Temporomandibular disorders comprise the most common non-infective pain condition of the orofacial region 1. It is by far the most predominant condition described that affects the temporomandibular system; other conditions include arthritis, arthrosis, arthralgia and disc displacement 12.

TMDs is clinically characterized by pain in the temporomandibular region or in the muscles of mastication, pain radiating (behind the eyes, in the face, shoulder, neck and/or the back), headaches, earaches or tinnitus, jaw clicking, locking or deviation, limited jaw opening, clenching or grinding of the teeth, dizziness and sensitivity of the teeth without the presence of an oral disease 23.

TMDs signs were also identified in asymptomatic individuals 456; a cross-sectional population-based survey 7 was conducted in the United Kingdom, involving 2504 participants (participation rate 74%), of whom 646 (26%) reported orofacial pain. Overall, 424 (79% adjusted participation rate) of those individuals participated at the four-year follow-up, of whom 229 (54%) reported orofacial pain and 195 (46%) did not report such pain. Persistent orofacial pain was associated with females, older age, psychological distress, widespread body pain, and taking medication for orofacial pain at baseline.

De Kanter et al. 8 carried out a nationwide survey of oral conditions, treatment needs, and attitudes toward dental health care in Dutch adults. They found that a total of 21.5% of the Dutch adult population reported dysfunction, but 85% of these perceived no need for treatment. With most of the remaining 15% either seeking or intending to seek treatment (or having had it before), a figure of 3.1% can be used to summarize the actual level of treatment need for TMDs in the Dutch adult population.

The aetiology of TMDs is both of structural and psychological concepts. Structural concepts are classified as conditions related to the temporomandibular joint (TMJ) itself (functional, structural, morphopathological; i.e. micro-/macro-trauma), conditions related to the muscles of mastication (muscle spasm i.e. parafunctional habits) or occlusal factors (i.e. bruxism); recent studies had shown that occlusal factors were not found to be directly involved with TMDs; nevertheless they could contribute with other factors or aggravate an existing condition 891011.

Psychological theories includes stressful life events 1213, post-traumatic stress disorder 14, psychiatric illness (anxiety and depression) 1516, somatoform disorders 17 and personality disorders (i.e. obsessive-compulsive disorder), hypochondriasis, paranoia, schizophrenia 1418.

Clinicians may obfuscate the problem by concentrating on examination of the physical component (location and severity of pain, TMJ and related muscles) and disregard the psycho-social and behavioral factors. The introduction of Research Diagnostic Criteria (RDC), by Dworkin and LeResche 19 at the University of Washington, for the TMDs established a proper diagnostic criterion for this condition; this dual-axis system may be superior to other instruments, since it can be used to classify and quantify both physical and psychosocial components of the TMDs.

The aim of this pilot study was to develop a simple, cost-effective and evidence-based management programme for TMDs, using CD-ROM. A comparison group received adjunctive relaxation training, known to be effective in the management of this disorder.

41 TMDs patients, awaiting for consultation appointment, took part in this pilot study; patients were then divided into three groups from which some received psycho-educational programmes and the other received placebo programmes; these programmes were designed at the Eastman Dental Institute, University College London. The multi-central trial protocol was approved by the joint UCL/UCLH committees of the ethics for human research.

Inclusion criteria included English speakers with age of 18–70 years old and should satisfy the research diagnostic criteria (RDC/TMD) 9. Patients were recruited from a variety of Oral and Maxillofacial Surgery (OMFS) Departments in London.

An information sheet explaining the aim of our study in simple non-scientific terms was given to each of the patients. Each patient was asked to sign a consent form. All patients were invited to complete a number of questionnaires at the time of the initial appointment (Table 1).

Information collected from every patient included: age, gender, pain duration (months), frequency of pain (days with pain during preceding month) and jaw opening. Additional information included information on joint sounds, myalgia, arthralgia, the number of healthcare visits over the past 6 months regarding their temporomandibular joint (TMJ) problems and information about their analgesic or prophylactic medications.

