Masticatory Muscle Pain Research Articles

Prevalence of temporomandibular disorder in children and adolescents with juvenile idiopathic arthritis \u2013 a Norwegian cross- sectional multicentre study

BackgroundChildren and adolescents with juvenile idiopathic arthritis (JIA) may suffer pain from temporomandibular disorder (TMD). Still, routines for the assessment of temporomandibular joint (TMJ) pain in health and dental care are lacking. The aims of this study were to examine the prevalence of TMD in children and adolescents with JIA compared to their healthy peers and to investigate potential associations between JIA and TMD.MethodsThis comparative cross-sectional study is part of a longitudinal multicentre study performed during 2015–2020, including 228 children and adolescents aged 4–16 years with a diagnosis of JIA according to the ILAR criteria. This particular substudy draws on a subset of data from the first study visit, including assessments of TMD as part of a broader oral health examination. Children and adolescents with JIA were matched with healthy controls according to gender, age, and centre site. Five calibrated examiners performed the clinical oral examinations according to a standardised protocol, including shortened versions of the diagnostic criteria for TMD (DC/TMD) and the TMJaw Recommendations for Clinical TMJ Assessment in Patients Diagnosed with JIA. Symptoms were recorded and followed by a clinical examination assessing the masticatory muscles and TMJs.ResultsIn our cohort of 221 participants with JIA and 221 healthy controls, 88 (39.8%) participants with JIA and 25 (11.3%) healthy controls presented with TMD based on symptoms and clinical signs. Painful TMD during the last 30 days was reported in 59 (26.7%) participants with JIA vs. 10 (5.0%) of the healthy controls (p < 0.001). Vertical unassisted jaw movement was lower in participants with JIA than in controls, with means of 46.2 mm vs. 49.0 mm, respectively (p < 0.001). Among participants with JIA, a higher proportion of those using synthetic disease-modifying antirheumatic-drugs and biologic disease-modifying antirheumatic-drugs presented with painful masticatory muscles and TMJs at palpation.ConclusionSymptoms and clinical signs of TMD were seen in approximately half of the JIA patients compared to about one fourth of their healthy peers. Painful palpation to masticatory muscles and decreased vertical unassisted jaw movement were more frequent in participants with JIA than among healthy controls and should be part of both medical and dental routine examinations in patients with JIA.

Bruxism, Related Factors and Oral Health-Related Quality of Life Among Vietnamese Medical Students.

Although bruxism is a common issue with a high prevalence, there has been a lack of epidemiological data about bruxism in Vietnam. This cross-sectional study aimed to determine the prevalence and associated factors of bruxism and its impact on oral health-related quality of life among Vietnamese medical students. Bruxism was assessed by the Bruxism Assessment Questionnaire. Temporomandibular disorders were clinically examined followed by the Diagnostic Criteria for Temporomandibular Disorders Axis I. Perceived stress, educational stress, and oral health-related quality of life were assessed using the Vietnamese version of Perceived Stress Scale 10, the Vietnamese version of the Educational Stress Scale for Adolescents, and the Vietnamese version of the 14-item Oral Health Impact Profile, respectively. The prevalence of bruxism, sleep bruxism, awake bruxism, and both conditions in Vietnamese medical students were 51.2%, 38.2%, 23.4%, and 10.4% respectively. Stress, temporomandibular joint pain, masticatory muscle pain, and tooth attrition were associated with the presence of bruxism. Vietnamese medical students were negatively affected by bruxism in terms of oral health-related quality of life.

Effect of multiple injections of botulinum toxin into painful masticatory muscles on bone density in the temporomandibular complex

BackgroundAdverse effects of masticatory muscle injections of Botulinum Toxin (Btx) have been noted in animal and, less dramatically, human studies.ObjectiveAmong women treated in multiple community‐based private practices, to compare TMJ bone density and mandibular condylar volume between patients with myofascial TMJD receiving multiple masticatory muscle Btx treatments and similarly diagnosed women not receiving such treatment.MethodsCohorts consisted of women whose treatment charts indicated a diagnosis of myofascial TMJD: 35 received at least 2 Btx treatment cycles; 44 received none. Bone density at pre‐specified regions of interest (ROI) was defined by grey scale values from Cone Beam CT, adjusting for a fixed density phantom included in each scan. Mean bone density and mandibular condyle volume were compared between groups. Dose‐response effects were tested within the Btx‐exposed group.ResultsThe mean density of primary and secondary ROIs was similar between exposure groups, as was condylar volume. Among Btx‐exposed women, increasing dose of Btx to the temporalis muscle was inversely proportional to the density of the trabecular area of the mandible body. Many Btx‐exposed women received smaller doses of Btx to the masseter muscles than in most TMJD Btx clinical trials.ConclusionMasticatory muscle injections of Btx failed to produce clinically significant TMJ bone‐related changes. Should Btx receive regulatory approval for treatment of myofascial TMJD, a phase IV study is recommended to evaluate potential adverse effects of Btx on bone and muscle when administered at higher doses and/or for more treatment cycles.

