Oral splints for patients with temporomandibular disorders or bruxism: a systematic review and economic evaluation

• Published in: Health technology assessment (Winchester, England) England), 2020-02, Vol.24 (7), p.1-224
• Main Authors: Riley, Philip, Glenny, Anne-Marie, Worthington, Helen V, Jacobsen, Elisabet, Robertson, Clare, Durham, Justin, Davies, Stephen, Petersen, Helen, Boyers, Dwayne
• Format: Article
• Language: English
• Subjects: Adolescent; Adult; bruxism; Bruxism - therapy; Child; Cost-Benefit Analysis; Humans; Markov Chains; Models, Econometric; Pain Measurement; quality of life; quality-adjusted life-years; Randomized Controlled Trials as Topic; splints; Splints - adverse effects; Splints - economics; State Medicine; Technology Assessment, Biomedical; temporomandibular joint disorders; Temporomandibular Joint Disorders - therapy; Young Adult
• ISSN: 1366-5278; 2046-4924
• DOI: 10.3310/hta24070

Splints are a non-invasive, reversible management option for temporomandibular disorders or bruxism. The clinical effectiveness and cost-effectiveness of splints remain uncertain. The objectives were to evaluate the clinical effectiveness and cost-effectiveness of splints for patients with temporomandibular disorders or bruxism. This evidence synthesis compared (1) all types of splint versus no/minimal treatment/control splints and (2) prefabricated versus custom-made splints, for the primary outcomes, which were pain (temporomandibular disorders) and tooth wear (bruxism). Four databases, including MEDLINE and EMBASE, were searched from inception until 1 October 2018 for randomised clinical trials. The searches were conducted on 1 October 2018. Cochrane review methods (including risk of bias) were used for the systematic review. Standardised mean differences were pooled for the primary outcome of pain, using random-effects models in temporomandibular disorder patients. A Markov cohort, state-transition model, populated using current pain and Characteristic Pain Intensity data, was used to estimate the incremental cost-effectiveness ratio for splints compared with no splint, from an NHS perspective over a lifetime horizon. A value-of-information analysis identified future research priorities. Fifty-two trials were included in the systematic review. The evidence identified was of very low quality with unclear reporting by temporomandibular disorder subtype. When all subtypes were pooled into one global temporomandibular disorder group, there was no evidence that splints reduced pain [standardised mean difference (at up to 3 months) -0.18, 95% confidence interval -0.42 to 0.06; substantial heterogeneity] when compared with no splints or a minimal intervention. There was no evidence that other outcomes, including temporomandibular joint noises, decreased mouth-opening, and quality of life, improved when using splints. Adverse events were generally not reported, but seemed infrequent when reported. The most plausible base-case incremental cost-effectiveness ratio was uncertain and driven by the lack of clinical effectiveness evidence. The cost-effectiveness acceptability curve showed splints becoming more cost-effective at a willingness-to-pay threshold of ≈£6000, but the probability never exceeded 60% at higher levels of willingness to pay. Results were sensitive to longer-term extrapolation assumptions. A value-of-information analysis indicated that further r