Journal of Oral Rehabilitation 2006 33; 393401

Clinical factors affecting the outcome of occlusal splint

therapy of temporomandibular joint disorders
R. EMSHOFF

University Clinic of Innsbruck, Oral and Maxillofacial Surgery, Innsbruck, Austria

SUMMARY The purpose of this study was to test

the hypothesis that (1) the presence of a clinical
temporomandibular joint-related disorder has effects on short-term changes in temporomandibular
joint pain, and that (2) clinical variables of time
since pain onset predict treatment outcomes of
occlusal splint therapy. The study comprised 76
patients with unilateral temporomandibular joint
pain. The clinical disorder subgroup included 47
patients with a clinical pain side-related diagnosis of
internal derangement type I (n = 16), internal
derangement type III (n = 19), and degenerative
joint disease (n = 12). The clinical non-disorder
subgroup consisted of 29 patients without a temporomandibular joint disorder. A logistic regression analysis was used to compute the odds ratio
for the clinical variables of time since pain onset,
adjusted for age, gender, pretreatment pain level,
and clinical subgroup. For the temporomandibular

Introduction
For a better definition of diagnostic subgoups of patients
with orofacial pain and temporomandibular disorders
(TMD) a measurable and reproducible set of clinical
diagnostic criteria for temporomandibular disorders
(CDC/TMD) for the most common forms of TMD was
published (1). The rationale for the development of
these criteria was the attempt to agree on a common set
of working critera for classifying subjects in studies of
TMD epidemiology and treatment. CDC/TMD classify
the most common forms of TMD into the main diagnostic subgroups of masticatory muscle disorder, temporomandibular joint (TMJ) internal derangement, and
TMJ degenerative joint disease. To verify that these
disorders truly represent distinct natural entities, data
2006 Blackwell Publishing Ltd

joint pain measurements there was no significant

session/clinical subgroup interaction (P = 0470).
Significant increase in benefit of a successful outcome of pain reduction >70% occurred with a time
since pain onset of 6 months (151 odds ratio)
(P = 0003). The odds ratio that a patient with a time
since pain onset of >2 years might belong to the
unsuccessful treatment group of pain reduction
<30% was strong (60) and significant (P = 0026).
Diagnosis of temporomandibular joint disorder
proved not to be linked to changes in therapeutic
outcome measures of temporomandibular joint
pain. Time since pain onset was an important
prognostic determinant of successful occlusal splint
therapy.
KEYWORDS: Orofacial pain, temporomandibular disorder, temporomandibular joint, occlusal splint
Accepted for publication 4 October 2005

supporting decisive differences in the areas of pathogenesis, treatment and/or prognosis are essential (2).
In patients with TMJ pain and dysfunction, clinical
trials suggested splint therapy (36), arthrocentesis
(7, 8), arthroscopic lysis and lavage (9, 10), and
arthrotomy (11, 12) to be effective on TMJ signs and
symptoms, while in terms of therapy there are only few
studies available concerned with the evaluation of
specific variables in relation to specific treatment
outcome measures. Kurita et al. (13) evaluated clinical
parameters in 51 TMJs of 45 patients undergoing splint
therapy, each TMJ characterized by the clinical finding
of reciprocal clicking. With 45 of the 51 TMJs showing a
successful disc recapature, the unsuccessful joints had
significant smaller mandibular opening and shorter
duration of their joint pain than the successful joints.
doi: 10.1111/j.1365-2842.2005.01584.x

