Level 1: Likely reliable evidence
Cognitive behavioral therapy (CBT) for chronic temporomandibular joint (TMJ) disorder reduces pain and depression at one year based on a recent randomized trial (Pain. 2006;121:181-194). Adults with chronic TMJ and facial pain-related disability (N = 156) were randomized to CBT vs. education/attention control for four sessions every other week over eight weeks. CBT was provided by a licensed clinical psychologist and included instruction and practice in progressive relaxation and abdominal/diaphragmatic breathing, as well as discussions of fear avoidance, identification and challenging of negative thoughts in response to pain, relapse prevention, and dealing with setbacks. The control sessions were led by patient educators. All patients received usual care from their dentist at a clinic specializing in orofacial pain, including instruction to keep jaws relaxed and teeth apart, advice to apply heat and/or cold to painful areas, and diet modifications; some patients were prescribed medications, jaw-stretching exercises, and/or occlusal splints. Both groups received telephone calls from treatment providers at 2, 4, 8, 12, 16, 20, and 24 weeks. An intention-to-treat analysis included 148 patients (95%) who completed at least one post-treatment or follow-up assessment.
Comparing CBT vs. control, activity interference was reported by 98.6% vs. 94.7% at baseline, 87.1% vs. 94.4% at three months (P = .05, NNT 14), 63.2% vs. 88.9% at six months (P = .0002, NNT 4), and 64.7% vs. 87.1% at 12 months (P = .004, NNT 5). From baseline to 12 months, 50% vs. 29% had at least 50% reduction in pain intensity (P = .01, NNT 5). CBT further reduced pain intensity at six and 12 months, but there were no differences between the groups at three months. In addition, CBT decreased mandibular function impairment at 3, 6, and 12 months and reduced Beck Depression Inventory scores at 3 and 12 months; the six-month differences were not statistically significant.
