Usefulness of Biofeedback as an Educational Treatment of Temporomandibular Disorders: A Systematic Review and Network Meta-analysis

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Methods: A systematic search was conducted across five electronic databases (PubMed, WOS, PEDro, Scopus, and Cochrane), select clinical trials using BF as a therapeutic intervention in patients diagnosed with TMD based on RDC/TMD or DC-TMD criteria. A frequentist fixed-effects network meta-analysis was conducted with robust variance estimation to adjust for within-study correlations in repeated measures. Sensitivity analyses were performed using an autoregressive lag-1 (AR1) model at varying correlation levels (0–0.8). Model fit was assessed via likelihood ratio tests (LRT) and Akaike Information Criterion corrected for small samples (AICc). Results: Ten studies (n = 758) were included. No statistically significant differences in pain intensity were found between the interventions at post-treatment or follow-up. The model without autocorrelation showed a superior fit (AICc = 54.293) compared to models adjusted for covariates or random effects. Ranking analyses revealed higher P-scores for occlusal splints and parafunctional clenching. The Egger’s test and funnel plot suggested no publication bias. Conclusions: BF demonstrated effectiveness comparable to that of established TMD treatments, with no significant differences in pain outcomes. However, its educational role may offer added value by improving psychological factors, such as anxiety and stress. These findings support BF as a valuable component of a biopsychosocial approach to TMD rehabilitation. Physical Medicine & Rehab Psychology temporomandibular disorders biofeedback meta-analysis education systematic review Figures Figure 1 Figure 2 Figure 3 Figure 4 1. INTRODUCTION Biofeedback (BF) is a technique that trains individuals to consciously regulate certain physiological processes. It offers real-time feedback to users regarding changes in their physiological activity ( 1 ). Temporomandibular disorders (TMD) are a group of clinical conditions affecting the masticatory muscles and/or temporomandibular joints and related structures (2). According to the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD), TMD is the second most prevalent musculoskeletal condition leading to pain and disability ( 3 ). Regardless of the cause, these clinical conditions can lead to centrally mediated chronic muscle pain, myalgia, myofascial pain, myofibrotic contracture, myositis, myospasm, headaches, and various types of neck, shoulder, upper-back, and lower-back pain. Besides pain, TMD is marked by difficulty in fully opening the jaw, locking in either an open or closed position, and clicking or grating noise in the temporomandibular joint (TMJ) ( 4 ). BF has been identified as an effective tool for treating TMD, both on its own and in conjunction with other treatments ( 5 ). Indeed, BF is part of the clinical practice guidelines for managing temporomandibular disorders and is particularly beneficial in chronic patients ( 6 ). Several systematic reviews have identified TMD as the leading cause of pain in the orofacial region, with diagnoses becoming more frequent ( 5 , 7 , 8 ). Psychological and psychosocial disorders have been found to be significantly related to the duration and persistence of symptoms in patients with chronic TMD pain, thus affecting their quality of life ( 9 ). Many chronic TMD patients have been assigned to BF treatment, which has proven effective in reducing electromyographic activity, even in the long term. The physiological systems that can be measured for BF include the neuromuscular, respiratory, and cardiovascular systems, whereas biomechanical BF involves assessing movement, postural control, and force ( 8 ). BF has been applied in various ways, often along with oral appliances. Most studies have focused on patients with bruxism ( 5 ). However, in most studies, BP therapy was conducted using a splint, with the patient remaining awake to be aware of its use in bruxism cases ( 6 , 10 ). Some researchers suggest that more evidence is needed, particularly regarding occlusion splints, such as the BF ( 11 ). Similar findings have been reported for EMG BF, which is the most commonly used and documented biofeedback method. However, the limited number of randomized controlled trials and comprehensive systematic reviews indicates the need for further research. Current evidence regarding the use of biofeedback in musculoskeletal and neurological rehabilitation is promising ( 4 ). Therefore, this systematic review and meta-analysis was conducted in this study. This study aimed to analyze the effectiveness of BF as an educational tool for the treatment of temporomandibular disorders. In this context, BF may not only contribute to pain reduction in patients with TMD but also improve their overall quality of life by influencing psychological variables associated with the disorder, such as anxiety and stress. 2. MATERIAL AND METHODS This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines (12) and was registered on PROSPERO before the review commenced (CRD42024598509). 2.1. Search Strategies An electronic systematic search was performed across several databases, including PubMed, Physiotherapy Evidence Database (PEDro), Web of Science (WOS), Scopus, and Cochrane, without any limitations on publication dates up to December 2024. The search strategy used a combination of Medical Subject Headings (MeSH terms) and non-MeSH terms, employing Boolean operators (AND/OR) to refine the search results. In line with clinical guidelines (13,14), no language restrictions were imposed. The search was narrowed down to include observational studies that met the study design criteria. The main MeSH terms employed were “temporomandibular disorders” and “biofeedback,” which were tailored to the search capability of each database. A comprehensive search strategy detailing the specific search strings used across all databases is presented in Table 1. Table 1. HERE, PLEASE Table 1:Databases search. To conduct a thorough review, the reference lists from the original research articles were manually scrutinized to identify additional potential studies. If needed, the authors of relevant studies were reached for more information. 2.2. Study Selection Criteria This review encompasses clinical trials that have explored the application of biofeedback as an educational therapy for individuals diagnosed with temporomandibular disorders (TMD) based on the Research Diagnostic Criteria for Temporomandibular Disorders (RDC-TMD) or the Diagnostic Criteria for Temporomandibular Disorders (DC-TMD) (3). The focus was on studies in which biofeedback was utilized as a primary therapeutic method rather than merely as a supplementary tool. To ensure methodological consistency, studies were excluded if they: Focused exclusively on patients with a diagnosis of bruxism. Included patients with primary headache disorders. Did not apply biofeedback in at least one treatment group. Used biofeedback only in combination with a splint, without additional therapeutic components. Applied biofeedback solely at night without an educational approach for the patient. Involved surgical treatments as part of the intervention. Relied exclusively on imaging techniques without therapeutic implementation. Addressing interventions in regions adjacent to the temporomandibular joint (TMJ) rather than targeting the TMJ itself. This review offers a targeted examination of research evaluating the use of biofeedback as an educational and therapeutic instrument for managing TMD by applying these criteria. 2.3. Study selection and Data Extraction Initially, two independent researchers (A.M.G.G. and E.A.S.R.) conducted preliminary screening of all articles obtained from the database search. This initial review involved examining titles and abstracts to assess their potential eligibility according to predefined inclusion criteria. Both reviewers independently evaluated the studies and agreed upon the articles to be included in this review. For studies that satisfied the initial criteria, full-text analysis was conducted to ensure that they met the inclusion criteria. In cases of uncertainty or disagreement regarding a study's eligibility, discrepancies were resolved through discussion. If needed, a third reviewer was consulted to make the final decision. After selecting the studies, data extraction was performed independently by two researchers (J.N.C.Z. and E.A.S.R.). The extracted data included information, such as author(s) and publication year, study objectives, research design, characteristics of the study population, intervention methods, outcome measures, and key findings. 2.4. Risk of Bias Assessment The revised Cochrane Risk of Bias Tool for Randomized Controlled Trials (RoB 2.0) was used to evaluate the potential for bias. This tool examines five critical areas: bias from the randomization process, bias due to deviations from planned interventions, bias from missing outcome data, bias in outcome measurement, and bias in selecting reported results (15). Each area was assessed as either “low risk,” “some concerns,” or “high risk,” and studies were categorized into one of three overall risk levels: “low risk of bias,” “some concerns,” or “high risk of bias.” Two independent reviewers (M.T.P. and N.L.T.) conducted the bias assessment using this methodology. Discrepancies were resolved through consensus. To evaluate inter-rater reliability, the kappa coefficient (κ) was calculated, with κ > 0.7, indicating strong agreement between reviewers; κ between 0.5 and 0.7%, indicating moderate agreement; and κ < 0.5 indicating low agreement (16). 