Occlusal Adjustment For Treating and Preventing Temporomandibular Joint Disorders

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Occlusal adjustment for treating and preventing temporomandibular joint

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DOI: 10.1002/14651858.CD003812
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Occlusal adjustment for treating and preventing
temporomandibular joint disorders (Review)
Koh H, Robinson PG
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2007, Issue 3
http://www.thecochranelibrary.com
Occlusal adjustment for treating and preventing temporomandibular joint disorders (Review) 1
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
TABLE OF CONTENTS
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW . . . . . . . . . . . . . . . . . . 2
SEARCH METHODS FOR IDENTIFICATION OF STUDIES . . . . . . . . . . . . . . . . . . . 3
METHODS OF THE REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
DESCRIPTION OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
METHODOLOGICAL QUALITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
POTENTIAL CONFLICT OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Characteristics of included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Characteristics of excluded studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Comparison 01. Occlusal adjustment vs placebo . . . . . . . . . . . . . . . . . . . . . . . . 11
Comparison 02. Occlusal adjustment vs reassurance . . . . . . . . . . . . . . . . . . . . . . . 11
Comparison 03. Occlusal adjustment vs no treatment . . . . . . . . . . . . . . . . . . . . . . 11
Comparison 04. Prevention of TMD . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
COVER SHEET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
GRAPHS AND OTHER TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Analysis 01.01. Comparison 01 Occlusal adjustment vs placebo, Outcome 01 Pain (frequency) . . . . . . . . 13
Analysis 01.02. Comparison 01 Occlusal adjustment vs placebo, Outcome 02 Pain (severity) . . . . . . . . . 13
Analysis 01.03. Comparison 01 Occlusal adjustment vs placebo, Outcome 03 Headache (frequency) . . . . . . 14
Analysis 01.04. Comparison 01 Occlusal adjustment vs placebo, Outcome 04 Headache (severity) . . . . . . . 14
Analysis 01.05. Comparison 01 Occlusal adjustment vs placebo, Outcome 05 Relief of globus . . . . . . . . 15
Analysis 02.01. Comparison 02 Occlusal adjustment vs reassurance, Outcome 01 Pain (frequency) . . . . . . . 15
Analysis 02.02. Comparison 02 Occlusal adjustment vs reassurance, Outcome 02 Headache (frequency) . . . . . 16
Analysis 02.03. Comparison 02 Occlusal adjustment vs reassurance, Outcome 03 Overall symptoms improvement . 16
Analysis 03.01. Comparison 03 Occlusal adjustment vs no treatment, Outcome 01 Pain (frequency) . . . . . . 17
Analysis 03.02. Comparison 03 Occlusal adjustment vs no treatment, Outcome 02 Pain (severity) . . . . . . . 17
Analysis 03.03. Comparison 03 Occlusal adjustment vs no treatment, Outcome 03 Headache (frequency) . . . . 18
Analysis 03.04. Comparison 03 Occlusal adjustment vs no treatment, Outcome 04 Headache (severity) . . . . . 18
Analysis 04.01. Comparison 04 Prevention of TMD, Outcome 01 Incidence of symptoms . . . . . . . . . 19
Occlusal adjustment for treating and preventing temporomandibular joint disorders (Review) i
Occlusal adjustment for treating and preventing
temporomandibular joint disorders (Review)
Koh H, Robinson PG
This record should be cited as:

Koh H, Robinson PG. Occlusal adjustment for treating and preventing temporomandibular joint disorders. Cochrane Database of
Systematic Reviews 2003, Issue 1. Art. No.: CD003812. DOI: 10.1002/14651858.CD003812.
This version first published online: 20 January 2003 in Issue 1, 2003.

Date of most recent substantive amendment: 13 November 2002
ABSTRACT
Background
There has been a long history of using occlusal adjustment in the management of temporomandibular disorders (TMD). It is not clear
if occlusal adjustment is effective in treating TMD.
Objectives
To assess the effectiveness of occlusal adjustment for treating TMD in adults and preventing TMD.
Search strategy
We searched the Cochrane Oral Health Group’s Trials Register (April 2002); the Cochrane Central Register of Controlled Trials
(CENTRAL) (The Cochrane Library Issue 2, 2002); MEDLINE (1966 to 8th April 2002); EMBASE (1980 to 8th April 2002) and
handsearched journals of particular importance to this review.
Additional reports were identified from the reference lists of retrieved reports and from review articles of treating TMD. There were
no language restrictions.
Unpublished reports or abstracts were considered from the SIGLE database.
Selection criteria
All randomised or quasi-randomised controlled trials (RCTs) comparing occlusal adjustment to placebo, reassurance or no treatment
in adults with TMD. The outcomes were global measures of symptoms, pain, headache and limitation of movement.
Data collection and analysis

Data were independently extracted, in duplicate, by two reviewers, Holy Koh (HK) and Peter G Robinson (PR). Authors were contacted
for details of randomisation and withdrawals and a quality assessment was carried out. The Cochrane Oral Health Group’s statistical
guidelines were followed and relative risk values calculated using random effects models where significant heterogeneity was detected
(P<0.1).
Main results
Over 660 trials were identified by the initial search. Six of these trials, which reported results from a total of 392 patients, were suitable
for inclusion in the review. From the data provided in the published reports, symptom-based outcomes were extracted from trials on
treatment. Data on incidence of symptoms were extracted from trials on prevention. Neither showed any difference between occlusal
adjustment and control group.
Authors’ conclusions
There is an absence of evidence, from RCTs, that occlusal adjustment treats or prevents TMD. Occlusal adjustment cannot be
recommended for the management or prevention of TMD. Future trials should use standardised diagnostic criteria and outcome
measures when evaluating TMD.
PLAIN LANGUAGE SUMMARY
No strong evidence of benefit from occlusal adjustment (adjusting the teeth’s biting surfaces) for problems associated with the joint
between the lower jaw and skull.
When the joint between the lower jaw and the base of the skull is not working well (temporomandibular disorders (TMD)), it can lead
to abnormal jaw movement or locking, noises (clicking or grating), muscle spasms, tenderness or pain. TMD is very common, and
might be caused by occlusion (the way the teeth bite), trauma or stress. Treatments include occlusal adjustment, splints, physiotherapy
and surgery. Occlusal adjustment involves adjusting the biting surface of teeth by grinding the enamel (outer layer of the tooth). The
review found there is no evidence from trials to show that occlusal adjustment can prevent or relieve temporomandibular disorders.
BACKGROUND clinical implications if OA is found to be ineffective in preventing