MRI of Temporomandibular Joint Disorders: Recent Advances and Future Directions.

Temporomandibular joint disorders (TMDs) are a prevalent disease covering pain and dysfunction of temporomandibular joints and masticatory muscles, which can be detrimental to quality of life. Magnetic resonance imaging (MRI) is a powerful and noninvasive tool for the imaging and understanding of TMD. With the recent technical development of dynamic and quantitative MRI techniques, including diffusion-weighted imaging, T2 mapping, and ultrashort/zero echo time, it is now feasible in TMD imaging and has been preliminarily investigated with promising results. In this review we will discuss the recent advances of MRI techniques in TMD and its future directions, and hope to highlight the scientific potential and clinical value of novel MRI techniques in diagnosing and treating TMD. LEVEL OF EVIDENCE: 4 TECHNICAL EFFICACY STAGE: 3.

Masticatory muscle pain: diagnostic considerations, pathophysiologic theories and future directions

Masticatory muscle pain: diagnostic considerations, pathophysiologic theories and future directions

Effect of manual therapy on pain and electromyographic activity of masticatory muscles in patients with temporomandibular disorders

Background: Temporomandibular disorders (TMD) are disorders of multifactorial origin that affect the temporomandibular joint and/or masticatory muscles. The TMD can generate compensations where physical therapy acts through myofascial releases and joint mobilizations to restore functionality. Objective: To verify the effects of manual therapy techniques on pain and electromyographic activity (EMG) of masticatory muscles in TMD patients. Methods: This is a quasi-experimental study composed of 10 subjects with TMD and 10 healthy subjects who underwent a session of myofascial release, joint mobilization and digit-pressure on the masticatory and cervical muscles. Pain levels and electromyographic activities of the temporal and masseter muscles were bilaterally assessed during the following situations: (1) Maximum Occlusion and (2) Chewing in the right and the left side with chewing gum. Data analysis was performed using BIOMEC-SAS software, in which the data were filtered with a 4th order Butterworth bandpass filter with 20-400hz and normalized as a percentage of maximum occlusion. Data were divided into homolateral and contralateral muscles alongside chewing. EMG variables were compared by factorial ANOVA, and pain by dependent t-test. Results: TMD patients had pain level reduction during maximum occlusion (Pre:4.55±2.2; Post:2.55±1.6; p=&lt;0.001), right chewing (Pre:2.3±2.16; Post:0.4±0.69; p = 0.02) and left chewing (Pre: 1.0±1.15; Post:0.10±0.31; p = 0.05). There was no effect of manual therapy techniques on the EMG activity bilaterally of the temporal (p = 0.617) and masseter (p = 0.926) muscles during chewing. Patients with TMD had higher EMG activities during chewing on the homolateral temporal (p = 0.001) and masseter (0.004) muscles compared to subjects without injury. Conclusion: Manual therapy techniques reduced pain level in TMD patients. No changes in EMG activity were observed after manual therapy techniques. Finally, the study provides evidence of the influence of manual therapy techniques on short-term pain.

Interdisciplinary aspects of rehabilitation of patients with the functional disorders of temporomandibular joint

Objective : Designing effective interdisciplinary scheme for the diagnosis and treatment of functional disorders of the temporomandibular joint (TMJ). Methods : 76 patients with complaints of pain, discomfort and constraint in masticatory muscles and TMJ, and headache were examined. When diagnosing, testing was carried out according to the Hamburg Protocol; according to its results three study groups were formed. Results: With minor initial functional changes in the muscles (group 1), splint therapy is sufficient to achieve the clinical effect. In more severe cases (2 nd and 3 rd groups), the use of transcranial electrical stimulation is effective, and muscle relaxants should be prescribed only if the latter is ineffective. Conclusions : An optimal differentiated scheme of interdisciplinary diagnosis and treatment of patients with functional TMJ disorders has been developed: an express examination according to the Hamburg Protocol determines the severity of the pathology, and electromyography is used not only as a diagnostic, but also as an evaluation criterion for the effectiveness of interdisciplinary rehabilitation at the intermediate and final stages.