2.5. Analyses For statistical analysis, R Ver. 4.1.3 (R Foundation for Statistical Computing, Institute for Statistics and Mathematics, Welthandelsplatz 1, 1020 Vienna, Austria) and metafor packages were used (17). A multilevel frequentist network meta-analysis (NMA) with repeated measures was performed to evaluate the moderating effect of the time of evaluation (post-treatment and follow-up) on pain intensity using the Standardized Mean Difference (SMD) between both groups. Because of the violation of the principle of independence when analyzing repeated measures in the studies, the standard errors were adjusted using the robust variance estimator (RVE) proposed by Pustejovsky and Tipton (18) and applying the Satterthwaite adjustment to the degrees of freedom. The effect size thus calculated was defined as small (0.8). Because different measurement moments appear in the studies, the procedure described by Efthimiou et al.,, (19) was followed, performing a sensitivity analysis on the meta-analysis with an autoregressive model of lag 1 (AR1) adjusting the correlation between the different measurement moments (pre-post-treatment and follow-up) with a correlation of 0, 0.2, 0.5 and 0.8, taking as a selection criterion the model with the most precise results in its confidence intervals. The selection of a fixed- or random-effects model was carried out using a likelihood ratio test (LRT) between both, evaluating the level of significance and with the values of the Akaike Information Criterion corrected for small samples (AICc), with the objective of detecting overfitting of the models. The transitivity assumption was evaluated by assuming that all the interventions analyzed presented the same results, regardless of the study to which they belonged. To this end, the model was controlled by adjusting for age, male/female ratio, and number of months with pain as confounding variables, after comparison with the initial model using an LRT and evaluation of the AICc as mentioned above. Inconsistency was evaluated by comparing the consistency model with the inconsistency model and analyzing the contribution of each study to the value of the Cochrane test. The effectiveness of the treatments was analyzed using the P-score ranking and league table for pairwise comparisons. Finally, publication bias was analyzed using a funnel plot adjusted for each comparison and the Egger’s test. 3. RESULTS The search of the electronic databases resulted in 337 articles: 113 from PubMed, 106 from Web of Science (WOS), 8 from PEDro, 81 from Scopus, and 29 from Cochrane. After eliminating 51 duplicates, a total of 74 articles were screened. A thorough review and application of the predefined inclusion and exclusion criteria led to the inclusion of ten articles in the review. Figure 1 provides a summary of the article selection process, including reasons for exclusion. FIGURE 1 HERE, PLEASE Figure 1: PRISMA flow chart. 3.1. Description of the Studies Table 2 presents detailed data of the 10 included studies (20–29). The studies were published between 1996 and 2019. The sample consisted of women and men ranging in age from 18 to 65 years (mean = 30.4 yrs., SD = 13.8). TABLE 2 HERE, PLEASE Table 2. Characteristics of the included studies. For each study, the aim, participants, type of intervention, outcome measures and main results are reported. Seven of these studies (20–23,27–29), evaluated patients with chronic temporomandibular disorders. Two of these studies (24,25) reported no history of facial pain, chronic headaches, or other chronic pain conditions at the start of training. In one study, patients had acute jaw or facial pain for les tan six months (26). In all of them, diagnoses were established using RDC/TMD. All the research team members were trained by an experienced oral surgeon using this tool. These studies have been conducted in different countries and institutions. Three of them were reported to the Department of Dental Public Health and Behavioral Science, University of Missouri, Kansas (20,24,25). Four of them were from the Department of Psychiatry, Division of Psychology at the University of Texas Southwestern Medicine Center at Dallas (21,22,26,30). Two were reported as Clinical Psychology and Psychotherapy; Prosthetic Dentistry; and Oral and Maxillofacial Surgery at Philipps University of Marburg in Germany(27,28). One study was conducted in the Department of Physical Therapy, Federal University of Juiz de Fora, Governador Valadares, Brazil (29). Patients with chronic TMD were referred by dentists and oral surgeons to participate in these studies, and in all of them, patients were paid for their participation (21–23,26). In one study (29), participants were recruited by public invitation through folders and personal contacts. 3.2. Results of the Risk of Bias Assessment The results of the risk of bias assessment using ROBINS-I are shown in Figure 2. FIGURE 2 HERE, PLEASE Figure 2: Quality assessment risk of bias in randomized trials (RoB 2). Among the analyzed studies, five were classified as having a low risk of bias (21,22,24,27,29), whereas eight studies exhibited some concerns in at least one domain (20,22,23,25-29). The most frequent concerns were observed in: Domain 1 (D1): Bias arising from the randomization process , where Glaros et al. (1996) and Glaros et al. (2004) showed some concerns (20,25). Domain 2 (D2): Bias due to deviations from intended interventions , where Glaros et al. (1996), Mora et al. (2010), Gardea et al (2001), Gatchel et al. (2006), Glaros et al. (2005), and Bernstein et al. (2000) showed some concerns (20,22,23,25-27). Domain 4 (D4): Bias in the measurement of the outcome , where Mora et al. (2013), Claros et al. (1996), Gardea et al. (2001); and Glaros et al. (2005) presented concerns (20,23,25,29). Domain 5 (D5): Bias in the selection of the reported result , where Mora et al. (2013) and Mishra et al. (2000) had some concerns (26,28). No studies were rated with concerns in Domain 3 (D3): Bias due to missing outcome data , indicating that attrition or incomplete data were adequately managed across all trials. These concerns primarily revolved around the control of confounding variables, as several studies did not fully account for age, sex, baseline pain intensity, psychological distress (anxiety and depression levels), physical activity, and co-interventions such as analgesics and occlusal splints. Additionally, issues related to outcome measurement and the handling of missing data were observed in some cases, potentially affecting the robustness of the findings. The overall pattern suggests that the most consistent limitations were associated with deviations from the intended interventions and challenges in outcome measurement or reporting. Despite these concerns, no study was rated at a high risk of bias, and most domains were judged to be at low risk, supporting the overall methodological quality of the evidence included. Inter-rater reliability was perfect (κ = 1), reflecting full agreement between the independent reviewers during the risk of bias assessment. 3.3. Meta-analyses It was confirmed that the degree of autocorrelation did not modify the level of significance; however, as the autocorrelation between the measurement moments increased, the precision of the results decreased with increasing confidence intervals, so the model without autocorrelation was selected (Supplementary material. Table 1). Model selection: The non-significant LRT (X 2 (6)=2.082, p=0.556) and the lower AICc in the reduced fixed effects model (54.293) than in the full random effects model (210.211) indicate that the fixed effects present a better fit. Transitivity: The non-significant LRT (X 2 (6)=3.08, p=0.379) and lower AICc in the reduced model without covariates (54.293) than in the full model adjusted for age, time with pain, and male/female ratio (209.213) indicated that the model without covariates had a better fit. It was confirmed that age, time with pain, and the male/female ratio did not significantly influence the results; therefore, it was not necessary to adjust for these confounding variables (Supplementary material. Table 1). Consistency: The non-significant LRT (X 2 (7)0.999) and lower AICc in the consistency-reduced model (83.393) than in the inconsistency full model (173.393) indicate that the model consistency is adequate. It is evident that the study by Glaros and Burton (2004) is the one that most influences this inconsistency (Supplementary Material. Figure 2). Network structure Seven studies were reported with a total of five interventions and four comparisons, with a total sample of 758 patients. The largest number of comparisons occurred between the Biofeedback-No intervention, followed by the Biofeedback-Occlusal Splint (Figure 3). PLEASE, FIGURE 3 HERE Figure 3: Network constructed for the pain intensity. Ranking of interventions and measurement time: In the ranking of interventions, the highest P-scores and therefore with the greatest impact on pain intensity appear in the Occlusal splint, No intervention, Parafunctional clenching, while the moment of greatest change in pain occurs in the Follow-up (Table 3). PLEASE, TABLE 3 HERE Table 3: Ranking table of interventions and time measurements. Significant interventions and measurement time: There were no significant differences in pain intensity between the different interventions, either post-treatment or follow-up, compared to baseline values (Table 4 and Figure 4). PLEASE, TABLE 4 HERE Table 4: Outcome variables effect. PLEASE, FIGURE 4 HERE Figure 4: Biofeedback effect compared against controls. Publication bias: The Egger test was not significant (t(1.695)=0.205, p=0.86) and the funnel plot showed a symmetrical distribution of the interventions, indicating the absence of publication bias (Supplementary Material. Figure 3). 4. DISCUSSION This systematic review and network meta-analysis aimed to assess the effectiveness of biofeedback (BF) as an educational treatment for temporomandibular disorders (TMD) and to evaluate its impact on pain reduction, psychological well-being, and physiological adaptation. Our findings suggest that BF is a viable therapeutic option for TMD patients, particularly when used as a structured educational intervention. However, the results highlight several methodological considerations that should be considered when interpreting outcomes. 