TMD.
The temporomandibular joint (TMJ) is the joint between the Only one qualitative systematic review has evaluated OA in treat-
lower jaw and the base of the skull. TMJ disorders (TMD) refers ing TMD (Forssell 1999) and it did not include a quantitative
to a group of disorders with symptoms that include pain, clicking, assessment.
grating in the jaw joint and/or problems chewing or opening the
jaw. It is also known as craniomandibular disorders (CMD) and
is a frequent cause of facial pain problems (Dworkin 1995). A OBJECTIVES
positive relationship between occlusal factors (the way the teeth
bite together) and TMD has been suggested (Ramfjord 1961). To establish the effectiveness of occlusal adjustment (OA) in re-
ducing symptoms in patients with temporomandibular disorders
Prevalence studies have reported approximately 75 per cent of the
(TMD) (compared with any control group receiving no treatment,
population having at least one sign of joint dysfunction (abnormal
placebo treatment or reassurance).
jaw movement, joint noises, tenderness on palpation, etc) and
approximately 33 per cent having at least one symptom (facial The following primary null hypotheses were tested:
pain, joint pain, etc) (Rugh 1985; Schiffman 1988). OA does not treat or prevent symptoms of TMD.
Specifically, the review addressed the hypotheses of no difference
There are many causes of TMD. Various theories have been put
between OA and control for TMD for the following outcomes
forward that relate the occlusion (bite of teeth), trauma, and stress
where data were available:
with TMD (Bell 1986).
• global symptoms;
The common signs and symptoms of TMD include pain, joint
sounds (clicking, grating), and limited or asymmetrical jaw move- • relief of headache;
ment. These symptoms may have an effect on health and quality • patient quality of life.
of life.
Treatment options for TMD include reassurance (patient educa-