394

R. EMSHOFF
Ekberg and Nilner (14) evaluated clinical variables
before stabilization appliance therapy in 60 patients,
each TMJ classified with a pretreatment clinical diagnosis of a TMD of arthrogeneous origin. With a
significant reduction in pain and an improvement of
subjective symptoms, the presence of severe and very
severe TMJ pain (negative) and male sex (positive)
were described as variables of significant importance for
treatment outcome. However, prior research has been
conducted as simple pair-wise tests of TMJ- and subjectrelated variables (13), but this assumes an all or none
role and ignores the simultaneous contribution of
multiple factors, which inevitably occur in biological
systems. Further, studies have relied on polychotomous
test items rather then using continuous scale data for
estimating changes and describing proportionate risks
and/or benefits (14), while they have also frequently
suffered from the inadequacy of sample size (13), and
the short-term duration of follow-up (13, 14).
The evaluation of an array of variables for the purpose
of predictive modeling would have significant clinical
implications, most notably the implementation of specific treatments during the acute and chronic phase of
TMJ pain, in an effort to prevent the development of
more costly chronic problems and associated psychosocial sequela. The purpose of this study was to test the
hypothesis that (1) the presence of a clinical TMJ-related
disorder has effects on short-term changes in TMJ pain,
and that (2) clinical variables of time since pain onset
predict treatment outcomes of occlusal splint therapy.

Materials and methods

Subjects
The study group, selected over a period of approximately 2 years, consisted of 76 consecutive patients
with unilateral TMJ pain; they were referred from
medical practitioners and dentists in the community to
the orofacial pain and TMD clinic in the Department of
Oral and Maxillofacial Surgery at the University of
Innsbruck. This clinic is the primary referral center for
TMD at the institution as both conservative and surgical
treatments are offered. Patients were referred to the
center for treatment with reported pain and dysfunction of the temporomandibular region as the primary
problem. The TMJ pain group included 68 females and
8 males, with a mean age of 333 years (range 1380).
The subjects were informed about the study procedure
and informed consent was received. From this series of
patients, the contribution of specific clinical parameters
to the outcome of management with occlusal splints
was investigated.
Criteria for including a TMJ disorder patient were (i)
the presence of a TMJ pain side-related single diagnosis
of internal derangement type I (disc displacement with
reduction), internal derangement type III (disc displacement without reduction), or degenerative joint
disease, and (ii) a report of orofacial pain referred to the
TMJ as well as the presence of unilateral TMJ pain
during function. Criteria for including a TMJ non-

Table 1. Comparison of clinical diagnostic criteria between TMJ disorder and TMJ non-disorder subgroups (n 76)
Clinical subgroup
Presence of TMJ disorder [n 47 (%)]
Clinical decision criteria for
TMD diagnostic categories
Click in the TMJ during mandibular
range of motion
Click in the TMJ during lateral or
protrusive excursion
Unassisted mandibular opening <35 mm
Mandibular opening with assistance increased
by 3 mm or less than unassisted opening
History of sudden reduction in opening
Hard grating or crepitus
Pain in the joint during palpation
Pain in the joint during function
Pain in the joint during assisted opening

Internal derangement Internal derangement Degenerative joint Absence of TMJ

disorder [n 29 (%)]
type I (n 16)
type III (n 19)
disease (n 12)
16 (100)

6 (500)

7 (241)

16 (100)

3 (250)

3 (104)

12 (100)
5 (417)
12 (100)

6 (207)
29 (100)

2 (125)

19 (100)
19 (100)

11 (688)
16 (100)

19
12
8
19

(100)
(255)
(421)
(100)

TMJ, temporomandibular joint; TMD, temporomandibular disorder.

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OUTCOME OF OCCLUSAL SPLINT THERAPY OF TMD

disorder patient were (i) absence of a TMJ disorder
diagnosis, and (ii) a report of orofacial pain referred to
the TMJ as well as the presence of unilateral TMJ pain
during function. Application of the criteria resulted in a
clinical disorder subgroup of 47 TMJ pain patients,
including 16 diagnosed with an internal derangement
type I, 19 with an internal derangement type III, and 12
with a degenerative joint disease; the clinical nondisorder subgroup consisted of 29 patients without a CDC/
TMD-defined clinical TMJ disorder condition (Table 1).

Clinical diagnosis was made according to the CDC/

TMD published by Truelove et al. (1). Criteria for each
diagnostic subgroup were specified as guidelines to
be used in the clinical diagnostic process. Clinical
evidence of absence of TMD was given in the absence
of clinical inclusion criteria defining one of the TMD
subgroups. Patients assigned a TMD diagnosis of myalgia, or collagen vascular disease, and patients with a
history of trauma, were not included in this study
(Table 2).

