1. Background and purpose
The 3rd Korean Medicine Comprehensive Development Plan (2016–2020) based on the Oriental Medicine Promotion Act stipulates, as the first objective, strengthening evidence-based approaches and enhancing credibility through the development and distribution of Korean Medicine Clinical Practice Guidelines (CPGs). For this purpose, the Korean Medicine CPGs have been developed and disseminated to reinforce the evidence for the use of the Korean medicine service, and through the guidelines, we aim to expand and consolidate the national health insurance coverage for the Korean medicine service and increase public access to the service.
In line with such efforts, Korean Medicine CPGs on temporomandibular disorders (TMDs) have been developed. TMDs collectively refer to the musculoskeletal and neuromuscular conditions occurring in the temporomandibular joint region, masticatory musculature, and associated structures. Representative and prevalent TMD symptoms include auricular and facial pain, headaches, limited range of motion (ROM) in the temporomandibular joint, and clicking sounds.
Over 420,000 outpatients visited medical institutions in Korea for treatment of TMD in 2015 alone and the number increased to 480,000 patients in 2019. Medical expenses related to TMD increased 41% from 35.0 billion KRW in 2015 to 49.3 billion KRW in 2019, indicating a sharp increase in TMD prevalence in recent years. TMDs frequently exhibit chronicization which is associated with migraines, fibromyalgia and depression, and affects quality of life (QoL), pointing to the significance of appropriate TMD treatment and prevention.
While Korean medicine treatment has been commonly used for TMDs in clinical practice, and evidence supports that Korean medicine interventions such as acupuncture are effective for TMD treatment, the fact that Korean medicine clinics provide TMD treatment is not widely known in patient populations among general public. Furthermore, Korean medicine clinical practice guidelines (CPGs) on TMDs employing evidence-based medicine (EBM) methodologies have not been established to date. through the development of Korean Medicine CPG on TMDs on this occasion, we aim to establish evidence-based standardized treatment practices in Korean Medicine clinics and Korean Medicine hospitals. Furthermore, through these guidelines, we aim to inform TMD patients of the effectiveness of Korean medicine treatment for TMD, facilitating the use of Korean medicine treatment for the condition and contributing to the patients overcoming TMDs.
In this regard, we aimed to develop evidence-based Korean medicine CPGs on TMDs through evidence-based methodologies such as systematic review, reflecting the actual experience of Korean medicine doctors (KMDs) in clinical practice. We hope that the present guidelines aid in the decision-making process of KMDs and TMD patients, and improve the overall quality of Korean medicine practice. through the dissemination of the Clinical Practice Guidelines on TMDs developed through this opportunity, we aim to provide effective and standardized Korean medicine treatment to TMD patients. In this way, TMD patients will have the opportunity to make objective and rational decisions in the process of selecting Korean medicine services and receiving treatments. In addition, if the standardized Korean medicine clinical practice for TMD is performed, the deterioration in QoL and loss of productivity occurring in TMD patients can be resolved, contributing to the improvement in public health.
2. Overview of disease
Temporomandibular disorders (TMDs) are defined as “musculoskeletal and neuromuscular conditions occurring in the temporomandibular joint region, masticatory musculature, and associated structures.”
TMDs consist of two main groups of conditions: pain-related disorders (i.e., muscular pain, headache, and arthritic pain), and temporomandibular joint-associated disorders (i.e., articular disc disorder and degenerative joint disease).
According to overseas reports, approximately 5–12% of the population has been affected by TMDs, indicating its significance as a major public health concern, and the number of TMD patients seeking treatment in South Korea is also on the rise, incurring increases in National Health Insurance reimbursement expenses.
Risk factors for TMD include sex (female), age (aged between 18 and 44 years), comorbidities (e.g., mood disorders and rheumatoid arthritis), behavioral factors (e.g., bruxism), pain hypersensitivity, and trauma. While the mechanism of TMD is not clearly understood, a combination of biological, behavioral, and environmental factors and perception changes are considered to contribute to its pathogenesis.
TMDs are diagnosed through evaluation of medical history and physical examination, and the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD), developed in 2014, is the widely accepted tool for diagnosis.
Combination of non-pharmacologic and pharmacologic treatment are currently frequently used as conservative treatment for TMDs. Non-pharmacologic treatment commonly consists of patient education, self-care, behavioral therapy, occlusion stabilizers, and physiotherapy, while nonsteroidal anti-inflammatory drugs (NSAIDs), anti-depressants, and muscle relaxants are often prescribed as pharmacological treatment.
Although surgery is also a treatment option, it should only be considered in patients who do not respond to non-surgical treatment over 3–6 months.
Survey results on the clinical practice of KMDs’ treatment for TMD showed that acupuncture (including electroacupuncture), Chuna manual therapy, pharmacopuncture (including bee venom therapy), intra-oral balancing devices, and herbal medicine were the most frequently adopted Korean medicine treatments for TMDs and a combination of Korean medicine treatments are also employed.
In the case of TMD patients, rather than visiting Korean medical institutions from the outset, they often visit dental clinics and Western medical institutions for examinations and primary treatment, and then visit Korean medical institutions in anticipation of rapid improvement. therefore, TMD patients who visit Korean medicine clinics and Korean medicine hospitals can be divided into two cases: 1) visiting Korean medical institutions due to TMD from the outset, and 2) visiting Korean medical institutions after receiving Western medical treatment. For development of clinical practice guidelines suitable for these situations, recommendations were derived for each situation of monotherapy, concurrent therapy, and integrative treatment.