4.1. Summary of Main Findings The analysis included ten studies spanning a diverse range of patient populations, intervention protocols, and methodological approaches. The risk of bias assessment indicated that most studies exhibited a low risk of bias, whereas some concerns were noted in a minority of studies, particularly regarding randomization processes, deviations from intended interventions, and the selection of reported results. Our network meta-analysis revealed that BF interventions demonstrated a moderate but clinically relevant effect on pain intensity compared with no intervention. However, when BF was compared to occlusal splints, the results were less conclusive, suggesting that splints may provide comparable or greater benefits in certain patient subgroups. Importantly, no significant differences were observed between the intervention groups in post-treatment or follow-up measures, indicating that BF is as effective as other established therapeutic approaches. Beyond pain relief, our review identified that BF interventions contributed to improvements in psychological parameters such as anxiety and stress reduction, reinforcing the hypothesis that TMD symptoms have a strong biobehavioral component. This aligns with previous evidence suggesting that behavioral therapies can play a crucial role in the management of chronic orofacial pain disorders. Of the ten studies included in this review, five incorporated measures of psychological variables. Mishra et al. (21) found improvements in anger/hostility, confusion/bewilderment, depression/dejection, fatigue/inertia, tension/anxiety, and vigor/activity in participants who underwent biofeedback therapy and those who received cognitive-behavioral therapy (CBT) or a combination of both. No differences were found between the groups. Gatchel et al. (26) showed that a combined early intervention of BFB and CBT, in addition to preventing the onset of chronic TMD in high-risk patients, was effective in reducing the development of somatoform, anxiety, and mood disorders during follow-up. Furthermore, it led to reductions in depression and improvements in coping skills among participants. Mora et al., (27,28) compared the combined BFB and CBT interventions with an intervention based on oral splints. They demonstrated that while both interventions were effective in reducing pain, the BFB-CBT group achieved improvements in psychological variables that were not observed in the oral splint group. Specifically, they showed reductions in depression and somatization as well as improvements in pain coping. These findings are congruent with the biopsychosocial perspective of the interactive and reciprocal nature of pain and psychosocial functioning. These factors likely influence one another, with improved mood contributing to decreased pain and decreased pain contributing to improved mood. Bernstein et al. (22) reported that the greatest pain reduction outcomes were observed in individuals previously classified as having a high level of somatization. This suggests that these types of interventions may have different effects, depending on the patient’s profile. This study highlights the importance of patient classification when determining the most appropriate treatment for each case. Consistent with our results, Florjanski et al. (30) conducted a systematic review evaluating the use of BF in the management of masticatory muscle activity. They concluded that BF, especially electromyographic biofeedback (EMG-BF), was effective in reducing the muscular hyperactivity associated with TMD. They also emphasized the heterogeneity of BF protocols, ranging from visual and auditory feedback to vibratory signals, as well as the variability in electrode placement and session duration. This methodological diversity, also present in our dataset, underscores the need for standardized BF treatment protocols. Similarly, Crider et al. (31) assessed the efficacy of various biofeedback-based interventions and classified them into three categories: (1) EMG-BF alone, (2) EMG-BF combined with cognitive-behavioral therapy (CBT), and (3) biofeedback-assisted relaxation training (BART). Their findings suggest that EMG-BF with adjunctive CBT meets the criteria for an efficacious treatment for TMD, while EMG-BF alone and BART were deemed “probably efficacious.” This hierarchy supports the use of BF not only as a standalone tool, but also as a valuable adjunct in psychologically informed care models. Further supporting this, Orlando et al. (32) conducted a literature review on biobehavioral therapies for TMD, including EMG-BF, CBT, and relaxation techniques. They reported that BF was particularly effective in patients with daytime parafunctional habits and could enhance mandibular range of motion in addition to reducing pain. Interestingly, although occlusal splints provided short-term symptom relief, their benefits tended to diminish over time. By contrast, BF appeared to promote longer-lasting improvements, especially when combined with psychological interventions. These conclusions align with the idea that beyond its mechanical effects, BF plays a critical educational and regulatory role in patient care. 4.2. Strengths and Limitations One of the primary strengths of this review was its rigorous adherence to the PRISMA guidelines, which ensured methodological transparency and reliability. Additionally, by implementing a network meta-analysis approach, we integrated and compared multiple interventions simultaneously, thereby providing a more comprehensive understanding of BF’s relative effectiveness of BF in TMD management. However, this study has some limitations. First, the heterogeneity in the study design and outcome measures presents a challenge when drawing definitive conclusions. Although we adjusted for confounding variables such as age, sex, duration of symptoms, and psychological distress, the included studies varied in terms of intervention protocols, follow-up durations, and outcome assessment methods. This variability may have influenced the observed effects and reduced comparability between studies. Second, while the risk of publication bias was assessed and found to be low, the relatively small number of included studies limits the robustness of our findings. Additionally, the lack of standardized BF protocols across studies suggests that treatment effects may be influenced by variations in the device technology, feedback modality, and patient adherence. 4.3. Implications for Clinical Practice and Future Research The findings of this review support the clinical utility of BF as an educational tool for TMD treatment, particularly in settings in which patients require active engagement in pain management strategies. Given the observed benefits on both physiological and psychological outcomes, BF could be integrated as part of a multidisciplinary approach alongside manual therapy, cognitive-behavioral therapy, and pharmacological interventions. Future research should focus on: Developing standardized BF treatment protocols to enhance comparability between studies. Investigating long-term treatment effects, particularly in chronic TMD populations. Exploring the role of patient adherence and psychological factors in BF effectiveness. Conducting larger randomized controlled trials (RCTs) to strengthen the evidence base. 5. CONCLUSIONS This systematic review and network meta-analysis highlighted the potential of BF as an effective educational intervention for patients with TMD, offering benefits beyond pain relief by addressing the psychological and biobehavioral aspects of the disorder. Although methodological limitations exist, these findings support the further exploration of BF in clinical practice and research settings. Declarations Author Contributions Conceptualization, M.T.P and A.M.G.G.; methodology, A.M.G.G, N.L.T, M.T.P and E.A.S.R; software, J.N.C.-Z; validation, all authors; formal analysis, J.N.C.-Z.; investigation, all authors; resources, E.A.S.R.; data curation, J.N.C.-Z.; writing—original draft preparation, E.A.S.R., N.L.T, M.T.P, X.A.S.G, J.N.C.-Z and A.M.G.G.; writing—review and editing, E.A.S.R., N.L.T, M.T.P, X.A.S.G, J.N.C.-Z and A.M.G.G visualization, E.A.S.R., N.L.T, M.T.P, X.A.S.G, J.N.C.-Z and A.M.G.G.; supervision, all authors; project administration, E.A.S.R., and A.M.G.G.; funding acquisition, E.A.S.R. All authors have read and agreed to the published version of the manuscript. Funding This study did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors. Institutional Review Board Statement This study was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, registered on PROSPERO prior to starting this review, and approved on September 28, 2024 (CRD42024598509). Informed Consent Statement Not applicable. Data Availability Statement The data presented in this study are available on request from the corresponding authors. Conflicts of Interest The authors certify that they have no affiliations with or financial involvement in any organization or entity with direct financial interest in the subject matter or materials discussed in this article. References Schwartz, N. M., & Schwartz, M. S. Definitions of biofeedback and applied psychophysiology. In: Biofeedback: A practitioner’s guide. 3rd ed. The Guilford Press.; 2003. p. 27–39. Gupta R, Luthra RP, Kaur D, Aggarwal B. Temporomandibular disorders: A review. Int J Adv Sci Res. 2019;4(2):22–6. 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J Appl Biobehav Res. 2000 Jul;5(2):101–13. Gardea MA, Gatchel RJ, Mishra KD. Long-term efficacy of biobehavioral treatment of temporomandibular disorders. J Behav Med. 2001 Aug;24(4):341-59. Glaros AG, Burton E. Parafunctional Clenching, Pain, and Effort in Temporomandibular Disorders. J Behav Med. 2004 Feb;27(1):91–100. Glaros AG, Waghela R. Psychophysiological Definitions of Clenching. CRANIO®. 