Are third molars associated with orofacial pain? Findings from the SHIP study.

To examine the association between third molars and orofacial pain. We hypothesized that impacted third molars are a cause of orofacial pain. Magnetic resonance images of 1808 participants from two population-based cohorts from Northeastern Germany were analysed to define the status of third molars according to the Pell and Gregory classification. A self-reported questionnaire and a clinical dental examination were used to detect chronic and acute complaints of orofacial pain, masticatory muscle pain, migraine and other types of headache. Logistic regression models were used to analyse the associations between third molar status and orofacial pain. Individuals with impacted third molars in the maxilla had a higher chance of chronic orofacial pain than those with erupted third molars (odds ratio 2.19; 95% CI 1.19-4.02). No such association was detected for third molars in the lower jaw. Third molars were not associated with masticatory muscle pain, migraine or other types of headache. Impacted maxillary third molars might be a cause of chronic orofacial pain. Thus, physicians should consider the eruption/impaction status of third molars in their decision-making process when treating patients who complain of orofacial pain.

Prevalence and clinical characteristics of patients with oromandibular dystonia seen in the orofacial pain clinic: a retrospective study.

The aim of this study was to describe the prevalence and clinical characteristics of patients with oromandibular dystonia (OMD) presenting to an academic orofacial pain clinic. OMD diagnosis was based on clinical signs and symptoms, presenting in varied forms and severities. Knowledge of clinical characteristics would help in early diagnosis and treatment of OMD. In this retrospective study, we identified patients with OMD (International Classification of Diseases [ICD]-9 diagnostic code 333.82 and ICD-10 code G24.4) who presented at the clinic from October 2012 to December 2017. Additional selection criteria were age greater than 18 years and confirmation of OMD diagnosis with at least 1 follow-up visit. Over a 5-year period, 22 patients with OMD were identified according to the ICD diagnostic codes, and of those, 6 patients met the selection criteria corresponding to a prevalence of 170 per 100,000 (95% confidence interval [CI] 70-390). The most common chief complaint was jaw pain (67%), and all patients had associated diagnosis of myofascial pain of masticatory muscles. The prevalence of patients with OMD in an academic orofacial pain clinic is higher than previously reported in population-based studies. The presentation of OMD often includes temporomandibular disorders (TMDs), with involvement of various masticatory muscles.

Plasma rich in growth factors injection effectiveness for myofascial pain treatment in masticatory muscles. Randomised controlled trial.

Myofascial pain in masticatory muscles is one of the most common temporomandibular disorder. Nowadays, the most usable treatment methods are based on the muscle taut band cell membrane disruption, which releases the taut band. Platelet-rich plasma, made with PRGF Endoret® method, gives an opportunity to use platelet-derived growth factors in treatment processes. It has been proven that platelet-derived growth factors can relief pain and activate muscle regeneration. To test a hypothesis that PRGF injections can be effective for treating myofascial pain in masticatory muscles. Fifty adult patients participated in the study. Participants were randomly divided into two groups. The first group received 1-mL lidocaine injections to trigger point in their masseter muscle. The second group of patients received 1-mL PRGF injections. The patients' pain was measured by using visual analogue scale (VAS). Statistically significant difference in pain levels before the procedure and 4weeks after it was found in both groups. There was no statistically significant difference between groups in pain levels before the procedure (P=.063) and 2weeks after it (P=.123); however, statistically significant difference was noticed 4weeks after the procedure (P<.001). Four weeks after the procedure, patients' average pain in lidocaine group was 3.4 on VAS, and it was 0.9 in PRGF group. PRGF injections in masseter muscle affected by myofascial pain syndrome are an effective treatment method. PRGF injections more effectively relief myofascial pain in masseter muscle than lidocaine injections.

Cytokines, Masticatory Muscle Inflammation, and Pain: an Update.

