Discussion of evidence

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The fact that such a variety of treatments is still used provides some evidence that there is no one method of treating these patients. The majority of patients will improve with very little need for therapy but with directed education. There then remains a small cohort of patients who remain difficult to manage. These are the patients who visit a wide range of healthcare providers and are ultimately seen in the tertiary care sector. Turp [2] showed that the average number of providers seen by TMD patients referred to a tertiary care center was 4.9 and that over 60% had at least one nondental treatment and 28% were dissatisfied with the care they had received.

From the current evidence, it is clear that as with other chronic pain, a biopsychosocial approach is necessary as behavior and attitudes need to change and patients need to self-manage their condition. Turner et al. [32] and Gatchel et al. [33] have shown that changing TMD patients' beliefs and pain-coping strategies through the use of CBT can have a modest effect on future pain and functioning. Combining CBT with biofeedback may yield even better results as the latter has a more immediate effect and appears to be more physiologically orientated.

There is some evidence that NSAIDs may be of some benefit but the side effects of these medications need to be taken into account. Benzodiazepines may be useful but they should not be used except in the short term due to dependency. As with other chronic pain, there is some evidence that tricyclic antidepres-sants as well as the newer SSRI may be of benefit. It is highly likely that dental treatment is not the way forward and the American Dental Association has stated that all treatments that attempt to address a possible occlusal disharmony should be reversible. Occlusal appliances which do not attempt to alter occlusion and which are only worn at night may be useful in patients who do not have a stable occlusion or those who have marked parafunctional habits. The EACD stress the importance of providing adequate information [36]. However, as with all other chronic pain conditions, a biopysychosocial approach is crucial especially in those patients who have pain beyond the TMJ area.

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