Table 2. Clinical decision criteria for TMD diagnostic categories (1)

TMD diagnosis

Required diagnostic (operational criteria)

Myalgia type I
Mild masticatory muscle symptoms

Report of orofacial pain

Muscle palpation pain in two or more muscle sites (masseter, temporalis,
tendon of the temporalis, suprahyoids, stylohyoid region,
lateral pterygoid) with muscle palpation pain of two or more on
a 03 scale in no more than a single muscle site
Report of orofacial pain
Muscle palpation pain in two or more muscle sites listed above with
two or more muscle sites rated two or greater on a 03 scale
Myalgia I or II
Unassisted mandibular opening of less than 40 mm and mandibular
opening with assistance of four or more millimeter greater
than unassisted opening
Click in the TMJ during mandibular range of motion (ROM)
Click in the TMJ during lateral or protrusive excursion
Normal closing with or without clicking
Same as internal derangement type I with periods of catching briefly
during opening
Unassisted mandibular opening <35 mm
Mandibular opening with assistance increased by 3 mm or
less than unassisted opening
History of sudden reduction in opening
If prior history of click, click disappearance and sudden decreased open coincide
No distinctive criteria requires imaging

Myalgia type II
Moderate/severe masticatory muscle symptoms
Myofacial pain dysfunction (MPD)
Muscle pain with jaw dysfunction

Internal derangement type I

Disc displacement with reduction
Internal derangement type II
Disc displacement with reduction and episodic catching
Internal derangement type III
Disc displacement without reduction

A-acute
B-chronic
Capsulitis/synovitis

Sprain/strain-trauma related

Perforation of the posterior ligament/disc

Degenerative joint disease (DJD)
arthritis with arthralgia

Degenerative joint disease arthtritis/

arthrosis without arthralgia
Of aging, traumatic, idiopathic
Collagen vascular diseases
Systemic diseases with local involvement

Pain in the joint during palpation

Pain in the joint during function
Pain in the joint during assisted opening
Same as capsulitis plus
History of recent trauma preceding onset of pain
Pain on right or left excursions, or pain on protruded or retruded movement
No distinctive clinical criteria
Same as capsulitis plus absence of positive laboratory tests
for collagen vascular disease
Hard grating or crepitus must be present to make
a clinical diagnosis of DJD
Same as DJD with arthralgia except no pain in joint during palpation,
function or excursion
Same as capsulitis plus
Positive laboratory tests for immune system disease or presence of
clinical criteria required to make a diagnosis of collgen disease

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R. EMSHOFF
The TMJ internal derangement type I subgroup was
defined to have a click in the TMJ during vertical
mandibular range of motion and lateral or protrusive
excursion, and normal closing with or without clicking
reproducible on two of three occasions.
The TMJ internal derangement type III subgroup was
characterized by a history of sudden reduction in
mandibular opening, an unassisted mandibular opening <35 mm, and mandibular opening with assistance
increased by 3 mm or less than unassisted opening.
With a prior history of click, click disappearance and
sudden decreased opening must coincide. Criteria for
including a patient with a TMJ disorder of degenerative
joint disease were presence of hard grating or crepitus
during mandibular range of motion.
The screening, history-taking, pretreatment and 2, 4
and 6-month follow-up clinical assessments were performed by a single clinician (R.E.). The clinical evaluation consisted of a standardized evaluation of signs and
symptoms of TMJ disorders, including mandibular range
of motion, joint sounds, muscle and joint pain on
palpation (15). Preoperative and follow-up evaluation
of TMJ pain on function was accomplished by patient
self-assessment using a visual analog scale (VAS) scale,
i.e. patients registered the mean pain perceived on
chewing or eating hard foods in the last 7 days.
At the 6-month follow-up, subjects whose signs and
symptoms characteristic of a pain reduction >70%
and a pain reduction <30%, were considered to have
a successful and unsuccessful outcome respectively.
Each patient received a hard acrylic, full-arch maxillary
stabilization-type splint with flat occlusal surfaces, and
occlusal contacts in centric occlusion for all opposing
teeth, and uniform anterior and canine guidance (16).
Patients were instructed to wear the splint only at
night for a period of 6 months. Patients who felt
discomfort associated with the use of the splint,
reported using the splint not every night, or received
additional therapy during the follow-up were not
included in this study.