tion, self care and behaviour therapy), physiotherapy (such as ul- CRITERIA FOR CONSIDERING
trasound, Megapulse, acupuncture, short wave diathermy laser, STUDIES FOR THIS REVIEW
heat exercises, and biofeedback), splint therapy, drug therapy, oc-
clusal adjustment, surgical intervention and combined treatment. Types of studies
Occlusal adjustment (OA) is the selective adjustment of the bit- All randomised controlled trials (RCTs) including quasi-ran-
ing surface of the teeth by grinding the enamel (outer layer of the domised assessing occlusal adjustment (OA) in temporomandibu-
tooth) so that the upper and lower teeth fit together (the inter- lar disorders (TMD).
cuspal position) harmoniously. Adjustments can also be made to
ensure that when the lower jaw is moved to one side the teeth Types of participants
on the other side do not touch (non-working side contacts) and Adults aged equal or above 18 years old with clinically diagnosed
that when the lower jaw moves forwards the back teeth do not TMD. There were no age restrictions for prevention trials.
touch. Cochrane reviews of other treatments (e.g. splint therapy)
are underway. The inclusion criteria required reports to state their diagnostic
criteria for TMD and for participant to exhibit two or more of
It is not clear if malocclusion has a causal role in TMD. However, the signs and/or symptoms listed below. This technique is well
OA has been used in studies to prevent TMD. There are ethical and established in clinical diagnosis and epidemiology and has the
principal advantages of objectivity and reliability where no gold • Relief from symptoms was assessed using global measures of
standard can exist. symptoms.
The list of symptoms (Austin 1995) included: • Data on pain were recorded according to frequency, severity or
duration. Where possible data for the frequency, severity and
• The occurrence of recurrent headache (equal or more than two
duration of pain were aggregated using weighted mean differ-
episodes a month).
ences (WMD) but depended on assessments of heterogeneity.
• Pain in the jaws, face, throat, neck, shoulders or back.
• Similarly, data on headache were recorded according to fre-
• Ear symptoms (includes tinnitus, stuffiness, diminished hear- quency, severity or duration. Where possible data for the fre-
ing, or pain). quency, severity and duration of pain were aggregated using
WMDs but depended on assessments of heterogeneity.
• Pain in the temporomandibular joint (TMJ) at rest and during
chewing. The interval required for outcome measurement was at least three
weeks after the intervention.
• Day and night time grinding or clenching.
SECONDARY OUTCOMES
• Vertigo.
Limitation of movement. Other signs were ignored because they
• Stiffness in jaws. are neither unique to the disease nor associated with the progres-
sion or outcomes of TMD.
• Difficulties in swallowing.
• Globus symptoms (associated with choking sensations or sore-
ness of the throat). SEARCH METHODS FOR
IDENTIFICATION OF STUDIES
• Joint sounds (including clicking and grating).
• Spontaneous luxation or locking of the jaws. See: Cochrane Oral Health Group methods used in reviews.
The list of signs included: The search was based on the Cochrane Oral Health Group search
strategy.
• Palpatory tenderness on either side of the masticatory muscles.
There was no language restriction for inclusion. Every effort was
• Joint sounds during jaw movements, elicited by auscultation.
made to translate non-English articles into English for inclusion.
Distinction is made between opening and closing clicks, crepi-
tations and reciprocal clicking. FROM ELECTRONIC SEARCHES
The list of databases searched was as follows:
• Tenderness during jaw movements.
Cochrane Oral Health Group Trials Register (April 2002);
• Deviation of the mandible on opening and closing. Cochrane Central Register of Controlled Trials (CENTRAL)
(Issue 2, 2002);
• Reduced mandibular range of motion.
MEDLINE (1966-April 2002);
• Presence of occlusal interference in retruded, protruded and EMBASE (1980-April 2002).
medio- and latero-trusion positions of the mandible.
To identify randomised controlled trials (RCTs), the search
• Wear facets. strategy combined the subject search with the Cochrane Optimal
Search Strategy (as published in Appendix 5c in the Cochrane
TMD was required to be clinically absent at baseline in studies on
Reviewers’ Handbook).
prevention.
The subject search used a combination of controlled vocabulary
Types of intervention
and free text terms based on the following search strategy for
The treatment group received OA while the control group received searching MEDLINE (BioMed Ovid 4.1.1):
no treatment, placebo or reassurance. Search strategies for other databases were revised appropriately
Studies where splints had been used prior to treatment were ex- and details of these are available from the lead reviewer.
cluded.
1 exp Temporomandibular Joint/ or exp Temporomandibular
Types of outcome measures Joint Disorders/
PRIMARY OUTCOMES 2 exp Temporomandibular Joint Dysfunction Syndrome/
The main outcomes considered were global symptoms, pain and 3 exp Myofascial Pain Syndromes/
headache: 4 exp Craniomandibular Disorders/
5 temporomandibular$.mp. [mp=title, abstract, registry number When necessary, authors were contacted for relevant original
word, mesh subject heading] data. Further recommendations were sought from colleagues on
6 craniomandibular$.mp. [mp=title, abstract, registry number unpublished studies.
word, mesh subject heading]
7 tmj$.mp. [mp=title, abstract, registry number word, mesh
subject heading] METHODS OF THE REVIEW
8 cmd$.mp. [mp=title, abstract, registry number word, mesh
subject heading] STUDY IDENTIFICATION
9 “temporo mandibular”.mp. [mp=title, abstract, registry The title, abstract, and key words of identified studies were
number word, mesh subject heading] screened independently by both reviewers for relevance to
10 temporo-mandibular$.mp. [mp=title, abstract, registry the systematic review. Studies meeting the inclusion criteria
number word, mesh subject heading] were retrieved as complete articles. Those with randomised
11 (“cranio mandibular” or cranio-mandibular).mp. [mp=title, and quasi-randomised controlled design, participants with
abstract, registry number word, mesh subject heading] temporomandibular disorders (TMD) confirmed clinically,
12 tmd$.mp. [mp=title, abstract, registry number word, mesh occlusal adjustment and control specified and the required
subject heading] outcome variables were included. The term quasi-randomised
13 exp Joint Diseases/ studies followed the definition in the Oral Health Review Group
14 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 Journal Handsearchers’ Manual and are studies where the method
15 exp Dental Occlusion, Balanced/ of allocation was known but was not considered strictly random.
16 exp Occlusal Adjustment/ Non-randomised trials were excluded.
17 (occlus$ adj5 (balance$ or treatment$ or equilibrat$ or DATA EXTRACTION
adjust$)).mp. [mp=title, abstract, registry number word, mesh Both reviewers independently extracted data from the included
subject heading] studies to a pre-designed data collection form. The data extraction
18 ((tooth or teeth) adj5 grind$).mp. [mp=title, abstract, registry form considered: bibliographic details, details of the study setting,
number word, mesh subject heading] characteristics of study population, frequency and course of the
19 (bite$ adj5 adjust$).mp. [mp=title, abstract, registry number interventions, baseline and outcome measures, etc. The different
word, mesh subject heading] requirements and techniques for adjustment were recorded as co-
20 (occlus$ adj5 (balance$ or treat$ or equilibrat$ or variates and assessed as possible sources of heterogeneity. Where
adjust$)).mp. [mp=title, abstract, registry number word, mesh available, data on psychosocial factors were included as a co-variate
subject heading] and assessed as a possible source of heterogeneity.
21 (bite$ adj5 (adjust$ or correct$ or modif$)).mp. [mp=title,
abstract, registry number word, mesh subject heading] Uncertainties on data extraction were resolved by discussion
22 (occlus$ adj5 (correct$ or modif$)).mp. [mp=title, abstract, between the reviewers.
registry number word, mesh subject heading] Where necessary, the authors of the original studies were consulted
23 exp Dental Occlusion/ by mail to obtain more information about the published study.
24 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23
25 14 AND 24 Agreement between reviewers was assessed using Cohen’s kappa.
QUALITY ASSESSMENT
HANDSEARCHING
Both reviewers independently assessed the quality of each study
The following journals were handsearched:
according to the guidelines in the Cochrane Reviewers’ Handbook.
Journal of Oral Rehabilitation (1974 - April 2002);
The strengths and weaknesses of the study design of each included
Journal of Oral and Maxillofacial Surgery (1982 - April 2002);
study were analysed. The allocation concealment of each study
Journal of Craniomandibular Practice (1986 - April 2002).
was graded as A (adequate), B (unclear), C (inadequate) or D
CHECKING REFERENCE LISTS (allocation concealment not used). Disagreements on validity
Additional reports were identified from the reference lists of assessment were resolved by consensus and discussion.
retrieved reports and from review articles of temporomandibular
DATA ANALYSIS
disorders treatments.
The Cochrane Oral Health Group’s statistical guidelines were
UNPUBLISHED LITERATURE followed. RevMan 4.1 was used for data processing.
Unpublished reports or abstracts were considered from the
Cochran’s test for heterogeneity was used to assess discrepancies in
SIGLE database (April 2002) using search strategy based on the
the estimates of treatment effects. A random effects model was used
search strategy presented above.
for assessment of any significant heterogeneity (P<0.1) detected.
PERSONAL COMMUNICATION The source of any statistical heterogeneity was investigated.
The studies were grouped according to types of control and trial included young adults, one trial included adolescents and one
duration of follow up. A sensitivity analysis was carried out upon study included children and adolescents.
different assumptions such as quality of the studies, whether the
CHARACTERISTICS OF INTERVENTIONS
trials were blind or not, missing data and different statistical
There were two groups of trials for assessment. One group consid-
approaches.
ered the intervention in treating patients with TMD. The other
The different requirements and techniques for adjustment were group of trials considered the prevention of TMD using occlusal
recorded as co-variate and assessed as possible sources of adjustment.
heterogeneity. Where available, psychosocial factors were included
All of the six trials provided a clear description of the type and
as a co-variate and assessed as a possible source of heterogeneity.
duration of intervention for both the test and control group. All
The proportion of observed and expected agreement between the but one trial (Vallon 1991) included a placebo control group.
reviewers for 45 variables was assessed using Cohen’s kappa. One trial compared adjustment and reassurance (Vallon 1991).
One trial had an additional ’no treatment’ control group (Kerstein
Publication bias was estimated using the symmetry of funnel plots. 1997) besides the test and placebo groups.
The strength and generalisability of the evidence were carefully
