RCT for TMD Utilizing Case Manager: Long Term Clinical Findings

Objectives: Although Case Managers are used with a variety of chronic medical conditions, there is no reported use of Case Managers for chronic orofacial pain conditions. The present study compares a self-care intervention, alone or in combination with a Case Manager, for effectiveness in reducing Temporomandibular Disorders (TMD) signs and symptoms compared with usual treatment alone. Methods: After initial evaluation, 272 TMD patients were randomized into Usual Treatment alone (UT, n=91), UT+Self-Care (SC, n=93) or UT+Self-Care +Case Manager (CM, n=88). Self-report follow up was conducted at 12mo on UT=83, SC=81, CM=75 and 24mo. on UT=73, SC=76 and CM=72 subjects. Fewer subjects completed follow-up RDC/TMD exams (n=54-71). Treatment outcomes for RDC/TMD findings and the Mandibular Function Impairment Questionnaire (MFIQ) were compared across groups at 12mo and 24mo using intent-to-treat, GEE logistic linear regression analyses, adjusting for baseline differences. Results: The number of painful extra-oral palpation sites (0-16) at 12mo was: UT=5.2, SC=5.8, CM=4.2, p<0.02; at 24mo, UT=4.8, SC=4.9, CM=3.6, p <0.02. For intra-oral palpations findings were similar, but statistically significant only at 24mo. Number of jaw symptoms (0-16) were significantly different across groups at 12mo and 24mo (e.g., 12 mo: UT=10.2, SC=10.1, CM=9.0, p=.02). MFIQ scores showed a similar pattern. Measures of vertical range of motion improved over time for all groups, with no differences among groups. Conclusion: When compared to a self-care regimen, use of a Case Manager in a stepped-care approach yielded consistently greater improvement over a two-year follow up, in decreasing muscle palpation pain and related jaw symptoms while increasing self-reported jaw function. The usual care group showed least improvement. These data suggest the addition of a simple self-care intervention to usual treatment improves clinical and self report outcomes, while these improvements are further enhanced by the addition of a Case Manager. Supported by NIDCR #DE08773.