Data analysis
Statistical analysis consisted of univariate analysis of
variance for repeated measurements. For the VAS
measurements, session (I, II, III and IV), and clinical
subgroup (presence and absence of TMJ disorder) were
independent variables. Statistical analysis of sessionrelated measurements of VAS and mandibular range of

motion consisted of univariate analysis of variance.

A Bonferroni correction of the alpha-level for sessionrelated data was performed. Statistical significance of
the pretreatment and 2, 4 and 6-month follow-up
differences in specific remission rates and TMJ disorder
diagnoses was evaluated using the McNemar test.
The pretreatment and 6-month follow-up data were
analyzed by chi-square analysis. A logistic regression
analysis of pretreatment data were used for the simultaneous assessment of each potential clinical variable of
time since pain onset (6 months; >6 months and
2 years and >2 years; 17), adjusted for age, gender,
pretreatment pain level and clinical subgroup.
Odds ratios were used to describe the proportionate
risk and benefit that an individual with a certain clinical
feature may belong to the successful and unsuccessful
treatment group. A significant odds ratio was defined as
an upper and lower 95% confidence limit not containing the value of one. For the odds ratio to be clinically
relevant or even clinically noticeable, it was assumed
that it would need to be >2. Significance was set at
P < 005. For all statistical analysis the SPSS 1007
software program* was used.

Results
For the VAS measurements, the main effect of the
variable session was significant (P 0000), i. e. the
session-related measurements did differ significantly.
However, there was no significant session/clinical
subgroup interaction (P 0470), indicating that the
difference between the session-related measurements
was the same for the clinical subgroups. For the
measurements of mandibular range of motion the
variable session was significant for the disorder of
internal derangement type III (P 0002; Table 3).
Comparison of the number of patients with specific
remissions for TMJ pain, the follow-up data showed for
pain reduction >70% a significant increase from
session II to session III (P 0017). At the 6-month
follow-up, the remission rates of pain reduction
<30%, pain reduction 30% and 70% and pain
reduction >70% showed a value of 33%, 21% and
46% respectively (Table 4).
The number of patients with total remission for TMJ
pain was 31 (41%); limitation of mandibular range of
motion, clicking, and crepitus showed a total remission
*SPSS Inc., Chicago, IL, USA.

2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 393401

OUTCOME OF OCCLUSAL SPLINT THERAPY OF TMD

Table 3. Mean and standard deviations of VAS pain levels and ROM (n 76)
Pretreatment
(session I)

2-month follow-up
(session II)

4-month follow-up
(session III)

6-month follow-up
(session IV)

Clinical subgroup

VAS (mm) ROM (mm)

Absence of TMJ disorder

(n 29)
Presence of TMJ disorder
(n 47)
Internal derangement
type I (n 16)
Internal derangement
type III (n 19)
Degenerative joint
disease (n 12)

345
215 407
49 206
162** 400
69 125
130

395
70 117
148

413
49

341
184 364
76 243
221*

385
63 128
200

395
69

82
115

405
58

264
137 421
62 244
192

424
35

432
75

71
65

434
73

359
216 307
50 239
269

336
68 184
283

358
66

67
124** 382
48**

414
155 377
67 250
191

408
25 103
140*** 403
29 120
160

VAS (mm)

ROM (mm)

VAS (mm)

ROM (mm)

79
71**

VAS (mm)

ROM (mm)

402
32

VAS, visual analog scale; ROM, mandibular range of motion; n, number of subjects; mm, millimeters.
*P < 005; **P < 001; ***P < 0001 significant session-related differences.
Table 4. Number of patients with specific remissions for TMJ pain after 2-, 4- and 6-month follow-up (n 76)
Number of patients with specific remissions (%)
2-month follow-up (session II)