Cytokines are proteins secreted by diverse types of immune and non-immune cells and play a role in the communication between the immune and nervous systems. Cytokines include lymphokines, monokines, chemokines, interleukins, interferons, colony stimulating factors, and growth factors. They can be both pro- and anti-inflammatory and have autocrine, paracrine, and endocrine activities. These proteins are involved in initiation and persistence of pain, and the progress of hyperalgesia and allodynia, upon stimulating nociceptive sensory neurons, and inducing central sensitization. The objective of this review is to discuss several types of pro- and anti-inflammatory mediators and their relation with inflammatory pain in masticatory muscles.

Effect of tooth loss on masticatory muscle pain of patients with bruxism

Aim: It was aimed to compare the patients’ masticatory muscle pain according to the gender, side of the face with pain, muscle tenderness, and tooth loss.Material and Methods: The patients were selected randomly and the data were collected from 109 patients aged 18-50 years. Patients were examined by a maxillofacial surgeon and a prosthodontist blindly. During intraoral examination grinding, clenching confirmed by sleep partners or roommates, hyperkeratosis of cheek mucosa (linea alba), indented tongue, the unilateral masseter muscle hypertrophy, tooth wear, hypersensitivity, pain and fatigue in the chewing muscles in the daytime or in the morning were recorded. To classify tooth loss the Eichner index was used. It was asked to participants to score the masticatory muscle pain. Each participant scored the masticatory muscle pain on a visual analog scale (VAS/0-10). Data were analyzed with a non-parametric Mann-Whitney U test to compare the VAS results because the data were distributed non-normally. Chi-square test was used to compare categorical variables and Spearsman correlation test was performed to test the possible correlation between the masticatory muscle pain and age. Results: The percentage of bruxism in female (52.3%) was higher than in male (47.7%). A total of 15 patients (13.7%) had tooth loss (premolar or molar). Pain score was higher in patients with tooth loss than without tooth loss (p=0.49).Conclusion: The tooth loss may be increased the masticatory muscle pain. It should be considered both muscle pain and tooth loss together in clinical examination and perform the preventive treatment.

Temporomandibular Disorders and Oral Features in Systemic Lupus Erythematosus Patients: An Observational Study of Symptoms and Signs.

Aims: Systemic Lupus Erythematosus (SLE) is a connective tissue disease characterized by a wide range of pleomorphic pictures, including mucocutaneous, renal, musculoskeletal and neurological symptoms. It involves oral tissues, with hyposalivation, tooth decay, gingivitis, angular cheilitis, ulcers and glossitis. Temporomandibular disorders represent a heterogeneous group of inflammatory or degenerative diseases of the stomatognatic system, with algic and/or dysfunctional clinical features involving temporomandibular joint (TMJ) and related masticatory muscles. The aim of this study was to investigate the prevalence of oral manifestations and temporomandibular disorders (TMD) in SLE patients (Lp) compared with a control group.Methods: Fifty-five patients (9 men and 46 women) with diagnosed Lupus were recruited in the study group. A randomly selected group of 55 patients, matched by sex and age, served as control group. The examination for TMD symptoms and signs was based on the standardized Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) through a questionnaire and clinical examination.Results: Lupus patients complained more frequently (95.8%) of oral and TMJ symptoms (dysgeusia, stomatodynia, masticatory muscle pain during function, neck and shoulder muscles pain and presence of tinnitus) but only xerostomia (χ2=4,1548 p=0,0415), temple headache (χ2=4,4542 p=0,035) and the sensation of a stuck jaw (Mid-p-test p=0,043) were significant. About signs, cheilitis (p=0,0284) oral ulcers (χ2=4,0104 p=0,045) and fissured tongue are significantly more frequent in study group. The salivary flow was significantly decreased in the study group respect to the control one (p<0.0001). As regard to the oral kinematics, restricted movements (RM) in protrusion and left lateral movement were significantly different between study group and controls. In particular, 85,2% of Lp showed limited protrusion versus 56,4% of controls (χ2= 10,91 p<0,001); 59,3% of Lp had also a limitation during left lateral movement versus 47,3% of controls (T=2,225 p=0,0282). About bruxism, only the indentations on the lateral edges of the tongue were found in Lp group (72,7%), with a significant difference respect to controls (χ2=7,37 p=0,007).Conclusions: While masticatory muscles have an overlapping behavior in both groups, the findings collected show a more severe TMJ kinematic impairment in Lp than in controls, with protrusion and left lateral movements significantly different. In addition, a remarkable reduction of salivary flow has been detected in Lp compared to controls. In conclusion, this autoimmune disease seems to play a role in oral manifestations and TMJ disorders, causing an increase in orofacial pain and an altered chewing function.

