Internet-Based Multimodal Pain Program With Telephone Support for Adults With Chronic Temporomandibular Disorder Pain: Randomized Controlled Pilot Trial

Abstract

Background Chronic pain from temporomandibular disorders remains an undertreated condition with debate regarding the most effective treatment modalities. Objective The aim of the study was to investigate the treatment effect of an internet-based multimodal pain program on chronic temporomandibular disorder pain and evaluate the feasibility of a larger randomized controlled trial. Methods An unblinded randomized controlled pilot trial was conducted with 43 participants (34 females, 9 males; median age 27, IQR 23-37 years) with chronic temporomandibular pain. Participants were recruited within the Public Dental Health Service and randomized to intervention (n=20) or active control (n=23). The intervention comprised a dentist-assisted internet-based multimodal pain program with 7 modules based on cognitive behavior therapy and self-management principles. The control group received conventional occlusal splint therapy. Primary outcomes included characteristic pain intensity, pain-related disability, and jaw functional limitation. Secondary outcomes were depression, anxiety, catastrophizing, and stress. Outcomes were self-assessed through questionnaires sent by mail at 3 and 6 months after treatment start. Feasibility evaluation included testing the study protocol and estimation of recruitment and attrition rates in the current research setting. Results Only 49% of participants (21/43) provided data at the 6-month follow-up (internet-based multimodal pain program: n=7; control: n=14). Of the 20 participants randomized to the internet-based multimodal pain program, 14 started treatment and 8 completed all 7 modules of the program. Between-group analysis showed no significant difference for any outcome measure at 3- or 6-month follow-up—characteristic pain intensity (3 months: P=.58; 6 months: P=.41), pain-related disability (3 months: P=.51; 6 months: P=.12), jaw functional limitation (3 months: P=.45; 6 months: P=.90), degree of depression (3 months: P=.64; 6 months: P=.65), anxiety (3 months: P=.93; 6 months: P=.31), stress (3 months: P=.66; 6 months: P=.74), or catastrophizing (3 months: P=.86; 6 months: P=.85). Within-group analysis in the internet-based multimodal pain program group showed a significant reduction in jaw functional limitation score at the 6-month follow-up compared to baseline (Friedman: χ2=10.2, P=.04; Wilcoxon: z=–2.3, P=.02). In the occlusal splint group, jaw function limitation was also reduced at the 6-month follow-up (Friedman: χ2=20.0, P=.045; Wilcoxon: z=–2.3, P=.02), and there was a reduction in characteristic pain intensity at the 3- and 6-month follow-up (Friedman: χ2=25.1, P=.01; Wilcoxon 3 months: z=–3.0, P=.003; Wilcoxon 6 months: z=-3.3, P=.001). Conclusions This study was not able to demonstrate a difference in treatment outcome between an internet-based multimodal pain program and occlusal splint therapy in patients with chronic temporomandibular pain. However, the findings suggested that the internet-based multimodal pain program improves jaw function. The results also confirmed the treatment effect of occlusal splint therapy for chronic temporomandibular pain. Furthermore, because of the high attrition rate, this pilot study showed that a randomized controlled trial with this design is not feasible. Trial Registration ClinicalTrials.gov NCT04363762; https://clinicaltrials.gov/show/NCT04363762

Supported self‐management in temporomandibular disorders: A systematic review of behavioural components

“…After screening, 83 articles were rejected as they did not meet the inclusion criteria for several reasons leaving 84 papers whose full text was obtained and read. After examining the full text of these 84 papers, 20 papers (19 original studies and one follow‐up report) were identified as eligible for inclusion in this systematic review: Komiyama et al, 1999 16 ; Wright et al, 2000 17 ; Carlson et al, 2001 3 ; Dworkin et al, 2002 18 ; Michelotti et al, 2004 19 ;Truelove et al, 2006 4 ; Turner et al, 2006 20 ; Mulet et al, 2007 21 ; Turner et al, 2011 22 ; Nie‐mela et al, 2012 23 ; Michelotti et al, 2012 24 ; Craane et al, 2012 25 ; De Vocht et al, 2013 26 ; Conti et al, 2015 27 ; Costa et al, 2015 28 ; Qvintus et al, 2015 29 ; Giro et al, 2016 30 ; Lam et al, 2020 31 ; De Resende et al, 2021 32 ; Peixoto et al, 2021 33 . A list of the 64 papers excluded with reasons for exclusion is available in the Appendix S3.…”

“…Sixteen of the studies used pain intensity as an outcome measure and it was measured using: the visual analogue scale (VAS) in nine studies 3,16,19,23–25,27,32,33 ; the characteristic pain intensity scale (CPI) in three studies 18,20,22 ; a numerical rating scale (NRS) in two studies 21,26 ; the symptom severity index (SSI) in one study 17 ; and the graded chronic pain scale (GCPS) in one study 31 …”

“…Sixteen of the studies used pain intensity as an outcome measure and it was measured using: the visual analogue scale (VAS) in nine studies 3,16,19,[23][24][25]27,32,33 ; the characteristic pain intensity scale (CPI) in three studies 18,20,22 ; a numerical rating scale (NRS) in two studies 21,26 ; the symptom severity index (SSI) in one study 17 ; and the graded chronic pain scale (GCPS) in one study. 31 The remaining studies had differing outcome measures including: change in number of painful sites within body 4 ; assessment of anxiety, depression and catastrophizing 28 and change in mandibular movement pattern. 30…”

Coexisting Substance Use Disorder and Chronic Pain During COVID-19

“…This method of delivery can also increase self-efficacy and has shown sustainability at follow up (Marsch et al, 2007;Smith et al, 2019). Online pain management has been successfully used in temporomandibular disorder pain (Lam et al, 2020), in veteran population (Higgins et al, 2020), for people with low back pain (Du et al, 2017). Although newer and less well-studied, an online relapse prevention program for adolescents was deemed to be both feasible and acceptable (Sanchez & Bartel, 2015), and efficacy was demonstrated for a computer-based SUD intervention (Marsch et al, 2007).…”

Effects of Prosthetic Rehabilitation on Temporomandibular Disorders: Protocol for a Randomized Controlled Trial

“…There are still disagreements over the most effective and cost-effective treatment approach that can be widely distributed and used [20]. It is based on the clinical experience that, as the teeth are the most important components of the masticatory system and as they have a close relationship with the temporomandibular joint and masticatory muscles, any change to their normal functioning can induce pathological changes in the temporomandibular joint.…”