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Limited evidence for tricyclic antidepressants in the treatment of temporomandibular joint disorders Critical Summary Prepared by: Arthur Jeske DMD, PhD 

OVERVIEW

  • Systematic Review Conclusion:

    There are no scientifically sound studies that demonstrate the effectiveness of tricyclic antidepressants (TCAs) in the treatment of temporomandibular joint disorders (TMDs).

  • Critical Summary Assessment:

    This systematic review found 11 studies of various types with only one small, double-blind study, and did not establish the efficacy or document the adverse effects of TCAs used in the treatment of TMD.

  • Evidence Quality Rating:

    Limited

A Critical Summary of:

The use of tricyclic antidepressants in the treatment of temporomandibular joint disorders: systematic review of the literature of the last 20 years

Cascos-Romero J, Vazquez-Delgado E, Vazquez-Rodriguez E, Gay-Escoda C. Medicina Oral, Patologia Oral y Cirugia Bucal. 2009;14(1):E3-7

  • Clinical Questions:

    What is the evidence for the effectiveness of tricyclic antidepressants (TCAs) for treating adults with tempormandibular disorder (TMD)?

  • Review Methods:

    The authors searched MEDLINE for English-language articles published between 1988 and 2008. They used keywords and medical subject headings for "TMD", and conducted a secondary search of the Cochrane Central Register of Controlled Trials using the keyword "TRICYCLIC ANTIDEPRESSANTS". Two authors independently reviewed abstracts to verify the relevance of articles identified in the search. They independently stratified the articles according to their level of evidence using the SORT criteria. Disagreements were resolved by a third author. The primary authors did not evaluate specific measures of efficacy or adverse events as secondary outcomes.

  • Main Results:

    This study identified 11 relevant articles which included 368 participants and various, unspecified treatment outcomes for TCAs in the management of TMD. The authors identified only one study controlled, double-blinded study. This study, which evaluated 12 female subjects during a 2-week period, with inconsistent outcomes between subjects. In addition, the auhtors identified a case-control study, a pilot study and eight literature reviews.

  • Conclusion:

    The authors of the review made a "level B" recommendation (limited evidence) in favor of using TCAs fo TMDs. However, this recommendation is based on a single controlled clinical trial that had significant methodological defects, such as insufficient sample size and lack of homogeneity in study populations. Currently, there are no scientifically valid studies that demonstrate effectiveness of TCAs for TMDs.

  • Source of funding:

    None identified.

Commentary:

  • Importance and Context:

    Temporomandibular joint disorder is a chronic and challenging condition that is typically refractory to therapy with conventional analgesics. The disorder often is accompanied by other co-morbid conditions, including depression. Tricyclic antidepressants may provide an analgesic action in addition to their antidepressant action. Although TCAs are referred to as "traditional therapy" (1), there is a lack of scientific validation. Appropriately designed randomized, controlled trials to study the efficacy of pharmacotherapy is important in determining the best treatment for patients with TMD.

    1. Sidebottom, AJ. Current thinking in temporomandibular joint management. Brit. J. Oral Maxillofac. Surg. 2009;47:91-94.

  • Strengths and Weaknesses of the Systematic Review:

    The authors clearly stated the research question. They searched two appropriate electronic databases. They defined the inclusion and exclusion criteria and utilized and two authors independently identified relevant studies using SORT criteria. Disagreements were adjudicated by a third author. The authors may have omitted relevant articles, since they included only articles written in English, and TCAs were introduced prior to the dates of the search, which also may have limted their search results. The authors did not perform a meta analysis.

  • Strengths and Weaknesses of the Evidence:

    Only one study was double-blind, with a small number of subjects of one sex and the use of one outcome measure (pain/discomfort). Of the relatively few (11) articles included, most (7) were literature reviews, which are inappropriate for use in a systematic review. The authors did not present any statistical analyses of the data.

  • Implications for Dental Practice:

    Current evidence from one recent systematic review provides insufficient evidence on which to base the use of TCAs for TMDs. There are no well-designed, randomized, controlled clinical trials reported thus far that offer the clinician evdience or guidance for selection of a specific TCA, dosage or duration of therapy for TMDs. Because TMDs may be associated with significant variations in symptomatology, implementation of appropriate studies of the efficacy of TCAs in TMD treatment will likely continue to be challenging. Issues include heterogeneity of study subjects, small sample size and pharmacologic and pharmacokinetic variations in different TCAs. Other reviewers conclude that TCAs may be considered in the managment of these patients, but with an interdisciplinary team that includes a pain specialist (1). TCAs are contraindicated in pregnancy and are relatively contraindicated in patients susceptible to adverse anticholinergic effects, such as those with narrow angle glaucoma, urinary retention, and seizure and cardiovascular disorders (3).

    2. Zonnenberg, AJJ. Inconsistent evidence for use of tricyclic antidepressants in the treatment of temporomandibular joint disorders. Evidence-Based Dent. 2009;10(2):56

    3. Killion, KH. Drug Facts and Comparisons. Wolter Kluwer Co., St. Louis, 64th ed., 2010:1333-7.

  • Critical Summary Publication Date: 6/14/2010

These summaries are not intended to, and do not, express, imply, or summarize standards of care, but rather provide a concise reference for dentists to aid in understanding and applying evidence from the referenced systematic review in making clinically sound decisions as guided by their clinical judgment and by patient needs. American Dental Association ©

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