12 of those patients were subjected to an attention placebo CD-ROM comprising anatomical information on the TMJ and the muscles of mastication group 1), 15 patients received information on CD-ROM designed to empower them (increasing their control and self-efficacy) (group 2); the rest of the patients received group 2 treatment with an additional introduction to self-relaxation techniques, followed by an audiotape of progressive muscle relaxation exercises to be dispatched from a central source (independent of the researcher) (group 3).

Patients were also asked to complete a number of questionnaires (OHIP, VAS, VRI, STAI and BDI) six weeks following the educational programme; which would enable us to conduct correlation analysis. Patients were also asked to complete feedback questionnaires {Pain Stages of Change Questionnaire (PSOCQ)}.

The literature on the topic of education programmes for chronic pain is sparse, despite their importance in the care of patients with, for example, fibromyalgia 20. Arthritis Self-Management Programme (ASMP) was found to produce long terms benefits in terms of reduced pain ratings and arthritisrelated physician visits 21.

A pilot study conducted by Tutty et al. 22 on telephone counseling as an adjunct to antidepressant treatment in the primary care system. 28 adult primary care patients starting antidepressant treatment (telephone counseling group) was compared with 94 patients receiving usual care (control group). Results have shown that telephone counseling patients showed significantly lower depressive symptoms than did control group patients at 3-month and 6-month follow-up.

Other studies have established benefits from telephone and mail-delivered self-assessment programmes 2324252627, for example arthritis 2324. In a randomized controlled trial of education and physical training for women with fibromyalgia, of which TMDs may be a variant, the education programme was found to enhance self-efficacy, although changes in disability and distress were more modest 28. These results are encouraging when one considers the potential effect of enhanced self-efficacy on perceived control over time. A Canadian group of mixed idiopathic chronic pain patients, assigned to a community based psycho-education programme modified from the Arthritis Self-Management Programme (ASMP), made significant short term improvements in pain, dependency, vitality, aspects of role functioning, life satisfaction and in self-efficacy and resourcefulness, compared to a waiting-list control group 25.

Although education programmes are advocated for TMDs, they have not been adequately evaluated. Relaxation training, however, has shown to be equally effective as conventional occlusal splint therapy 26 and benefits may be longer lasting 27.

TMDs patient improvement after conservative dental treatment was modestly associated with changes in beliefs and coping with and without a brief cognitive-behavior intervention 28, suggesting that such changes may accompany simpler treatments. A single trial of a psycho-educational group intervention showed modest but enduring reduction in TMDs-related interference compared to usual treatment 29.

In this study, it was hypothesized that the two experimental groups (2nd & 3rd) would be equally effective in reducing, pain disability and distress, and both are more effective than the attention placebo group. Primary outcome improvements were expected to be associated with the modest ameliorations in pain related cognitions, including self-efficacy.

The experimental groups (2nd & 3rd) appeared to have improved at follow-up relative to the placebo-group in terms of disability, pain and depressed mood. However, it should be noted that the groups, although randomly selected, did in fact differ at the outset, and these trends must be discounted.

The ultimate goal is an interventions specifically aimed at ameliorating cognitions and behavior in TMDs, in order to reduce the associated pain, disability and distress.

This pilot study demonstrates the feasibility and acceptability of the design. A full, randomized, controlled trial is required to confirm the efficacy of the interventions developed here.

The author(s) declare that they have no competing interests.

WJ: carried out the literature research, manuscript preparation, and manuscript review

GM: designed the study, carried out the literature research, clinical study and statistical analysis

CF: designed the study, carried out the literature research, clinical study, statistical analysis and manuscript preparation

ME: carried out the literature research, manuscript preparation, and manuscript review

MK: carried out the literature research, manuscript preparation, and manuscript review

CH: carried out the literature research, manuscript preparation, and manuscript review

TU: carried out the literature research, manuscript preparation, and manuscript review

SN: designed the study, carried out the literature research, clinical study, statistical analysis and manuscript preparation