explained. CHARACTERISTICS OF OUTCOME MEASURES
Three trials reported both signs and symptoms of TMD (Vallon
Any adverse reactions were recorded and described. 1991; Kerstein 1997; Kirveskari 1985). There was variation be-
tween the trials in the assessment of symptoms for TMD. Two
trials (Vallon 1991; Kerstein 1997) reported data on pain and
DESCRIPTION OF STUDIES headache. Two trials presented data on globus (Kirveskari 1985;
Vallon 1991).
See ’Characteristics of included studies’ table.
There was variation in the type of measurement used for the main
See ’Characteristics of excluded studies’ table.
outcomes. One trial used a Visual Analogue Scale for pain and
CHARACTERISTICS OF TRIAL SETTING AND INVESTI- the presence or absence of headache and globus (Vallon 1991).
GATORS One trial used the frequency and intensity of pain and headache
Of the seventeen eligible trials, 11 trials were excluded for the (Kerstein 1997). One trial used number of improvements in globus
following reasons: attrition bias (three trials), incomparable dura- symptoms (Kirveskari 1985).
tion of intervention and measurement (two trials), two trials of
The three studies on prevention (Karjalainen 1997; Kirveskari
treatment for temporomandibular disorders (TMD) had control
1989; Kirveskari 1998) reported data on the incidence of TMD.
groups that did not have the condition, no valid control group
(two trials), invalid treatment group (one trial) and inadequate Additional clinical outcomes reported included range of mandibu-
duration of measurement (one trial). lar movement (Vallon 1991), disclusion times (Kerstein 1997) and
the presence of an unstable occlusion (Kirveskari 1985). There
Of the six included trials, four were conducted in Finland
were no data on psychosocial outcomes, costs or quality of life in
(Karjalainen 1997; Kirveskari 1985; Kirveskari 1989; Kirveskari
any of the trials. There were no reports of adverse reactions.
1998), one in the USA (Kerstein 1997) and one in Sweden (Vallon
1991). All trials had a randomised, parallel group study design. Approval from an ethical committee was reported in all except two
The trials were published in six reports between 1985 and 1998, trials (Kerstein 1997; Kirveskari 1985).
with two trials published in 1997, one in 1998, one in 1991,
Two trials (Karjalainen 1997; Kirveskari 1998) had a peer-re-
one in 1989 and one trial in 1985. One study had more than
viewed grant while the remaining trials did not report about fund-
one publication (Kirveskari 1985). Two of the trials (Karjalainen
ing.
1997; Kirveskari 1998) received external funding, four trials did
not. The percentage of patients lost to follow up ranged from 0
to 23%, with a median value of 11%. One study (Vallon 1991)
reported no drop outs. One trial (Kerstein 1997) did not have a METHODOLOGICAL QUALITY
blind outcome assessment.
Electronic mails were sent to authors of one trial and data was
CHARACTERISTICS OF PARTICIPANTS obtained from one included study (Kirveskari 1998). The infor-
Three trials (Kirveskari 1985; Kerstein 1997; Vallon 1991) re- mation supplied was from questionnaires administered pre- and
cruited patients with symptoms of TMD for treatment. post-treatment regarding symptoms in subjects who did not re-
quest treatment.
For prevention, three trials (Karjalainen 1997; Kirveskari 1989;
Kirveskari 1998) recruited only healthy subjects. Of these, one SELECTION BIAS
No major differences were found in the baseline characteristics of headache and relief of globus (all one study each). Occlusal ad-
the groups in terms of the number randomised, age, gender or justment (OA) did not significantly reduce any of these symptoms
the outcomes in Kirveskari 1998; Vallon 1991. It was unclear if (see ’Analyses for Comparisons 01 to 03’).
differences in the age and gender existed in one trial (Kirveskari
The outcomes in the three studies for preventing TMD were inci-
1985), age alone in one trial (Kirveskari 1989) and gender alone
dence of symptoms. OA did not significantly reduce the incidence
in two trials (Karjalainen 1997; Kerstein 1997). There were no
of these symptoms (see ’Analyses for Comparison 04, Outcome
major differences in the other baseline characteristics.
01’).
The generation of allocation was adequate in three trials
There were no data on psychosocial outcomes, costs and quality
(Kirveskari 1998; Kirveskari 1985; Karjalainen 1997), inadequate
of life.
in one trial (Kerstein 1997) and unclear in two trials (Kirveskari
1989; Vallon 1991). HETEROGENEITY
Heterogeneity was assessed for the incidence of symptoms in the
PERFORMANCE BIAS
prevention trials (’Comparison 04, Outcome 01’). The meta-anal-
All the trials were performed by dentists trained in occlusal adjust-
ysis shows overlap in the confidence intervals and suggests that the
ment and control. Adjustment for confounders was either absent
variation in the results was not due to chance (P=0.05).
or unclear in all trials.
PUBLICATION BIAS
The concealment of allocation was inadequate for one of the six
Publication bias was assessed for the incidence of symptoms in
trials (Kerstein 1997) and it was unclear for the remaining five.
the prevention trials (’Comparison 04, Outcome 01’). The funnel
ATTRITION BIAS plot is based on three studies and is insufficiently powerful for any
Data were analysed on an intention to treat basis in all except clear indication. The other comparisons had only one trial.
two trials (Kirveskari 1985; Vallon 1991). The withdrawals were
adequately reported in four trials, unclear in one trial (Kerstein The following decisions and assumptions were examined in the
sensitivity analyses:
1997). One trial did not have any withdrawals (Vallon 1991).
DETECTION BIAS • changing the inclusion criteria for the duration of study;
All but one trial (Kerstein 1997) reported blinding during the • reanalysing the data inputing a continuous outcome instead of
outcome assessment. a dichotomous outcome;
• reanalysing the data using improvement of symptoms rather
RESULTS than the absence;
• reanalysing the data using random effects models instead of a
The search strategy identified over 660 titles and abstracts and
fixed effects or vice versa;
from this we obtained 23 full reports. Seventeen trials were con-
sidered eligible according to the defined criteria for trial design, • reanalysing the data by aggregating the data from the placebo,
participants, interventions and outcomes. Of the seventeen, 11 reassurance and no treatment groups;
trials were excluded for the following reasons: no oral outcome
• reanalysing the data by aggregating the data relating to fre-
(14 trials), no useable outcome or data in wrong form (five trials),
quency and severity of pain or headache.
the data were presented as episodes not patients (eight trials), two
reports with insufficient information and one study where it was The results of the sensitivity analyses were not statistically signifi-
unclear if it was a randomised clinical trial or not. cant (P>0.05).
For the six trials included in the review the results are based on
391 patients who were assessed for temporomandibular disorders
DISCUSSION
(TMD). There were 92 patients in the treatment trials and 299 in
the prevention trials. The range of patients was from 9 to 74 per
There is an absence of evidence that occlusal adjustment (OA)
treatment/control group.
treats or prevents temporomandibular disorders (TMD). Data
The proportion of observed and expected agreement between the available in the six trials indicate no significant differences between
reviewers for 45 variables in all 17 data extraction forms was as- OA and placebo, reassurance or no treatment in the treatment or
sessed using Cohen’s kappa. The test showed a high agreement prevention of TMD.
between the reviewers (K=0.88).
It is important to distinguish between absence of evidence and
The outcomes in the studies for treatment of TMD were sever- evidence of absence. There may not be evidence of an effect because
ity of pain, frequency of pain, severity of headache, frequency of there are few data regarding the effectiveness of occlusal adjustment
for TMD. The small number of studies and participants meant (2) Consideration needs to be given to developing valid and stan-
that the confidence intervals (CIs) were wide. An implication is dardised diagnostic criteria for TMD.
that more trials on the effectiveness of occlusal adjustment for (3) Consideration needs to be given to standardised outcome mea-
TMD are needed. surements for evaluating interventions for TMD.
(4) There should be more trials reporting cost-outcome compar-
Based on these data OA cannot be recommended in the treatment
isons of different treatment modalities. The analysis could also in-
and prevention of TMD.
clude the opportunity costs of using a particular intervention over
The inclusion of future trials on prevention into the current anal- other alternatives.
ysis may further reduce the confidence interval and achieve statis- (5) Guidelines, produced by the CONSORT Group, have been
tical significance. published for reporting of randomised controlled trials in the med-
ical literature (CONSORT 2001). The use of such guidelines
There are concerns of the validity and reliability of the criteria
would improve the quality of trials and reports of the management
used in the trials. Inaccurate and inconsistent diagnosis of TMD
of TMD.
would cause misleading reporting of TMD and incomparability
of results with other trials.
Although the sensitivity analyses do not materially change the POTENTIAL CONFLICT OF
results of the review, there are too few trials, of low quality and INTEREST
with few participants, for the results to be robust.
There were some limitations of the methods used in the trials. None known.
These limitations should be considered in their historical context.
Recommendations for future research include:
(1) Reporting the odds ratio, relative risk, relative risk reduction, ACKNOWLEDGEMENTS
absolute risk reduction or weighted mean difference and associated
95% CIs where appropriate.
Thanks go to Emma Tavender, Co-ordinator for the Cochrane
(2) Reporting data on psychosocial outcomes, costs and quality of
Oral Health Group for her help with the administration and sup-
life.
port of the review, Jayne Harrison for her help in the editorial pro-
(3) The use of standardised diagnostic criteria for TMD.
cess, Lee Hooper and Sylvia Bickley, for carrying out the searches
(4) The use of standardised outcome measures for evaluating treat-
for the review and Anne-Marie Glenny for her help in locating all
ments of TMD.
the articles for the review.
(5) Reporting of any side effects, especially if they were directly
The help and expertise of the following is gratefully acknowledged:
related to the intervention.
Jacob Riis (Swedish translations; Nordic Cochrane Centre).
(6) Providing intra- or extra-examiner variability where appropri-
We would also like to thank the following investigators who
ate.
replied to our request for additional information about their trials:
(7) Future research should use samples of adequate size based on
P Kirveskari (University of Turku) and P Alanen (University of
power calculations. The existing trials should be used as the basis
Turku).
of such power calculations.
We would also like to thank those who have provided comments
and editorial input into this review.
AUTHORS’ CONCLUSIONS
Implications for practice SOURCES OF SUPPORT
There is an absence of evidence of effectiveness for occlusal ad-