Clinical subgroup
Absence of TMJ
disorder (n 29)
Presence of TMJ
disorder (n 47)
Internal derangement
type I (n 16)
Internal derangement
type III (n 19)
Degenerative joint
disease (n 12)
Sum (n 76)

4-month follow-up (session III)

6-month follow-up (session IV)

<30%

30% and
70%

>70%

<30%

30% and
70%

>70%

<30%

30% and
70%

>70%

15 (517)

8 (276)

6 (207)

4 (138)

13 (448)

12 (414)

9 (310)

8 (276)

12 (414)

23 (489)

13 (277)

11 (234)

15 (319)

10 (213)

22 (468)

16 (340)

8 (170)

23 (489)

9 (563)

4 (250)

3 (188)

5 (313)

3 (188)

8 (500)

8 (500)

3 (188)

5 (313)

10 (526)

3 (158)

6 (316)

7 (368)

6 (316)

6 (316)

5 (263)

2 (105)

12 (632)

4 (333)

6 (500)

2 (167)

3 (250)

1 (83)

8 (667)

3 (250)

3 (250)

6 (500)

38 (500)

21 (276)

17 (215)

19 (250)

23 (303)

34* (447)

25 (329)

16 (211)

35 (461)

TMJ, temporomandibular joint; n, number of subjects.

*P < 005 significant session-related differences.

rate of 95%, 44% and 67% respectively (Table 5).

Evaluation of TMD diagnoses revealed a significant
reduction in TMJ pain side-related findings of TMJ
disorders (P 0002), and those of a disorder of
internal derangement type III (P 0002) and internal
derangement type I (P 0040). There was no significant change in TMD diagnoses of degenerative joint
disease during the 6-month follow-up (P 0457).
For the outcome criteria of pain reduction at the
6-month follow-up, there was a significant association
between the variable of time since pain onset and the
clinical findings of successful (P 0002) and unsuccessful outcome (P 0018). The odds ratio that a

patient with a time since pain onset of 6 months

might belong to the successful treatment group of pain
reduction >70% was very strong and highly significant
(152; P 0002). The odds ratio that a patient with a
time since pain onset of >2 years might belong to the
unsuccessful treatment group of pain reduction <30%
was strong (60) and significant (P 0026).

Discussion
TMJ pain was associated with a significant decrease in
VAS levels at the 6-months follow-up. Further, there
was a significant decrease in VAS levels at the 2-months

2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 393401

397

16

16

19

12

76

16

47

16

29

12

12

12

Pain Clicking Crepitus

19

19

19

Limitation
of ROM*

2
(167)
13
(176)

4
(211)

6
(207)
7
(149)
1
(63)

Pain

10
(132)

10
(213)
10
(625)

4
(333)
4
(53)

4
(85)

Clicking Crepitus

2-month follow-up

10
(132)

10
(526)

Limitation
of ROM*

4
(333)
20
(263)

4
(211)

7
(241)
13
(277)
5
(313)

Pain

7
(92)

7
(149)
7
(438)

8
(667)
8
(105)

8
(170)

Clicking Crepitus

4-month follow-up

16
(211)

16
(842)

16
(340)

Limitation
of ROM*

6
(500)
31
(408)

10
(526)

9
(310)
22
(468)
6
(375)

Pain

7
(92)

7
(149)
7
(438)

8
(667)
8
(105)

8
(170)

Clicking Crepitus

6-month follow-up

18
(237)

18
(947)

18
(383)

Limitation
of ROM*

TMJ, temporomandibular joint; ROM, mandibular range of motion.

*Clinical evidence of limitation of ROM was given in the presence of an unassisted mandibular opening <35 mm, and mandibular opening with assistance increased by 3 mm or
less than unassisted opening; n, number of subjects.