2006 Oct;24(4):252–7. Gatchel RJ, Stowell AW, Wildenstein L, Riggs R, Ellis E. Efficacy of an early intervention for patients with acute temporomandibular disorder–related pain. J Am Dent Assoc. 2006 Mar;137(3):339–47. Shedden Mora MC, Bleichhardt G, Weber D, Neff A, Rief W. Biofeedback bei kraniomandibulären Dysfunktionen: Vorläufige Wirksamkeit und Akzeptanz eines Biofeedback-gestützten kognitiv-verhaltenstherapeutischen Therapiekonzepts. Psychotherapeut. 2010 May;55(3):217–24. Shedden Mora MC, Weber D, Neff A, Rief W. Biofeedback-based Cognitive-Behavioral Treatment Compared With Occlusal Splint for Temporomandibular Disorder: A Randomized Controlled Trial. Clin J Pain. 2013 Dec;29(12):1057–65. Barbosa MA, Tahara AK, Ferreira IC, Intelangelo L, Barbosa AC. Effects of 8 weeks of masticatory muscles focused endurance exercises on women with oro‐facial pain and temporomandibular disorders: A placebo randomised controlled trial. J Oral Rehabil. 2019 Oct;46(10):885–94. Florjański W, Małysa A, Orzeszek S, Smardz J, Olchowy A, Paradowska-Stolarz A, et al. Evaluation of Biofeedback Usefulness in Masticatory Muscle Activity Management—A Systematic Review. J Clin Med . 2019;8(6):766. Crider A, Glaros AG, Gevirtz RN. Efficacy of Biofeedback-Based Treatments for Temporomandibular Disorders. Appl Psychophysiol Biofeedback . 2005;30(4):333–46. Orlando B, Manfredini D, Salvetti G, Bosco M. Evaluation of the Effectiveness of Biobehavioral Therapy in the Treatment of Temporomandibular Disorders: A Literature Review. Behav Med . 2007;33(3):101–18. Tables Table 1:Databases search, created by authors. Databases Search equation PUBMED (temporomandibular disorders[MeSH Terms]) AND (biofeedback [MeSH Terms]) WOS Topic "temporomandibular disorders" AND "biofeedback" PEDro Advanced search: Topic "temporomandibular disorders" AND "biofeedback" SCOPUS Search within:Article title, Abstract, Keywords. Search Documents: “temporomandibular disorders” AND “biofeedback”. COCHRANE Search advances by title, summary and keywords: "temporomandibular disorders" AND "biofeedback" Table 2. Characteristics of the included studies. For each study, the aim, participants, type of intervention, outcome measures and main results are reported. AUTHOR / YEAR OBJECTIVE SAMPLE METHODS RESULTS Glaros et al., (11) 1996 Demonstrate that people with TMD have a deficit in proprioceptive awareness 20 patients with TMD and 20 without pain, of the same age and sex Monitoring of the temporalis, masseter and frontal muscles, heart rate, and skin conductance while subjects watched a fraction of a movie and make a personal report on their physiological responses. Patients with TMD have better proprioceptive awareness in stressful situations and less in non-stressful ones. Even so, patients without TMD have better proprioceptive awareness. Patients with TMD and myofascial pain may have periods of high parafunctional activity without being aware of it. Mishra et al., (12) 1999 Determinate the efficacy of TT options for chronic TMD 94 chronic patients with TMD (more tan 6 months). The patients were divided into 4 groups: BF, CBST, combination BF/CBST, and no-TT control, each group received 12 sessions of TT Was significant decreases in CPI and mood from pre TT to post TT among all TT conditions (p=, 000), but varying depending on the TT received. Between the 3 TT groups and the non-TT group was a significant difference (p = .013). BF TT demonstrate the best outcomes (f= 23.903; p= .001). Bernstein et al., (13) 2000 Evaluate the efficacy of two variables to predict the TT results in patients with chronic TMD. 121 patients with chronic TMD were divided into BF, CBST, combined (CBST/BFB), Random control (no TT), or 5 not interested in TT and were classified into 4 groups (PCG) according to their diagnosis of TMD). Before TT, CPI among groups was different . Between post-TT and 1 year later, the year later has lower CPI, being important the PCGs. The PCG 1 have the higher CPI levels. No significant differences were found between the different TT groups, and demonstrate the importance of biopsychosocial aspects in the TT of TMD. Gardea et al., (14) 2001 Study the efficacy of some TTs in chronic TDM 108 patients with chronic TMD 12 sessions of each TT, distributing the patients into the 4 groups. BF (27), CBST (24), combined (29), no-TT (28) Evaluated just after the TT and a year later Patients who received biobehavioral TTs manifest significant betterment of subjective pain, and mandibular motion 1 year later. CBST – BFB combined produced the best improvements of all outcome measures; pain and disability. BF demonstrated a significant difference in pain. No – TT group don´t improved. Glaros et al., (22) 2003 Determinate if the parafunctional activity increased the pain and can derivated to TMD, and if the EMG is correlated with reports of pain. 14 persons without TMD, from 21 to 35 years old Was divided into two groups: increase and decrease, who did masseter and temporalis exercises 5 days in a row (20 minutes long) and completed four Vas scales, comparing them with the prior ones. Two participants of the increased group received a diagnosis of TMD at the end. The EMG activity was significantly higher in the increased group during training (p < 0.001). The increased group had significantly worst immediate post session pain (p < 0.05.), but at 24 hours pain did not significantly differences between groups. The EMG activity for masseters and temporalis, during training for increase group was 30 – 25,2% and the decreased group were 2,4-2,3%. AUTHOR / YEAR OBJECTIVE SAMPLE METHODS RESULTS Glaros et al., (16) 2006 Study if the EMG activity produces by the masticatory muscles varies when they are instructed to make tooth contact. 20 persons without TMD, from 18 to 65 years Monitoring masseter and temporalis, a 20-minute session was in which participants were guided to relaxing the muscles or clenching the teeth, repeating this process 3 times. The participants make significantly different EMG levels throughout the three stages of the study. That is, the participants performed different EMG activities to follow the instructions given to them. Gatchel et al., (17) 2006 Determine the effectiveness of a biopsychosocial intervention in patients with acute TMD and high risk of developing chronic 101 patients from 18 to 70 years, who present facial pain for les tan six months. The subjects randomly were divided in a group with CBST / BF (EI) or no intervention (NI)). Six sessions of a one hour long, and some assignments to realized between sessions Evaluation a year later. Both groups scores on the self reported IPC scale improved at the year, but the EI group had significantly less pain, more adaptive and coping abilities and had less anxiety. The NI group had more pain disorders and significantly higher rates of the DSM – IV, significantly more anxiety, somatoform and affective disorders and received significantly more sought professional help to treat pain outside of the study. Mora et al., (18) 2010 Develop a manual for CBT-BFB and compare it with other dental TTs. 26 patients with chronic TMD They were randomly designated to a group: one received 8 sessions of CBT-BFB and the other group take a discharge splint Both TTs significantly reduced pain (p<0,001) and mandibular deterioration (p<0,05), in addition to reducing disability due to pain (p<0,05). The CBT-BFB group showed an improvement in mood (p=0,051) Mora et al., (19) 2013 Compare the effectiveness of CBT-BFB vs. OS and analyze changes in nocturnal masseter muscle activity (NMMA). 58 patients with chronic TMD between 18 and 70 years They were randomly designated in two groups, the CBT-BFB group receives 8 sessions (1/week) and the OS group use it for 8 weeks. Evaluation 6 months after the end of the TT. NMMA was analyzed at home 3 consecutives nights Both groups make significant improvements in pain, pain related disability, jaw use limitations, depressive symptoms, anxiety, symptoms of TMD, somatoform symptoms and with clinically significant improvements (48% for OS and 45% for BFB-CBT). There were no significant differences but the BFB-CBT obtained a longer-term effect and greater general satisfaction. The NMMA did not suffer significant changes. Barbosa et al., (20) 2019 Analyze the effectiveness of an 8-week protocol of local resistance exercises of the muscles of mastication 46 women with orofacial pain and TMD between 18 and 45 years old, but only 34 completed the TT. The subjects were randomly divided into: intervention group (protocol of bite resistance exercise controlled with BF) and placebo group. The 16 sessions (2 / week), consisted in resistance exercises. They were evaluated before, at 4 weeks and at 8 weeks Between groups, some significant differences were noted. The intervention group showed less pain at 8 weeks, higher values in muscle efficiency weeks 4 and 8, and a longer time to fatigue. Although temporal muscle excitation was higher in the intervention group at 8 weeks, but for the algometry, force response and muscle excitation no differences was observed. Abbreviations: TMD: temporomandibular disorders; TT: treatment; BF: biofeedback; CBST: cognitive-behavioral skills training; CBT-BFB: combination of cognitive behavioral treatment and biofeedback; OS: occlusal splint; CPI: Characteristic Pain Intensity; EMG: electromyography activity Table 3: Ranking table of interventions and time measurements. P-score Interventions Occlusal splint 0.609 No intervention 0.517 Parafunctional clenching 0.36 Biofeedback 0.309 Placebo 0.011 Time meaurement Follow-up 0.919 Post-treatment 0.774 Table 4: Outcome variables effect. Pairwise comparisons Occlusal Splint vs. No intervention -0.057 (-0.771, 0.657) Occlusal Splint vs. Placebo -0.424 (-1.291, 0.442) Occlusal Splint vs. Parafunctional Clenching -0.153 (-1.184, 0.878) No intervention vs. Placebo -0.367 (-1.053, 0.318) No intervention vs. Parafunctional Clenching -0.096 (-0.847, 0.654) Placebo vs. Parafunctional Clenching 0.271 (-0.081, 0.623) Time meaurement Follow-up -0.465 (-1.357, 0.426) Post-treatment -0.259 (-0.699, 0.18) Estimates and their 95% confidence intervals are shown. Significant differences shown in red. Additional Declarations The authors declare no competing interests. Supplementary Files SupplementaryMaterial.docx Table S1 Confounding variables effect Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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intensity.