External sources of support
justment (OA). Based on these data OA cannot be recommended
for the treatment or prevention of temporomandibular disorders
• No sources of support supplied
(TMD).
Implications for research Internal sources of support
(1) More research is needed to elucidate whether there is any ben- • Guy’s, King’s and St Thomas’ School of Dentistry UK
efit from treating TMD with occlusal adjustment. • University of Sheffield , School of Dentistry UK
REFERENCES
References to studies included in this review Vallon 1995

Karjalainen 1997 {published data only} Vallon D, Ekberg EC, Nilner M, Kopp S. Occlusal adjustment in
Karjalainen M, Le Bell Y, Jamsa T, Karjalainen S. Prevention of tem- patients with craniomandibular disorders including headaches. A 3-
poromandibular disorder-related signs and symptoms in orthodon- and 6-month follow-up. Acta Odontologica Scandinavica 1995;53:
tically treated adolescents. Acta Odontologica Scandinavica 1997;55: 55–9.
319–24. Vallon 1997
Kerstein 1997 {published data only} Vallon D, Nilner M. A longitudinal follow-up of the effect of occlusal
Kerstein RB, Chapman R, Klein M. A Comparison of ICAGD to adjustment in patients with craniomandibular disorders. Swedish
Mock ICAGD for Symptom Reductions in Chronic Myofascial Pain Dental Journal 1997;21:85–91.
Dysfunction Patients. Journal of Craniomandibular Practice 1997;15 Vallon 1998
(1):21–37. Vallon D, Nilner M, Soderfeldt B. Treatment Outcome in Patients
Kirveskari 1985 {published data only} with Craniomandibular Disorders of Muscular Origin: A 7-Year Fol-
Kirveskari P, Puhakka H. Effect of occlusal adjustment on globus low-up. Journal of Orofacial Pain 1998;12:210–8.
symptom. Journal of Prosthetic Dentistry 1985;54(6):832–5.
Wenneberg 1988
Kirveskari 1989 {published and unpublished data} Wenneberg B, Nystrom T, Carlsson GE. Occlusal equilibration and
Kirveskari P, Le Bell Y, Salonen M, Forssell H. Effect of elimination other stomatognathic treatment in patients with mandibular dys-
of occlusal interferences on signs and symptoms of craniomandibular function and headache. Journal of Prosthetic Dentistry 1988;59(4):
disorder in young adults. Journal of Oral Rehabilitation 1989;16:21– 478–83.
6. Werndahl 1971
Kirveskari 1998 {published data only} Werndahl L, Seeman L, Carlsson GE. Warren PR, Chater B. The
Kirveskari P, Jamsa T, Alanen P. Occlusal adjustment and the inci- role of the electric toothbrush in the control of plaque and gingivitis:
dence of demand for temporomandibular disorder treatment. Journal a review of 5 years clinical experience with the Braun Oral-B Plaque
of Prosthetic Dentistry 1998;79:433–8. Remover [D7]. American Journal of Dentistry 1996 Jul:S5-11. Tand-
Vallon 1991 {published data only} lakartidningen 1971;63:560–5.
Vallon D, Ekberg EC, Nilner M, Kopp S. Short-term effect of occlusal
adjustment on craniomandibular disorders including headaches. Acta
Additional references
Odontologica Scandinavica 1991;49:89–96. Austin 1995
Austin DG, Pertes RA. Examination of the TMD Patient. In:
References to studies excluded from this review PertesRA, GrossSG editor(s). Clinical Management of Temporo-
Forssell 1986 mandibular Disorders and Orofacial Pain. First Edition. Illinois:
Forssell H, Kirveskari P, Kangasniemi P. Effect of occlusal adjustment Quintessence Publishing Co, Inc, 1995:123–61.
on mandibular dysfunction. Acta Odontologica Scandinavica 1986; Bell 1986
44:63–9. Bell WE. Classification of temporomandibular disorders. In: BellWE
Forssell 1987 editor(s). Temporomandibular disorders. Classification, Diagnosis,
Forssell H, Kirveskari P, Kangasniemi P. Response to occlusal treat- Management. Chicago: Year Book Medical Publishers Inc, 1986:172–
ment in headache patients previously treated by mock occlusal ad- 214.
justment. Acta Odontologica Scandinavica 1987;45:77–80. Bell 1990
Karppinen 1999 Bell WE. Temporomandibular Disorders: Classification, Diagnosis, and
Karppinen K, Eklund S, Suoninen E, Eskelin M, Kirveskari P. Ad- Management. 3rd Edition. Chicago: Year Book, 1990:289–357.
justment of dental occlusion in treatment of chronic cervicobrachial CONSORT 2001
pain and headache. Journal of Oral Rehabilitation 1999;26:710–4. Moher D, Schulz KF, Altman DG. The CONSORT statement: re-
Kopp 1979 vised recommendation for improving the quality of reports of parallel
Kopp S. Short term evaluation of counselling and occlusal adjust- group andomised trials. Lancet 2001;357:1191–4.
ment in patients with mandibular dysfunction involving the tem-
Dworkin 1995
poromandibular joint. Journal of Oral Rehabilitation 1979;6:101–9.
Dworkin S. Personal and societal impact of orofacial pain. Orofa-
Puhakka 1988 cial pain and temporomandibular disorders. New York: Raven Press,
Puhakka J, Kirveskari P. Globus hystericus: globus syndrome?. Journal 1995:15–32.
of Laryngology and Otology 1988;102:231–4.
Forssell 1999
Tsolka 1992 Forssell H, Kalso E, Koskela P, Vehmanen R, Puukka P, Alenen P.
Tsolka P, Morris RW, Preiskel HW. Occlusal adjustment therapy for Occlusal treatments in temporomandibular disorders: a qualitative
craniomandibular disorders: A clinical assessment by a double-blind systematic review of randomized controlled trials. Pain 1999;83:549–
method. Journal of Prosthetic Dentistry 1992;68:957–64. 60.
List 1996
List T, Dworkin SF. Research diagnostic criteria for TMJ guidelines.
Journal of Orofacial Pain 1996;10:240–53.
Ramfjord 1961
Ramfjord SP. Dysfunctional temporomandibular joint and muscle
pain. Journal of Prosthetic Dentistry 1961;11:353–74.
Rugh 1985
Rugh JD, Solberg WK. Oral health status in the United States.
Temporomandibular disorders. Journal of Dental Education 1985;49:
398–404.
Schiffman 1988
Schiffman E, Fricton JR. Epidemiology of TMJ and craniofacial pain.
In: FrictonJR, KroeningRJ, HathawayKM editor(s). TMJ and Cran-
iofacial Pain: Diagnosis and Management. St Louis: IEA Publications,
1988:1–10.
TABLES
Characteristics of included studies
Study Karjalainen 1997