Absence of TMJ
disorder (n 29)
Presence of TMJ
disorder (n 47)
Internal
derangement
type I (n 16)
Internal
derangement
type III (n 19)
Degenerative joint
disease (n 12)
Sum (n 76)

Clinical subgoup

Pretreatment findings

Number of patients with total remission (%)

Table 5. Number of patients with total remission for TMJ pain, clicking, crepitus, and limitation of ROM after 2-, 4-, and 6-month follow-up (n 76)

398
R. EMSHOFF

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OUTCOME OF OCCLUSAL SPLINT THERAPY OF TMD

follow-up for patients without a clinical TMJ disorder,
which is a much earlier time period than the 6-months
follow-up observed for the internal derangement type
III subgroup. This is of clinical significance and may be
implicated as a possible aspect in the implementation of
specific treatments during the acute and chronic phase
of TMJ pain, in an effort to prevent the development of
more costly chronic problems and associated psychosocial sequela. Specifically, patients who have an internal
derangement type III may be at risk to develop a
chronic pain condition. This observation may contrast
the results of other authors reporting that TMD patients
whose condition were deemed chronic at the 6-month
follow-up were more often diagnosed with a group I
(muscle) disorder than were those in the nonchronic
group (18, 19), while there was no significant difference between chronic and nonchronic patients meeting
criteria for group II (disc displacement) disorders (18).
However, such data may be not directly comparable,
because these studies using the Research Diagnostic
Criteria for TMD (RDC/TMD), failed to use TMD groupspecific subgroups, reporting prevalences of chronic and
nonchronic relationships in subjects classified as groups
I, II and III disorder patients. In view of the fact that
efforts in making a differential diagnosis are only useful
in instances when there are decisive differences in at
least prognosis and/or treatment, ongoing studies
would be in order to evaluate whether specific criteria
for TMD-related diagnoses may predict differences in
specific treatment-related outcome measures (20, 21).
The results of the present study showed the time
since pain onset of patients of the unsuccessful outcome
group to be significant higher than that of the successful
outcome group. Further, in the study group of patients
with TMJ pain the parameters of time since pain onset
of 6 months and time since pain onset of >2 years
contributed a significant amount to the change in
prognosis of occlusal splint therapy outcomes. It is
generally accepted that one of most significant factors
in the maintenance of TMD pain is time since pain
onset (22, 23). In addition, it is well-established that as
the duration of pain increases, the condition becomes
more refractory to traditional medical treatment
approaches (22, 24).
The literature is sparse regarding assessment of clinical
predictive factors in the treatment of TMJ pain patients
with stabilization-type occlusal splints. In a doubleblind, controlled, short-term study of patients with TMD
of arthrogeneous orign, Ekberg et al. (14) found that not

only the kind of treatment, but also sex and intensity of

TMJ pain before treatment were of significant importance for treatment outcome. However, the results may
be not directly comparable as the populations were
not described in a comparable manner and also did
not match for signs and symptoms. Further studies
that pay attention to method of allocation, outcome
assessment, large sample size, and enough duration of
follow-up are warranted to answer the question, which
additional features may have to be defined as diagnostic
for disorder, namely with significant elevated risk/
benefit for adverse/successful outcomes.
The results of stabilization-type occlusal splint therapy in the present study showed TMJ disorder patients
to be associated with a moderate total remission rate for
TMJ pain (41%). This observation compares favorably
with the results of other authors reporting frequencies
of total remissions of pain in TMJ pain and dysfunction
patients ranging from 30% to 70% (4, 2528). TMJ
sounds such as TMJ clicking and crepitus showed a
major respond to treatment. This observation may
contradict the results of other authors reporting no
change in the occurrence of TMJ clicking (28) or
crepitus (4) with the use of flat occlusal splints, while
others described total remissions of TMJ clicking
ranging from 37% to 80% (4, 25). These differences
may be related to the diagnostic approach of TMD and
TMJ-related signs and symptoms applied in the respective studies. Using strict inclusion and exlcusion criteria
to define homogeneous TMJ groups, further studies
including a large sample size of TMD patients and nonTMD subjects may be warranted to describe TMJ
specific data on TMJ side-related effects of stabilization-type occlusal splint therapy.
In the present study, the beneficial use of stabilization-type occlusal splints was observed in TMJ pain
patients with and without a TMJ disorder, the results of
which may raise the question of how occlusal splints
works and why they may be effective in some patients
but not in others. Arthroscopic studies have confirmed
the concept that inflammatory processes of the synovium, capsule, or retrodiscal tissues are the underlying
mechanisms for the occurrence of TMJ pain (29, 30).
Mechanical disturbances were regarded as etiologic in
the production of an imbalance between anabolic and
catabolic processes, progressive cartilage degradation
and secondary inflammatory components (31, 32),
while therapeutic procedures such as splint therapy
were described to correct the dysfunctional state by