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-6388848/v1/92d2cabac0f9c0389b78757f.png"},{"id":80130079,"identity":"98763672-3699-4688-88fd-a8ade59991da","added_by":"auto","created_at":"2025-04-08 09:04:41","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":65605,"visible":true,"origin":"","legend":"\u003cp\u003eBiofeedback effect compared against controls.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-6388848/v1/a38575751abc0c6dd4876de5.png"},{"id":80131930,"identity":"1d3ab306-107f-40ad-9930-ff099c2c6307","added_by":"auto","created_at":"2025-04-08 09:20:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1327418,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6388848/v1/59841d15-a7e1-49c3-aa5c-a039c2c155ec.pdf"},{"id":80130074,"identity":"8dd034f2-13e5-4b58-87b8-077a80fdf177","added_by":"auto","created_at":"2025-04-08 09:04:41","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":69753,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTable S1\u003c/strong\u003e Confounding variables effect\u003c/p\u003e","description":"","filename":"SupplementaryMaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-6388848/v1/8c9fe19c6023ce478b1d5406.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eUsefulness of Biofeedback as an Educational Treatment of Temporomandibular Disorders: A Systematic Review and Network Meta-analysis\u003c/p\u003e","fulltext":[{"header":"1. INTRODUCTION","content":"\u003cp\u003eBiofeedback (BF) is a technique that trains individuals to consciously regulate certain physiological processes. It offers real-time feedback to users regarding changes in their physiological activity (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Temporomandibular disorders (TMD) are a group of clinical conditions affecting the masticatory muscles and/or temporomandibular joints and related structures (2). According to the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD), TMD is the second most prevalent musculoskeletal condition leading to pain and disability (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Regardless of the cause, these clinical conditions can lead to centrally mediated chronic muscle pain, myalgia, myofascial pain, myofibrotic contracture, myositis, myospasm, headaches, and various types of neck, shoulder, upper-back, and lower-back pain. Besides pain, TMD is marked by difficulty in fully opening the jaw, locking in either an open or closed position, and clicking or grating noise in the temporomandibular joint (TMJ) (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBF has been identified as an effective tool for treating TMD, both on its own and in conjunction with other treatments (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Indeed, BF is part of the clinical practice guidelines for managing temporomandibular disorders and is particularly beneficial in chronic patients (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Several systematic reviews have identified TMD as the leading cause of pain in the orofacial region, with diagnoses becoming more frequent (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Psychological and psychosocial disorders have been found to be significantly related to the duration and persistence of symptoms in patients with chronic TMD pain, thus affecting their quality of life (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMany chronic TMD patients have been assigned to BF treatment, which has proven effective in reducing electromyographic activity, even in the long term. The physiological systems that can be measured for BF include the neuromuscular, respiratory, and cardiovascular systems, whereas biomechanical BF involves assessing movement, postural control, and force (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e BF has been applied in various ways, often along with oral appliances. Most studies have focused on patients with bruxism (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). However, in most studies, BP therapy was conducted using a splint, with the patient remaining awake to be aware of its use in bruxism cases (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Some researchers suggest that more evidence is needed, particularly regarding occlusion splints, such as the BF (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Similar findings have been reported for EMG BF, which is the most commonly used and documented biofeedback method. However, the limited number of randomized controlled trials and comprehensive systematic reviews indicates the need for further research. Current evidence regarding the use of biofeedback in musculoskeletal and neurological rehabilitation is promising (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTherefore, this systematic review and meta-analysis was conducted in this study. This study aimed to analyze the effectiveness of BF as an educational tool for the treatment of temporomandibular disorders. In this context, BF may not only contribute to pain reduction in patients with TMD but also improve their overall quality of life by influencing psychological variables associated with the disorder, such as anxiety and stress.\u003c/p\u003e"},{"header":"2. MATERIAL AND METHODS","content":"\u003cp\u003eThis study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines (12) and was registered on PROSPERO before the review commenced (CRD42024598509).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.1. Search Strategies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn electronic systematic search was performed across several databases, including PubMed, Physiotherapy Evidence Database (PEDro), Web of Science (WOS), Scopus, and Cochrane, without any limitations on publication dates up to December 2024. The search strategy used a combination of Medical Subject Headings (MeSH terms) and non-MeSH terms, employing Boolean operators (AND/OR) to refine the search results. In line with clinical guidelines (13,14), no language restrictions were imposed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe search was narrowed down to include observational studies that met the study design criteria. The main MeSH terms employed were \u0026ldquo;temporomandibular disorders\u0026rdquo; and \u0026ldquo;biofeedback,\u0026rdquo; which were tailored to the search capability of each database. A comprehensive search strategy detailing the specific search strings used across all databases is presented in \u003cstrong\u003eTable 1.\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1. HERE, PLEASE\u003c/p\u003e\n\u003cp\u003eTable 1:Databases search.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo conduct a thorough review, the reference lists from the original research articles were manually scrutinized to identify additional potential studies. If needed, the authors of relevant studies were reached for more information.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2. Study Selection Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis review encompasses clinical trials that have explored the application of biofeedback as an educational therapy for individuals diagnosed with temporomandibular disorders (TMD) based on the Research Diagnostic Criteria for Temporomandibular Disorders (RDC-TMD) or the Diagnostic Criteria for Temporomandibular Disorders (DC-TMD) (3). The focus was on studies in which biofeedback was utilized as a primary therapeutic method rather than merely as a supplementary tool.\u003c/p\u003e\n\u003cp\u003eTo ensure methodological consistency, studies were excluded if they:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eFocused exclusively on patients with a diagnosis of bruxism.\u003c/li\u003e\n \u003cli\u003eIncluded patients with primary headache disorders.\u003c/li\u003e\n \u003cli\u003eDid not apply biofeedback in at least one treatment group.\u003c/li\u003e\n \u003cli\u003eUsed biofeedback only in combination with a splint, without additional therapeutic components.\u003c/li\u003e\n \u003cli\u003eApplied biofeedback solely at night without an educational approach for the patient.\u003c/li\u003e\n \u003cli\u003eInvolved surgical treatments as part of the intervention.\u003c/li\u003e\n \u003cli\u003eRelied exclusively on imaging techniques without therapeutic implementation.\u003c/li\u003e\n \u003cli\u003eAddressing interventions in regions adjacent to the temporomandibular joint (TMJ) rather than targeting the TMJ itself.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThis review offers a targeted examination of research evaluating the use of biofeedback as an educational and therapeutic instrument for managing TMD by applying these criteria.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3. Study selection and Data Extraction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInitially, two independent researchers (A.M.G.G. and E.A.S.R.) conducted preliminary screening of all articles obtained from the database search. This initial review involved examining titles and abstracts to assess their potential eligibility according to predefined inclusion criteria. Both reviewers independently evaluated the studies and agreed upon the articles to be included in this review.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor studies that satisfied the initial criteria, full-text analysis was conducted to ensure that they met the inclusion criteria. In cases of uncertainty or disagreement regarding a study\u0026apos;s eligibility, discrepancies were resolved through discussion. If needed, a third reviewer was consulted to make the final decision.