Methods Randomised, parallel group study conducted in Finland. Blind outcome assessment. Clear information on
reasons for withdrawal. Drop outs: 4%.
Participants Healthy adolescents and treated orthodontically. 123 eligible patients, with 118 completing.
Interventions Two groups, adjustment versus placebo. 3 visits (intervention for first 2 visits, measurement 3 years after
intervention). Duration: 3 years.
Outcomes Incidence of symptom after 3 years. Other outcomes: symptoms of pain, headache and globus.
Notes Prevention.
Allocation concealment B – Unclear
Study Kerstein 1997

Methods Randomised, parallel group study conducted in USA. Outcome assessment not blind. Unclear information
on reasons for withdrawal. Drop outs: 17%.
Participants Dental students with myofascial pain. 30 eligible patients, with 25 completing.
Interventions Three groups, adjustment, no treatment versus placebo. 4 visits (intervention for first 2 visits, measurement
at 1 month and 6 months after intervention). Duration: 6 months.
Outcomes Symptoms of pain (severity and frequency) and headache (severity and frequency).
Other outcomes: disclusion times.
Notes Treatment.
Allocation concealment C – Inadequate
Study Kirveskari 1985

Participants Patients with globus. 22 eligible patients, with 17 completing.
Interventions Two groups, adjustment versus placebo. 2-7 visits (intervention for first 2-6 visits, measurement 2-3 months
after intervention). Duration: 2-3 months.
Outcomes Symptoms of globus (relief ).
Other outcomes: muscular tenderness and mandibular range.
Notes Treatment.

Participants Young adults without temporomandibular disorders. 65 eligible patients, with 62 completing.
Interventions Two groups, adjustment versus placebo. 3-4 visits (intervention for first 2-3 visits, measurement 2 years after
intervention). Duration: 2 years.
Outcomes Incidence of symptom after 2 years. Other outcomes: mean range of mandibular movement.
Notes Prevention.

Participants Healthy chidren and adolescents. 146 eligible patients, with 119 completing.
Interventions Two groups, adjustment versus placebo. 4 or more visits (interventions within 2 weeks, measurements every
6 months thereafter). Duration: 4 years.
Outcomes Incidence of symptom after 4 years. Other outcomes: muscular tenderness.
Notes Prevention.
Study Vallon 1991

Methods Randomised, parallel group study conducted in Sweden. Blind outcome assessment. No withdrawal. Drop
outs: 0%.
Participants Patients with craniomandibular disorders. 64 eligible patients, with 50 completing.
Interventions Two groups, adjustment versus placebo. 3 visits (intervention 2 weeks after examination, measurement 4
weeks after intervention). Duration: 4 weeks.
Outcomes Symptoms of pain (frequency), headache (frequency) and globus (relief ). Other outcomes: muscular tender-
ness.
Notes Treatment.
Characteristics of excluded studies
Study Reason for exclusion

