Evidence-based management and clinical decision-making in temporomandibular joint disc displacement without reduction

Abstract

Disc displacement without reduction (DDwoR), also known as “closed lock” (CL), is a temporomandibular disorder that may cause painful and limited mouth opening. Patients with DDwoR may present to any clinician in practice, but in the acute phase, patients often seek care immediately from clinicians at the frontline in emergency or primary care. There is, however, a lack of understanding on how frontline clinicians behave and what decisions they make when initially presented with a DDwoR patient. The suggested therapeutic interventions for DDwoR vary considerably in invasiveness with contradictory opinions about the appropriate conservative or surgical intervention, and their timing, for managing DDwoR. This may cause confusion for clinicians and lead management of DDwoR to become based more on experience than evidence. The aim of this project is to inform and facilitate the development of a virtually delivered, evidence-informed, behavioural intervention for clinicians to aid management of DDwoR, through the identification of: the best available evidence for timing of intervention, and the intervention itself, for DDwoR; the influences on clinicians’ decision-making processes in the management of DDwoR. This project involved three separate, but sequential, studies. The first study was a systematic review of closed lock studies to investigate the effects of locking duration on DDwoR management. The second study was a systematic review of randomised trials to examine the therapeutic effects of interventions on DDwoR. The third study was a qualitative study interviewing clinicians at the frontline and specialist services in order to understand the decision-making processes in DDwoR management. The two systematic reviews suggest that the best available evidence for managing DDwoR is by intervening early with the simplest and least invasive intervention. The qualitative data suggest that the main behavioural influences on frontline clinicians’ decision to refer DDwoR early were their lack of condition-specific knowledge, skills, and experience which represent the theoretically-based core targets for a future intervention to support their decisions.