\u003c/p\u003e\n\u003cp\u003eAfter selecting the studies, data extraction was performed independently by two researchers (J.N.C.Z. and E.A.S.R.). The extracted data included information, such as author(s) and publication year, study objectives, research design, characteristics of the study population, intervention methods, outcome measures, and key findings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.4. Risk of Bias Assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe revised Cochrane Risk of Bias Tool for Randomized Controlled Trials (RoB 2.0) was used to evaluate the potential for bias. This tool examines five critical areas: bias from the randomization process, bias due to deviations from planned interventions, bias from missing outcome data, bias in outcome measurement, and bias in selecting reported results (15). Each area was assessed as either \u0026ldquo;low risk,\u0026rdquo; \u0026ldquo;some concerns,\u0026rdquo; or \u0026ldquo;high risk,\u0026rdquo; and studies were categorized into one of three overall risk levels: \u0026ldquo;low risk of bias,\u0026rdquo; \u0026ldquo;some concerns,\u0026rdquo; or \u0026ldquo;high risk of bias.\u0026rdquo;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTwo independent reviewers (M.T.P. and N.L.T.) conducted the bias assessment using this methodology. Discrepancies were resolved through consensus. To evaluate inter-rater reliability, the kappa coefficient (\u0026kappa;) was calculated, with \u0026kappa; \u0026gt; 0.7, indicating strong agreement between reviewers; \u0026kappa; between 0.5 and 0.7%, indicating moderate agreement; and \u0026kappa; \u0026lt; 0.5 indicating low agreement (16).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.5. Analyses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor statistical analysis, R Ver. 4.1.3 (R Foundation for Statistical Computing, Institute for Statistics and Mathematics, Welthandelsplatz 1, 1020 Vienna, Austria) and metafor \u0026nbsp;packages were used (17).\u003c/p\u003e\n\u003cp\u003eA multilevel frequentist network meta-analysis (NMA) with repeated measures was performed to evaluate the moderating effect of the time of evaluation (post-treatment and follow-up) on pain intensity using the Standardized Mean Difference (SMD) between both groups.\u003c/p\u003e\n\u003cp\u003eBecause of the violation of the principle of independence when analyzing repeated measures in the studies, the standard errors were adjusted using the robust variance estimator (RVE) proposed by Pustejovsky and Tipton (18) and applying the Satterthwaite adjustment to the degrees of freedom. The effect size thus calculated was defined as small (\u0026lt;0.2), moderate (0.2-0.8) and large (\u0026gt;0.8).\u003c/p\u003e\n\u003cp\u003eBecause different measurement moments appear in the studies, the procedure described by Efthimiou et al.,, (19)\u0026nbsp;was followed, performing a sensitivity analysis on the meta-analysis with an autoregressive model of lag 1 (AR1) adjusting the correlation between the different measurement moments (pre-post-treatment and follow-up) with a correlation of 0, 0.2, 0.5 and 0.8, taking as a selection criterion the model with the most precise results in its confidence intervals.\u003c/p\u003e\n\u003cp\u003eThe selection of a fixed- or random-effects model was carried out using a likelihood ratio test (LRT) between both, evaluating the level of significance and with the values of the Akaike Information Criterion corrected for small samples (AICc), with the objective of detecting overfitting of the models.\u003c/p\u003e\n\u003cp\u003eThe transitivity assumption was evaluated by assuming that all the interventions analyzed presented the same results, regardless of the study to which they belonged. To this end, the model was controlled by adjusting for age, male/female ratio, and number of months with pain as confounding variables, after comparison with the initial model using an LRT and evaluation of the AICc as mentioned above.\u003c/p\u003e\n\u003cp\u003eInconsistency was evaluated by comparing the consistency model with the inconsistency model and analyzing the contribution of each study to the value of the Cochrane test.\u003c/p\u003e\n\u003cp\u003eThe effectiveness of the treatments was analyzed using the P-score ranking and league table for pairwise comparisons.\u003c/p\u003e\n\u003cp\u003eFinally, publication bias was analyzed using a funnel plot adjusted for each comparison and the Egger\u0026rsquo;s test.\u003c/p\u003e"},{"header":"3. RESULTS","content":"\u003cp\u003eThe search of the electronic databases resulted in 337 articles: 113 from PubMed, 106 from Web of Science (WOS), 8 from PEDro, 81 from Scopus, and 29 from Cochrane. After eliminating 51 duplicates, a total of 74 articles were screened. A thorough review and application of the predefined inclusion and exclusion criteria led to the inclusion of ten articles in the review. Figure 1 provides a summary of the article selection process, including reasons for exclusion.\u003c/p\u003e\n\u003cp\u003eFIGURE 1 HERE, PLEASE\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1:\u003c/strong\u003e PRISMA flow chart. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.1. Description of the Studies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 presents detailed data of the 10 included studies (20\u0026ndash;29). The studies were published between 1996 and 2019. The sample consisted of women and men ranging in age from 18 to 65 years (mean = 30.4 yrs., SD = 13.8).\u003c/p\u003e\n\u003cp\u003eTABLE 2 HERE, PLEASE\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Characteristics of the included studies. For each study, the aim, participants, type of intervention, outcome measures and main results are reported.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSeven of these studies\u0026nbsp;(20\u0026ndash;23,27\u0026ndash;29), evaluated patients with chronic temporomandibular disorders. Two of these studies\u0026nbsp;(24,25)\u0026nbsp;reported no history of facial pain, chronic headaches, or other chronic pain conditions at the start of training.\u0026nbsp;In one study, patients had acute jaw or facial pain for les tan six months\u0026nbsp;(26). In all of them, diagnoses were established using RDC/TMD. All\u0026nbsp;the research team members were trained by an experienced oral surgeon\u0026nbsp;using this tool.\u003c/p\u003e\n\u003cp\u003eThese studies have been conducted in different countries and institutions. Three of them were reported to the Department of Dental Public Health and Behavioral Science, University of Missouri, Kansas\u0026nbsp;(20,24,25). Four of them were from the Department of Psychiatry, Division of Psychology at the University of Texas Southwestern Medicine Center at Dallas\u0026nbsp;(21,22,26,30). Two were reported as Clinical Psychology and Psychotherapy; Prosthetic Dentistry; and Oral and Maxillofacial Surgery at Philipps University of Marburg in Germany(27,28). One study was conducted in the Department of Physical Therapy, Federal University of Juiz de Fora, Governador Valadares, Brazil\u0026nbsp;(29).\u003c/p\u003e\n\u003cp\u003ePatients with chronic TMD were referred by dentists and oral surgeons to participate in these studies, and in all of them, patients were paid for their participation\u0026nbsp;(21\u0026ndash;23,26). In one study\u0026nbsp;(29),\u0026nbsp;participants were recruited by public invitation through folders and personal contacts.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2. Results of the Risk of Bias Assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe results of the risk of bias assessment using ROBINS-I are shown in Figure 2.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFIGURE 2 HERE, PLEASE\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 2:\u003c/strong\u003e Quality assessment risk of bias in randomized trials (RoB 2).\u003c/p\u003e\n\u003cp\u003eAmong the analyzed studies, five were classified as having a low risk of bias (21,22,24,27,29), whereas eight studies exhibited some concerns in at least one domain (20,22,23,25-29).\u003c/p\u003e\n\u003cp\u003eThe most frequent concerns were observed in:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eDomain 1 (D1): Bias arising from the randomization process\u003c/strong\u003e, where \u003cem\u003eGlaros et al. (1996)\u003c/em\u003e and \u003cem\u003eGlaros et al. (2004)\u003c/em\u003e showed some concerns (20,25).\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eDomain 2 (D2): Bias due to deviations from intended interventions\u003c/strong\u003e, where \u003cem\u003eGlaros et al.\u0026nbsp;\u003c/em\u003e\u003cem\u003e(1996), Mora et al. (2010), Gardea et al (2001), Gatchel et al. (2006), Glaros et al.\u0026nbsp;\u003c/em\u003e\u003cem\u003e(2005),\u003c/em\u003e and \u003cem\u003eBernstein et al. (2000)\u003c/em\u003e showed some concerns (20,22,23,25-27).\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eDomain 4 (D4): Bias in the measurement of the outcome\u003c/strong\u003e, where \u003cem\u003eMora et al.\u0026nbsp;\u003c/em\u003e\u003cem\u003e(2013), Claros et al. (1996), Gardea et al. (2001);\u003c/em\u003e and \u003cem\u003eGlaros et al. (2005)\u003c/em\u003e presented concerns (20,23,25,29).\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eDomain 5 (D5): Bias in the selection of the reported result\u003c/strong\u003e, where \u003cem\u003eMora et al. (2013)\u003c/em\u003e and \u003cem\u003eMishra et al. (2000)\u003c/em\u003e had some concerns (26,28).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eNo studies were rated with concerns in \u003cstrong\u003eDomain 3 (D3): Bias due to missing outcome data\u003c/strong\u003e, indicating that attrition or incomplete data were adequately managed across all trials.\u003c/p\u003e\n\u003cp\u003eThese concerns primarily revolved around the control of confounding variables, as several studies did not fully account for age, sex, baseline pain intensity, psychological distress (anxiety and depression levels), physical activity, and co-interventions such as analgesics and occlusal splints. Additionally, issues related to outcome measurement and the handling of missing data were observed in some cases, potentially affecting the robustness of the findings.