Forssell 1986 Incomparable duration of intervention and measurement.
Forssell 1987 Follow up to Forssell 1986. Not randomised.
Karppinen 1999 Treatment group did not have temporomandibular joint disorders.
Characteristics of excluded studies (Continued )
Kopp 1979 Treatment group received adjustment, splints, partial dentures and/or occlusal correction. Not all had adjustment.
Puhakka 1988 Treatment group had globus but no temporomandibular joint disorders.
Tsolka 1992 Insufficient duration of the study. Results were recorded 10 days after treatment.
Vallon 1995 Attrition bias.
Vallon 1997 Follow up to Vallon 1995. Attrition bias.
Vallon 1998 Follow up to Vallon 1995. Attrition bias and combined groups.
Wenneberg 1988 No placebo, no treatment or reassurance as control group.
Werndahl 1971 Both groups had reassurance. Reassurance group additionally received muscle exercise.
ANALYSES
Comparison 01. Occlusal adjustment vs placebo
No. of No. of
Outcome title studies participants Statistical method Effect size
01 Pain (frequency) 1 18 Odds Ratio (Fixed) 95% CI 0.50 [0.07, 3.85]
02 Pain (severity) 1 18 Odds Ratio (Fixed) 95% CI 0.50 [0.07, 3.85]
03 Headache (frequency) 1 18 Odds Ratio (Fixed) 95% CI 0.90 [0.13, 6.08]
04 Headache (severity) 1 18 Odds Ratio (Fixed) 95% CI 0.90 [0.13, 6.08]
05 Relief of globus 1 17 Odds Ratio (Fixed) 95% CI 6.00 [0.72, 49.84]
Comparison 02. Occlusal adjustment vs reassurance
No. of No. of
03 Overall symptoms 1 50 Odds Ratio (Fixed) 95% CI 3.12 [0.12, 80.39]
improvement
Comparison 03. Occlusal adjustment vs no treatment
No. of No. of
02 Pain (severity) 1 17 Odds Ratio (Fixed) 95% CI 0.10 [0.00, 2.15]
04 Headache (severity) 1 17 Odds Ratio (Fixed) 95% CI 0.10 [0.00, 2.15]
Comparison 04. Prevention of TMD
No. of No. of
01 Incidence of symptoms 3 300 Odds Ratio (Random) 95% CI 0.43 [0.14, 1.37]
INDEX TERMS
Medical Subject Headings (MeSH)
∗ Occlusal Adjustment; Randomized Controlled Trials; Temporomandibular Joint Disorders [prevention & control; ∗ therapy]
MeSH check words
Adult; Humans
COVER SHEET
Title Occlusal adjustment for treating and preventing temporomandibular joint disorders
Authors Koh H, Robinson PG
Contribution of author(s) Holy Koh (HK) and Peter G Robinson (PR) wrote the protocol and review. PR co-ordinated
the review and wrote the letters to authors. HK and PR independently and in duplicate
assessed the eligibility of trials, extracted data and assessed the quality of trials. HK conducted
the statistical analysis.
Issue protocol first published 2002/3
Review first published 2003/1
Date of most recent amendment 24 February 2005
Date of most recent 13 November 2002

SUBSTANTIVE amendment
What’s New Information not supplied by author
Date new studies sought but Information not supplied by author

none found
Date new studies found but not Information not supplied by author
yet included/excluded
Date new studies found and Information not supplied by author

included/excluded
Date authors’ conclusions Information not supplied by author

section amended
Contact address Dr Holy Koh

General Dental Practitioner
Department of Dental Public Health & Community Dental Education
Guy’s, King’s and St. Thomas’ School of Dentistry, King’s College London
London
SE5 8AN
UK
E-mail: holykoh@dr.com
DOI 10.1002/14651858.CD003812
Cochrane Library number CD003812
Editorial group Cochrane Oral Health Group
Editorial group code HM-ORAL

GRAPHS AND OTHER TABLES
Analysis 01.01. Comparison 01 Occlusal adjustment vs placebo, Outcome 01 Pain (frequency)
Review: Occlusal adjustment for treating and preventing temporomandibular joint disorders
Comparison: 01 Occlusal adjustment vs placebo
Outcome: 01 Pain (frequency)
Study Adjustment Placebo Odds Ratio (Fixed) Weight Odds Ratio (Fixed)
n/N n/N 95% CI (%) 95% CI
Kerstein 1997 6/10 6/8 100.0 0.50 [ 0.07, 3.85 ]
Total (95% CI) 10 8 100.0 0.50 [ 0.07, 3.85 ]

Total events: 6 (Adjustment), 6 (Placebo)
Test for heterogeneity: not applicable
Test for overall effect z=0.67 p=0.5
0.1 0.2 0.5 1 2 5 10

Favours treatment Favours control
Analysis 01.02. Comparison 01 Occlusal adjustment vs placebo, Outcome 02 Pain (severity)

Outcome: 02 Pain (severity)
n/N n/N 95% CI (%) 95% CI
Kerstein 1997 6/10 6/8 100.0 0.50 [ 0.07, 3.85 ]
Total (95% CI) 10 8 100.0 0.50 [ 0.07, 3.85 ]

0.1 0.2 0.5 1 2 5 10

Analysis 01.03. Comparison 01 Occlusal adjustment vs placebo, Outcome 03 Headache (frequency)
Outcome: 03 Headache (frequency)
n/N n/N 95% CI (%) 95% CI
Kerstein 1997 6/10 5/8 100.0 0.90 [ 0.13, 6.08 ]
Total (95% CI) 10 8 100.0 0.90 [ 0.13, 6.08 ]

0.1 0.2 0.5 1 2 5 10

Analysis 01.04. Comparison 01 Occlusal adjustment vs placebo, Outcome 04 Headache (severity)

Outcome: 04 Headache (severity)
n/N n/N 95% CI (%) 95% CI
Kerstein 1997 6/10 5/8 100.0 0.90 [ 0.13, 6.08 ]
Total (95% CI) 10 8 100.0 0.90 [ 0.13, 6.08 ]

0.1 0.2 0.5 1 2 5 10

Analysis 01.05. Comparison 01 Occlusal adjustment vs placebo, Outcome 05 Relief of globus
Outcome: 05 Relief of globus
n/N n/N 95% CI (%) 95% CI
Kirveskari 1985 6/8 3/9 100.0 6.00 [ 0.72, 49.84 ]
Total (95% CI) 8 9 100.0 6.00 [ 0.72, 49.84 ]

0.1 0.2 0.5 1 2 5 10

Analysis 02.01. Comparison 02 Occlusal adjustment vs reassurance, Outcome 01 Pain (frequency)

Comparison: 02 Occlusal adjustment vs reassurance
Study Adjustment Reassurance Odds Ratio (Fixed) Weight Odds Ratio (Fixed)
n/N n/N 95% CI (%) 95% CI
Vallon 1991 22/25 25/25 100.0 0.13 [ 0.01, 2.58 ]
Total (95% CI) 25 25 100.0 0.13 [ 0.01, 2.58 ]

Total events: 22 (Adjustment), 25 (Reassurance)
0.1 0.2 0.5 1 2 5 10

Analysis 02.02. Comparison 02 Occlusal adjustment vs reassurance, Outcome 02 Headache (frequency)
n/N n/N 95% CI (%) 95% CI
Vallon 1991 11/25 9/25 100.0 1.40 [ 0.45, 4.35 ]
Total (95% CI) 25 25 100.0 1.40 [ 0.45, 4.35 ]