The mechanism of beneficial effect of radiofrequency therapy on masticatory muscles in temporomandibular disorders - a literature review.

Temporomandibular disorders (TMD) is one of the most common problem in contemporary dentistry. It is a term covering dysfunction of the masticatory muscles and the temporomandibular joints. Patients are suffering from severe pain, followed by limited mandibular opening and sounds in the temporomandibular joints during jaw movement. TMD influences the quality of life because the symptoms can become chronic and difficult to manage. Radiofrequency waves (RF) are electromagnetic waves with low energy and high frequency. They provide pain relief without causing significant damage to the nervous tissue. The RF therapy is commonly used for physiotherapeutic treatment of skeletal muscle relaxation, as a supportive therapy. The rehabilitation effect of these waves is based on diathermy by means of high-voltage quick alternating current. RF has also found application in physical therapy, as a therapeutic tool for various types of chronic pain syndromes. The aim of this literature review is to show the beneficial effect of radiofrequency waves on the pain of the masticatory muscles in the course of TMD.

Microcurrent electrical nerve stimulation in dentistry: A narrative review

Application of electricity in the field of medicine is not a new invention. In fact, it has been used over the past 150 years ago to treat bone fractures. Electromedicine was not in much use, and it has been recently revived due to its therapeutic benefits. Electrotherapy modality, especially transcutaneous electrical nerve stimulation (TENS), is traditionally used for a pain relief and also frequently used modality in the management of dental-related pain. However, microcurrent electrical therapy which is fairly a new technology used for tissue repair along with electroanalgesia for a variety of clinical conditions has been less explored in dental practice microcurrent electrical nerve stimulation (MENS) uses theoretically negligible amount of current at cellular level in relieving pain and promoting accelerated healing of damaged and inflamed tissue, which makes it as an efficient treatment modality in the management of pain with least number of side effects than drugs in chronic situations. It is also proposed that MENS is a superior modality in the treatment of masticatory muscle pain due to its electroanalgesia and tissue repair action. Hence, this article briefly reviews the application, effects, and side effects of MENS compared to traditional TENS.

Pathophysiology and treatment strategies for masticatory muscle pain: Change from rest to exercise

Pathophysiology and treatment strategies for masticatory muscle pain: Change from rest to exercise

The effectiveness of stabilization appliance therapy among patients with myalgia.

BackgroundThe efficacy of stabilization appliance therapy for masticatory muscle pain is debated. Therefore, there are currently no clear usage standards. We analyzed patient factors influencing its efficacy and characterized masticatory muscle pain subtypes to determine appropriate therapy candidates.MethodsThis case series study recruited patients diagnosed with local myalgia or myofascial pain and used variables related to temporomandibular disorders in the analysis. We used temporary appliance to screen patients for sleep bruxism for 2 weeks. Afterwards, we initiated therapy with stabilization appliances. Efficacy was evaluated via tenderness intensity during muscle palpation and the treatment satisfaction score after 2 months of treatment.ResultsWe analyzed 62 (91%) patients. Tenderness upon muscle palpation was mitigated in 27 patients. Mitigated tenderness odds ratios were 0.035 for myofascial pain, 0.804 for 15‐item Patient Health Questionnaire scores, and 1.915 for facet length. Thirty‐nine patients expressed satisfaction; satisfaction odds ratios were 0.855 for 9‐item Patient Health Questionnaire scores, 1.606 for facet length, and 4.023 for awake bruxism awareness.ConclusionsStabilization appliance therapy is most effective for patients with awake bruxism awareness, local myalgia, long facets, and no psychosocial risk factors.