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R. EMSHOFF
decreasing TMJ loading and promote healthy synovial
fluid production (3, 4, 16, 33).
The results of the present study may compare
favourably with the findings of other authors describing
the beneficial use of occlusal splint therapy in patients
with a clinical disorder of TMJ pain and dysfunction (4
6, 14, 2528). However, there is insufficient evidence
either for or against the use of stabilization splint
therapy for the treatment of TMJ pain and dysfunction.
Findings from double-blind, controlled, short-term
studies of patients with TMD of arthrogeneous orign
suggested that the use of stabilization splints for the
treatment of TMJ pain may be beneficial for reducing
pain severity, at rest and on palpation, when compared
with a control appliance (5, 14). These observations are
inconsistent with those of a randomized, controlled
evaluation of nonsurgical treatments for painful TMJ
disc displacement without reduction, which showed no
significant difference in the effectiveness of stabilization
appliance therapy in reducing pain intensity compared
with a control condition (34). Further, a recent review
of research on stabilization splint therapy in
patients with pain dysfunction syndrome stated that
well-designed randomized clinical trials with long-term
evaluation are lacking, and that there is not enough
evidence from trials to show whether or not stabilization splint may reduce pain in painful TMDs (35). The
specific therapeutic efficacy and the scientific basis of
occlusal splint therapy has not been validated, and
competing theoretical concepts may increase the degree
of uncertainty in the therapeutic decision-making
process. Using randomized clinical trials and wellaccepted quantified outcome measures, further studies
including non, standard and occlusal splint therapy
treatment groups in TMJ disorder specific subgroups
may be warranted to assess the therapeutic efficacy of
occlusal splint therapy, and the diagnostic validity of
the specific clinical TMD variables.
Provision of a reliable and valid TMD system is
necessary to describe and evaluate the prevalence and
incidence of TMD, and its natural history and clinical
course, as well as to evaluate risk factors and associated
conditions. These efforts yielded a set of clinical (CDC/
TMD) and research diagnostic criteria for TMD (RDC/
TMD), which are offered to allow standardization and
replication of research into the most common forms of
muscle- and joint-related TMD. The CDC/TMD are
limited by design to include only the most powerful
criteria needed for clinical decision-making. The criteria

are formulated primarily for epidemiologic studies, and

were established to not require imaging (1). Because of
the proven validity of the included criteria, as well as
the omission of the questionable criteria, the CDC/TMD
may provide the opportunity for researchers and
clinicians to devise more reliable and succinct assessment procedures that may be conducted easily in a busy
clinical practice. The RDC/TMD system, reflecting the
complex interaction between physical and psychological dimensions of persistent pain, has evolved its dualaxis approach as an attempt to allow reliable measurement of physical findings (RDC/TMD axis I) and
reliable assessment of psychological status, yielding a
profile of chronic pain dysfunction, depression, anxiety
and preoccupation with other physical symptoms
(RDC/TMD axis II; 36). Because psychological factors
have been implicated in the predisposition, initiation,
and perpetuation of TMD (37, 38), and psychological
therapies have been found to be beneficial for some
TMD patients (39), the RDC/TMD has become an
internationally recognized and widely adopted tool for
TMD research.

Conclusion
Diagnosis of TMJ disorder proved not to be linked to
changes in therapeutic outcome measures of TMJ pain.
Time since pain onset was an important prognostic
determinant of successful occlusal splint therapy.

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Correspondence: Dr R. Emshoff, University Clinic of Innsbruck, Oral

and Maxillofacial Surgery, Innsbruck, Austria.
E-mail: ruediger_emshoff@hotmail.com

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