Consortium External Assessment Centre (BBC EAC). 2015. URL: www.nice.org.uk/guidance/ng30/documents/oral-health-promotion-approaches-for-dental-teams-health-economic-analysis2 (accessed October 2018).
  106. NHS Business Services Authority. NHS Payments to General Practice, England, 2015–16. URL: https://www.nhsbsa.nhs.uk/search?aggregated_field=contract+payment (accessed October 2018).
  107. NHS Digital. NHS Dental Statistics for England – 2016–17. 2017. URL: https://digital.nhs.uk/data-and-information/publications/statistical/nhs-dental-statistics/nhs-dental-statistics-for-england-2016-17 (accessed October 2018).
  108. Campbell Collaboration, EPPI Centre. CCEMG – EPPI-Centre Cost Converter. 2016. URL: http://eppi.ioe.ac.uk/costconversion/default.aspx (accessed April 2018).
  109. Tuffaha HW, Roberts S, Chaboyer W, Gordon LG, Scuffham PA. Cost-effectiveness and value of information analysis of nutritional support for preventing pressure ulcers in high-risk patients: implement now, research later. Appl Health Econ Health Policy 2015;13:167–79. https://doi.org/10.1007/s40258-015-0152-y doi: 10.1007/s40258-015-0152-y. [DOI] [PubMed]
  110. Slade GD. Epidemiology of temporomandibular joint disorders and related painful conditions. Molecular Pain 2014;10(Suppl. 1):O16. https://doi.org/10.1186/1744-8069-10-S1-O16 doi: 10.1186/1744-8069-10-S1-O16. [DOI]
  111. Office for National Statistics. Population Estimates. URL: www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates (accessed October 2018).
  112. Strong M, Brennan A, Oakley J. How to calculate value of information in seconds using ‘SAVI’, the Sheffield Accelerated Value of Information web app. Value Health 2015;18:A725–6. https://doi.org/10.1016/j.jval.2015.09.2759 doi: 10.1016/j.jval.2015.09.2759. [DOI]
  113. Health Economics Research Unit, University of Aberdeen. Oral Splints for Orofacial Symptoms: An Evidence Synthesis. URL: www.abdn.ac.uk/heru/research/assessment-of-technologies/inuse-tech/oral-splints-for-orofacial-symptoms--an-/ (accessed 23 October 2019).
  114. Dworkin RH, Turk DC, Wyrwich KW, Beaton D, Cleeland CS, Farrar JT, et al. Interpreting the clinical importance of treatment outcomes in chronic pain clinical trials: IMMPACT recommendations. J Pain 2008;9:105–21. https://doi.org/10.1016/j.jpain.2007.09.005 doi: 10.1016/j.jpain.2007.09.005. [DOI] [PubMed]
  115. Dworkin RH, Turk DC, Farrar JT, Haythornthwaite JA, Jensen MP, Katz NP, et al. Core outcome measures for chronic pain clinical trials: IMMPACT recommendations. Pain 2005;113:9–19. https://doi.org/10.1016/j.pain.2004.09.012 doi: 10.1016/j.pain.2004.09.012. [DOI] [PubMed]
  116. Williamson PR, Altman DG, Bagley H, Barnes KL, Blazeby JM, Brookes ST, et al. The COMET Handbook: version 1.0. Trials 2017;18:280. https://doi.org/10.1186/s13063-017-1978-4 doi: 10.1186/s13063-017-1978-4. [DOI] [PMC free article] [PubMed]
  117. Prinsen CA, Vohra S, Rose MR, Boers M, Tugwell P, Clarke M, et al. How to select outcome measurement instruments for outcomes included in a ‘Core Outcome Set’ – a practical guideline. Trials 2016;17:449. https://doi.org/10.1186/s13063-016-1555-2 doi: 10.1186/s13063-016-1555-2. [DOI] [PMC free article] [PubMed]
  118. Gurevitch J, Koricheva J, Nakagawa S, Stewart G. Meta-analysis and the science of research synthesis. Nature 2018;555:175–82. https://doi.org/10.1038/nature25753 doi: 10.1038/nature25753. [DOI] [PubMed]
  119. Murad MH, Montori VM. Synthesizing evidence: shifting the focus from individual studies to the body of evidence. JAMA 2013;309:2217–18. https://doi.org/10.1001/jama.2013.5616 doi: 10.1001/jama.2013.5616. [DOI] [PubMed]
  120. Manfredini D, Greene CS, Ahlberg J, De Laat A, Lobbezoo F, Klasser GD. Evidence-based dentistry or meta-analysis illness? A commentary on current publishing trends in the field of temporomandibular disorders and bruxism. J Oral Rehabil 2019;46:1–4. https://doi.org/10.1111/joor.12707 doi: 10.1111/joor.12707. [DOI] [PubMed]
  121. Schulz KF, Altman DG, Moher D, CONSORT Group. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. BMJ 2010;340:c332. https://doi.org/10.1136/bmj.c332 doi: 10.1136/bmj.c332. [DOI] [PMC free article] [PubMed]
  122. The Cochrane Library. How CENTRAL is Created. URL: www.cochranelibrary.com/help/central-creation-details.html (accessed 22 October 2019).
  123. Healthcare Improvement Scotland, Scottish Intercollegiate Guidelines Network. Search Filters. URL: www.sign.ac.uk/search-filters.html (accessed 22 October 2019).
  124. Doepel M, Nilner M, Ekberg E, Vahlberg T, Bell Yl. Headache: short- and long-term effectiveness of a prefabricated appliance compared to a stabilization appliance. Acta Odontol Scand 2011;69:129–36. https://doi.org/10.3109/00016357.2010.538719 doi: 10.3109/00016357.2010.538719. [DOI] [PubMed]
  125. NHS Digital. 2: Disease and Related Disorders – A Report from the Adult and Dental Health Survey 2009. URL: https://files.digital.nhs.uk/publicationimport/pub01xxx/pub01086/adul-dent-heal-surv-summ-them-the2-2009-rep4.pdf (accessed March 2019).

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