Alterations in Surface Electromyography Are Associated with Subjective Masticatory Muscle Pain

Background Tenderness of masseters and temporalis can be considered a relevant tool for diagnosis of myo-type craniofacial pain disorders, but a limit of pain score systems is that they are based on subjective pain perception. Surface electromyography (sEMG) is a noninvasive and reliable tool for recording muscle activity. Therefore, we investigated whether a correlation exists between tenderness on masseters and temporalis, assessed by subjective pain scale, and muscles activity, evaluated by sEMG, in patients with painful temporomandibular disorder (TMD) and concurrent tension-type headache (TTH). Methods A cross-sectional study on fifty adult volunteer patients with TMD and TTH, who underwent tenderness protocol according to Diagnostic Criteria for TMD (DC/TMD) guidelines, was conducted followed by sEMG recording of temporalis and masseters. Pearson's correlation was performed to investigate the correlation between muscular activity and subjective pain scores. Results An overall moderate correlation between muscle tenderness and sEMG values (y = 1 + 1.2 · x; r2 = 0.62; p < 0.0001), particularly in the temporalis, was observed. Segregation of data occurred according to tenderness and sEMG values. At the highest pain score, the mean sEMG absolute value was higher at the temporalis than the masseters. Conclusions Our study provides evidence that subjective pain perception can be objectively quantified at a magnitude proportional to pain severity. At greater tenderness scores, higher sEMG activity at the level of temporalis could help discriminate clinically prevalent TTH versus prevalent TMD. sEMG confirms to be an accurate tool to reliably objectify the subjective perception of pain. When combined with clinical evaluation and patients' symptoms, sEMG increases diagnostic sensitivity in the field of myo-type craniofacial pain disorders. This trial is registered with NCT02789085.

Effectiveness of applied relaxation method vs splint in treatment of temporomandibular disorders in Finnish students.

Temporomandibular disorders (TMDs) include pain and dysfunction in masticatory muscles and temporomandibular joints (TMJs). Applied relaxation (AR) is a coping skill that may be applicable for treatment of TMD. The aim of this randomised, controlled study was to evaluate the effectiveness of AR as compared to stabilisation splint (SS), for treatment of TMD during 12-month follow-up. The data were derived from 96 university students seeking treatment due to TMD symptoms at Finnish Student Health Service in Finland. The subjects were randomly divided into two treatment groups: SS (n=41) and AR (n=51) groups. Clinical TMD examinations (a modified version of DC/TMD, Axis I) were performed for both the groups at baseline and 3-, 6- and 12-month follow-ups. Depressive and non-specific physical symptoms (NSPS) were estimated with Axis II questionnaire (RDC/TMD), and a number of other pain sites were screened at baseline and 12-month follow-up. Data were analysed by means of chi-square test for both groups on five variables, t test for VAS pain intensity and repeated measures ANOVA for palpation pain at follow-up points. Statistical significance was set on P<.05. Decrease in the number of painful masticatory muscles and TMJs and VAS on pain intensity did not differ between groups. During follow-up, NSPS and number of body pain sites decreased significantly more in the AR than the SS group. The dropout was 56 patients. Neither of the treatments showed more benefit in decreasing local TMD pain. AR gave more benefit on psychological well-being and general pain symptoms.

The treatment modalities of masticatory muscle pain a network meta-analysis.

Numerous treatment modalities have been attempted for masticatory muscle pain in patients with temporomandibular disorders (TMD). To compare the treatment efficacy of more than 2 competing treatments, a network meta-analysis (NMA) was conducted. This study was reported with reference to the extended Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement for reporting of systematic reviews incorporating network meta-analyses. Medline via Pubmed, Embase via OVID, and Cochrane Library Central were searched (up to February 11, 2019). Axis I protocol of Diagnostic Criteria or Research Diagnostic Criteria for Temporomandibular Disorders (DC/TMD, RDC/TMD) were chosen as diagnostic standards. The PICOS (Problem/patient, Intervention, Comparison, Outcome, Study design) method was used to screen trials under eligibility criteria. And the NMA was performed with mvmeta commands in Stata (StataCorp, Tex). Of 766 studies searched, 12 randomized clinical trials (RCTs) were finally included. Nineteen different therapies were found and further categorized into 9 treatment modalities. The general heterogeneity was not found among included trials. But predictive intervals (PrIs) were conspicuously wider than confidential intervals (CIs) of all pairwise comparisons, indicating that heterogeneity may exist between studies. Complementary therapy showed the greatest probability (42.7%) to be the best intervention. It also had the highest mean rank (2.3) in the rankogram and the biggest value of surface under the cumulative ranking (SUCRA, 84.1%). Based on the limited evidence of available trials, complementary therapy seemed to be slightly more effective than remaining treatment modalities for pain reduction in TMD patients with masticatory muscle pain. High-quality randomized controlled trials are expected to validate the findings.