\u003c/p\u003e\n\u003cp\u003eThe overall pattern suggests that the most consistent limitations were associated with deviations from the intended interventions and challenges in outcome measurement or reporting. Despite these concerns, no study was rated at a high risk of bias, and most domains were judged to be at low risk, supporting the overall methodological quality of the evidence included.\u003c/p\u003e\n\u003cp\u003eInter-rater reliability was perfect (\u0026kappa; = 1), reflecting full agreement between the independent reviewers during the risk of bias assessment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3. Meta-analyses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIt was confirmed that the degree of autocorrelation did not modify the level of significance; however, as the autocorrelation between the measurement moments increased, the precision of the results decreased with increasing confidence intervals, so the model without autocorrelation was selected (Supplementary material. Table 1).\u003c/p\u003e\n\u003cp\u003eModel selection: The non-significant LRT (X\u003csup\u003e2\u003c/sup\u003e(6)=2.082, p=0.556) and the lower AICc in the reduced fixed effects model (54.293) than in the full random effects model (210.211) indicate that the fixed effects present a better fit.\u003c/p\u003e\n\u003cp\u003eTransitivity: The non-significant LRT (X\u003csup\u003e2\u003c/sup\u003e(6)=3.08, p=0.379) and lower AICc in the reduced model without covariates (54.293) than in the full model adjusted for age, time with pain, and male/female ratio (209.213) indicated that the model without covariates had a better fit. It was confirmed that age, time with pain, and the male/female ratio did not significantly influence the results; therefore, it was not necessary to adjust for these confounding variables (Supplementary material. Table 1).\u003c/p\u003e\n\u003cp\u003eConsistency: The non-significant LRT (X\u003csup\u003e2\u003c/sup\u003e(7)\u0026lt;0.001, p\u0026gt;0.999) and lower AICc in the consistency-reduced model (83.393) than in the inconsistency full model (173.393) indicate that the model consistency is adequate. It is evident that the study by Glaros and Burton (2004) is the one that most influences this inconsistency (Supplementary Material. Figure 2).\u003c/p\u003e\n\u003cp\u003eNetwork structure Seven studies were reported with a total of five interventions and four comparisons, with a total sample of 758 patients. The largest number of comparisons occurred between the Biofeedback-No intervention, followed by the Biofeedback-Occlusal Splint (Figure 3).\u003c/p\u003e\n\u003cp\u003ePLEASE, FIGURE 3 HERE\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 3:\u003c/strong\u003e Network constructed for the pain intensity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRanking of interventions and measurement time: In the ranking of interventions, the highest P-scores and therefore with the greatest impact on pain intensity appear in the Occlusal splint, No intervention, Parafunctional clenching, while the moment of greatest change in pain occurs in the Follow-up (Table 3).\u003c/p\u003e\n\u003cp\u003ePLEASE, TABLE 3 HERE\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3:\u003c/strong\u003e Ranking table of interventions and time measurements.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSignificant interventions and measurement time: There were no significant differences in pain intensity between the different interventions, either post-treatment or follow-up, compared to baseline values (Table 4 and Figure 4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePLEASE, TABLE 4 HERE\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4:\u003c/strong\u003e Outcome variables effect.\u003c/p\u003e\n\u003cp\u003ePLEASE, FIGURE 4 HERE\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 4:\u003c/strong\u003e Biofeedback effect compared against controls.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePublication bias: The Egger test was not significant (t(1.695)=0.205, p=0.86) and the funnel plot showed a symmetrical distribution of the interventions, indicating the absence of publication bias (Supplementary Material. Figure 3).\u003c/p\u003e"},{"header":"4. DISCUSSION","content":"\u003cp\u003eThis systematic review and network meta-analysis aimed to assess the effectiveness of biofeedback (BF) as an educational treatment for temporomandibular disorders (TMD) and to evaluate its impact on pain reduction, psychological well-being, and physiological adaptation. Our findings suggest that BF is a viable therapeutic option for TMD patients, particularly when used as a structured educational intervention. However, the results highlight several methodological considerations that should be considered when interpreting outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.1. Summary of Main Findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe analysis included ten studies spanning a diverse range of patient populations, intervention protocols, and methodological approaches. The risk of bias assessment indicated that most studies exhibited a low risk of bias, whereas some concerns were noted in a minority of studies, particularly regarding randomization processes, deviations from intended interventions, and the selection of reported results.\u003c/p\u003e\n\u003cp\u003eOur network meta-analysis revealed that BF interventions demonstrated a moderate but clinically relevant effect on pain intensity compared with no intervention. However, when BF was compared to occlusal splints, the results were less conclusive, suggesting that splints may provide comparable or greater benefits in certain patient subgroups. Importantly, no significant differences were observed between the intervention groups in post-treatment or follow-up measures, indicating that BF is as effective as other established therapeutic approaches.\u003c/p\u003e\n\u003cp\u003eBeyond pain relief, our review identified that BF interventions contributed to improvements in psychological parameters such as anxiety and stress reduction, reinforcing the hypothesis that TMD symptoms have a strong biobehavioral component. This aligns with previous evidence suggesting that behavioral therapies can play a crucial role in the management of chronic orofacial pain disorders.\u003c/p\u003e\n\u003cp\u003eOf the ten studies included in this review, five incorporated measures of psychological variables. Mishra et al. (21) found improvements in anger/hostility, confusion/bewilderment, depression/dejection, fatigue/inertia, tension/anxiety, and vigor/activity in participants who underwent biofeedback therapy and those who received cognitive-behavioral therapy (CBT) or a combination of both. No differences were found between the groups. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGatchel et al. \u0026nbsp;(26) showed that a combined early intervention of BFB and CBT, in addition to preventing the onset of chronic TMD in high-risk patients, was effective in reducing the development of somatoform, anxiety, and mood disorders during follow-up. Furthermore, it led to reductions in depression and improvements in coping skills among participants. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMora et al., (27,28) \u0026nbsp;compared\u0026nbsp;the combined BFB and CBT interventions with an intervention based on oral splints. They demonstrated that while both interventions were effective in reducing pain, the BFB-CBT group achieved improvements in psychological variables that were not observed in the oral splint group. Specifically, they showed reductions in depression and somatization as well as improvements in pain coping. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThese findings are congruent with the biopsychosocial perspective of the interactive and reciprocal nature of pain and psychosocial functioning. These factors likely influence one another, with improved mood contributing to decreased pain and decreased pain contributing to improved mood. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBernstein et al. (22) reported that the greatest pain reduction outcomes were observed in individuals previously classified as having a high level of somatization. This suggests that these types of interventions may have different effects, depending on the patient\u0026rsquo;s profile. This study highlights the importance of patient classification when determining the most appropriate treatment for each case. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsistent with our results, \u003cstrong\u003eFlorjanski et al.\u0026nbsp;\u003c/strong\u003e(30) conducted a systematic review evaluating the use of BF in the management of masticatory muscle activity. They concluded that BF, especially electromyographic biofeedback (EMG-BF), was effective in reducing the muscular hyperactivity associated with TMD. They also emphasized the heterogeneity of BF protocols, ranging from visual and auditory feedback to vibratory signals, as well as the variability in electrode placement and session duration. This methodological diversity, also present in our dataset, underscores the need for standardized BF treatment protocols.\u003c/p\u003e\n\u003cp\u003eSimilarly, \u003cstrong\u003eCrider et al.\u0026nbsp;\u003c/strong\u003e(31) assessed the efficacy of various biofeedback-based interventions and classified them into three categories: (1) EMG-BF alone, (2) EMG-BF combined with cognitive-behavioral therapy (CBT), and (3) biofeedback-assisted relaxation training (BART). Their findings suggest that EMG-BF with adjunctive CBT meets the criteria for an efficacious treatment for TMD, while EMG-BF alone and BART were deemed \u0026ldquo;probably efficacious.