0.1 0.2 0.5 1 2 5 10

Analysis 02.03. Comparison 02 Occlusal adjustment vs reassurance, Outcome 03 Overall symptoms

improvement
Outcome: 03 Overall symptoms improvement
n/N n/N 95% CI (%) 95% CI
Vallon 1991 1/25 0/25 100.0 3.12 [ 0.12, 80.39 ]
Total (95% CI) 25 25 100.0 3.12 [ 0.12, 80.39 ]

0.1 0.2 0.5 1 2 5 10

Analysis 03.01. Comparison 03 Occlusal adjustment vs no treatment, Outcome 01 Pain (frequency)
Comparison: 03 Occlusal adjustment vs no treatment
Study Adjustment no treatment Odds Ratio (Fixed) Weight Odds Ratio (Fixed)
n/N n/N 95% CI (%) 95% CI
Kerstein 1997 6/10 7/7 100.0 0.10 [ 0.00, 2.15 ]
Total (95% CI) 10 7 100.0 0.10 [ 0.00, 2.15 ]

Total events: 6 (Adjustment), 7 (no treatment)
0.1 0.2 0.5 1 2 5 10

Analysis 03.02. Comparison 03 Occlusal adjustment vs no treatment, Outcome 02 Pain (severity)

Outcome: 02 Pain (severity)
n/N n/N 95% CI (%) 95% CI
Kerstein 1997 6/10 7/7 100.0 0.10 [ 0.00, 2.15 ]
Total (95% CI) 10 7 100.0 0.10 [ 0.00, 2.15 ]

0.1 0.2 0.5 1 2 5 10

Analysis 03.03. Comparison 03 Occlusal adjustment vs no treatment, Outcome 03 Headache (frequency)
n/N n/N 95% CI (%) 95% CI
Kerstein 1997 6/10 7/7 100.0 0.10 [ 0.00, 2.15 ]
Total (95% CI) 10 7 100.0 0.10 [ 0.00, 2.15 ]

0.1 0.2 0.5 1 2 5 10

Analysis 03.04. Comparison 03 Occlusal adjustment vs no treatment, Outcome 04 Headache (severity)

Outcome: 04 Headache (severity)
n/N n/N 95% CI (%) 95% CI
Kerstein 1997 6/10 7/7 100.0 0.10 [ 0.00, 2.15 ]
Total (95% CI) 10 7 100.0 0.10 [ 0.00, 2.15 ]

0.1 0.2 0.5 1 2 5 10

Analysis 04.01. Comparison 04 Prevention of TMD, Outcome 01 Incidence of symptoms
Comparison: 04 Prevention of TMD
Outcome: 01 Incidence of symptoms
Study Adjustment Placebo Odds Ratio (Random) Weight Odds Ratio (Random)
n/N n/N 95% CI (%) 95% CI
Karjalainen 1997 33/59 33/59 43.7 1.00 [ 0.48, 2.07 ]
Kirveskari 1989 13/30 22/32 37.0 0.35 [ 0.12, 0.98 ]
Kirveskari 1998 1/60 9/60 19.3 0.10 [ 0.01, 0.78 ]
Total (95% CI) 149 151 100.0 0.43 [ 0.14, 1.37 ]

Test for heterogeneity chi-square=5.99 df=2 p=0.05 I² =66.6%
0.1 0.2 0.5 1 2 5 10

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Occlusal adjustment for treating and preventing temporomandibular joint

Chapter in Cohrane Database of Systematic Reviews · January 2004

HIV and oral health China, 2009 View project

The user has requested enhancement of the downloaded file.

This record should be cited as:

This version first published online: 20 January 2003 in Issue 1, 2003.

Unpublished reports or abstracts were considered from the SIGLE database.

Data collection and analysis

BACKGROUND clinical implications if OA is found to be ineffective in preventing

Treatment options for TMD include reassurance (patient educa-

Implications for practice SOURCES OF SUPPORT

There is an absence of evidence of effectiveness for occlusal ad-

References to studies included in this review Vallon 1995

Characteristics of included studies

Study Karjalainen 1997

Study Kerstein 1997

Study Kirveskari 1985

Study Kirveskari 1989

Study Kirveskari 1998

Study Vallon 1991

Characteristics of excluded studies

Study Reason for exclusion

Comparison 01. Occlusal adjustment vs placebo

Comparison 02. Occlusal adjustment vs reassurance

Comparison 03. Occlusal adjustment vs no treatment

Comparison 04. Prevention of TMD

Authors Koh H, Robinson PG

Issue protocol first published 2002/3

Review first published 2003/1

Date of most recent amendment 24 February 2005

Date of most recent 13 November 2002

What’s New Information not supplied by author

Date new studies sought but Information not supplied by author

Date new studies found and Information not supplied by author

Date authors’ conclusions Information not supplied by author

Contact address Dr Holy Koh

Cochrane Library number CD003812

Editorial group Cochrane Oral Health Group

Editorial group code HM-ORAL

Kerstein 1997 6/10 6/8 100.0 0.50 [ 0.07, 3.85 ]

Total (95% CI) 10 8 100.0 0.50 [ 0.07, 3.85 ]

0.1 0.2 0.5 1 2 5 10

Analysis 01.02. Comparison 01 Occlusal adjustment vs placebo, Outcome 02 Pain (severity)

Kerstein 1997 6/10 6/8 100.0 0.50 [ 0.07, 3.85 ]

Total (95% CI) 10 8 100.0 0.50 [ 0.07, 3.85 ]

0.1 0.2 0.5 1 2 5 10

Kerstein 1997 6/10 5/8 100.0 0.90 [ 0.13, 6.08 ]

Total (95% CI) 10 8 100.0 0.90 [ 0.13, 6.08 ]

0.1 0.2 0.5 1 2 5 10

Analysis 01.04. Comparison 01 Occlusal adjustment vs placebo, Outcome 04 Headache (severity)

Kerstein 1997 6/10 5/8 100.0 0.90 [ 0.13, 6.08 ]

Total (95% CI) 10 8 100.0 0.90 [ 0.13, 6.08 ]

0.1 0.2 0.5 1 2 5 10

Kirveskari 1985 6/8 3/9 100.0 6.00 [ 0.72, 49.84 ]

Total (95% CI) 8 9 100.0 6.00 [ 0.72, 49.84 ]

0.1 0.2 0.5 1 2 5 10

Analysis 02.01. Comparison 02 Occlusal adjustment vs reassurance, Outcome 01 Pain (frequency)

Vallon 1991 22/25 25/25 100.0 0.13 [ 0.01, 2.58 ]