\u0026rdquo; This hierarchy supports the use of BF not only as a standalone tool, but also as a valuable adjunct in psychologically informed care models.\u003c/p\u003e\n\u003cp\u003eFurther supporting this, \u003cstrong\u003eOrlando et al.\u0026nbsp;\u003c/strong\u003e(32) conducted a literature review on biobehavioral therapies for TMD, including EMG-BF, CBT, and relaxation techniques. They reported that BF was particularly effective in patients with daytime parafunctional habits and could enhance mandibular range of motion in addition to reducing pain. Interestingly, although occlusal splints provided short-term symptom relief, their benefits tended to diminish over time. By contrast, BF appeared to promote longer-lasting improvements, especially when combined with psychological interventions. These conclusions align with the idea that beyond its mechanical effects, BF plays a critical educational and regulatory role in patient care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.2. Strengths and Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOne of the primary strengths of this review was its rigorous adherence to the PRISMA guidelines, which ensured methodological transparency and reliability. Additionally, by implementing a network meta-analysis approach, we integrated and compared multiple interventions simultaneously, thereby providing a more comprehensive understanding of BF\u0026rsquo;s relative effectiveness of BF in TMD management.\u003c/p\u003e\n\u003cp\u003eHowever, this study has some limitations. First, the heterogeneity in the study design and outcome measures presents a challenge when drawing definitive conclusions. Although we adjusted for confounding variables such as age, sex, duration of symptoms, and psychological distress, the included studies varied in terms of intervention protocols, follow-up durations, and outcome assessment methods. This variability may have influenced the observed effects and reduced comparability between studies.\u003c/p\u003e\n\u003cp\u003eSecond, while the risk of publication bias was assessed and found to be low, the relatively small number of included studies limits the robustness of our findings. Additionally, the lack of standardized BF protocols across studies suggests that treatment effects may be influenced by variations in the device technology, feedback modality, and patient adherence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.3. Implications for Clinical Practice and Future Research\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings of this review support the clinical utility of BF as an educational tool for TMD treatment, particularly in settings in which patients require active engagement in pain management strategies. Given the observed benefits on both physiological and psychological outcomes, BF could be integrated as part of a multidisciplinary approach alongside manual therapy, cognitive-behavioral therapy, and pharmacological interventions.\u003c/p\u003e\n\u003cp\u003eFuture research should focus on:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eDeveloping standardized BF treatment protocols to enhance comparability between studies.\u003c/li\u003e\n \u003cli\u003eInvestigating long-term treatment effects, particularly in chronic TMD populations.\u003c/li\u003e\n \u003cli\u003eExploring the role of patient adherence and psychological factors in BF effectiveness.\u003c/li\u003e\n \u003cli\u003eConducting larger randomized controlled trials (RCTs) to strengthen the evidence base.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"5. CONCLUSIONS","content":"\u003cp\u003eThis systematic review and network meta-analysis highlighted the potential of BF as an effective educational intervention for patients with TMD, offering benefits beyond pain relief by addressing the psychological and biobehavioral aspects of the disorder. Although methodological limitations exist, these findings support the further exploration of BF in clinical practice and research settings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization, M.T.P and A.M.G.G.; methodology, A.M.G.G, N.L.T, M.T.P and E.A.S.R; software, J.N.C.-Z; validation, all authors; formal analysis, J.N.C.-Z.; investigation, all authors; resources, E.A.S.R.; data curation, J.N.C.-Z.; writing\u0026mdash;original draft preparation, E.A.S.R., N.L.T, M.T.P, X.A.S.G, J.N.C.-Z and A.M.G.G.; writing\u0026mdash;review and editing, E.A.S.R., N.L.T, M.T.P, X.A.S.G, J.N.C.-Z and A.M.G.G visualization, E.A.S.R., N.L.T, M.T.P, X.A.S.G, J.N.C.-Z and A.M.G.G.; supervision, all authors; project administration, E.A.S.R., and A.M.G.G.; funding acquisition, E.A.S.R. All authors have read and agreed to the published version of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstitutional Review Board Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, registered on PROSPERO prior to starting this review, and approved on September 28, 2024 (CRD42024598509).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data presented in this study are available on request from the corresponding authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors certify that they have no affiliations with or financial involvement in any organization or entity with direct financial interest in the subject matter or materials discussed in this article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSchwartz, N. M., \u0026amp; Schwartz, M. S. Definitions of biofeedback and applied psychophysiology. In: Biofeedback: A practitioner\u0026rsquo;s guide. 3rd ed. The Guilford Press.; 2003. p. 27\u0026ndash;39. \u003c/li\u003e\n\u003cli\u003eGupta R, Luthra RP, Kaur D, Aggarwal B. Temporomandibular disorders: A review. Int J Adv Sci Res. 2019;4(2):22\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eSchiffman E, Ohrbach R, Truelove E, Look J, Anderson G, Goulet JP, et al. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: Recommendations of the International RDC/TMD Consortium Network* and Orofacial Pain Special Interest Group\u0026dagger;. J Oral Facial Pain Headache. 2014 Jan;28(1):6\u0026ndash;27. \u003c/li\u003e\n\u003cli\u003eFlorjanski W, Malysa A, Orzeszek S, Smardz J, Olchowy A, Paradowska-Stolarz A, et al. Evaluation of Biofeedback Usefulness in Masticatory Muscle Activity Management-A Systematic Review. J Clin Med. 2019 May 30;8(6):766. \u003c/li\u003e\n\u003cli\u003eMinakuchi H, Fujisawa M, Abe Y, Iida T, Oki K, Okura K, et al. Managements of sleep bruxism in adult: A systematic review. Jpn Dent Sci Rev. 2022 Nov;58:124\u0026ndash;36. \u003c/li\u003e\n\u003cli\u003eBergmann A, Edelhoff D, Schubert O, Erdelt KJ, Pho Duc JM. Effect of treatment with a full-occlusion biofeedback splint on sleep bruxism and TMD pain: a randomized controlled clinical trial. Clin Oral Investig. 2020 Nov;24(11):4005-4018. doi: 10.1007/s00784-020-03270-z. Epub 2020 May 19. PMID: 32430774; PMCID: PMC7544753.\u003c/li\u003e\n\u003cli\u003eVillar-Arag\u0026oacute;n-Berzosa, V.; Obrero-Gait\u0026aacute;n, E.; L\u0026eacute;rida-Ortega, M.\u0026Aacute;.; L\u0026oacute;pez-Ruiz, M.d.C.; Rodr\u0026iacute;guez-Almagro, D.; Achalandabaso-Ochoa, A.; Molina-Ortega, F.J.; Ib\u0026aacute;\u0026ntilde;ez-Vera, A.J. Manual Therapy Techniques Versus Occlusal Splint Therapy for Temporomandibular Disorders: A Systematic Review with Meta-Analysis. \u003cem\u003eDent. J.\u003c/em\u003e \u003cstrong\u003e2024\u003c/strong\u003e, \u003cem\u003e12\u003c/em\u003e, 355.\u003c/li\u003e\n\u003cli\u003eGiggins OM, Persson UM, Caulfield B. Biofeedback in rehabilitation. J Neuroengineering Rehabil. 2013 Jun 18;10:60. \u003c/li\u003e\n\u003cli\u003eFelin GC, Tagliari CVDC, Agostini BA, Collares K. Prevalence of psychological disorders in patients with temporomandibular disorders: A systematic review and meta-analysis. J Prosthet Dent. 2024 Aug;132(2):392-401. \u003c/li\u003e\n\u003cli\u003eSato M, Iizuka T, Watanabe A, Iwase N, Otsuka H, Terada N, et al. Electromyogram biofeedback training for daytime clenching and its effect on sleep bruxism. J Oral Rehabil. 2015 Feb;42(2):83\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eAbd-Elwahab Radi I, Tahoon M. More evidence is needed to determine the effectiveness of full occlusion biofeedback splints used for sleep bruxism (sb) and temporomandibular disorder (tmd) pain. J Evid Based Dent Pract. 2021 Dec 1;21(4):101650. \u003c/li\u003e\n\u003cli\u003ePage MJ, Moher D, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews. BMJ. 2021 Mar 29;n160. \u003c/li\u003e\n\u003cli\u003eMoher D, Pham B, Jones A, Cook DJ, Jadad AR, Moher M, et al. Does quality of reports of randomised trials affect estimates of intervention efficacy reported in meta-analyses? Lancet Lond Engl. 1998 Aug 22;352(9128):609\u0026ndash;13. \u003c/li\u003e\n\u003cli\u003eStone PW. Popping the (PICO) question in research and evidence-based practice. Appl Nurs Res ANR. 2002 Aug;15(3):197\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eCiapponi A. Herramientas ROBINS para evaluar el riesgo de sesgo de estudios no aleatorizados. Evid Actual En Pr\u0026aacute;ctica Ambulatoria. 2022 Aug 24;25(3):e007024\u0026ndash;e007024. \u003c/li\u003e\n\u003cli\u003eMcHugh ML. Interrater reliability: the kappa statistic. Biochem Medica. 2012;22(3):276\u0026ndash;82. \u003c/li\u003e\n\u003cli\u003eViechtbauer W. Conducting Meta-Analyses in R with the metafor Package. J Stat Softw. 2010 Aug 5;36:1\u0026ndash;48. \u003c/li\u003e\n\u003cli\u003eTipton E, Pustejovsky JE. Small-Sample Adjustments for Tests of Moderators and Model Fit Using Robust Variance Estimation in Meta-Regression. J Educ Behav Stat. 2015;40(6):604\u0026ndash;34. \u003c/li\u003e\n\u003cli\u003eEfthimiou O, Mavridis D, Debray TPA, Samara M, Belger M, Siontis GCM, et al. Combining randomized and non-randomized evidence in network meta-analysis. Stat Med. 2017 Apr 15;36(8):1210\u0026ndash;26. \u003c/li\u003e\n\u003cli\u003eGlaros AG. Awareness of physiological responding under stress and nonstress conditions in temporomandibular disorders. Biofeedback Self-Regul. 1996 Sep;21(3):261\u0026ndash;72. \u003c/li\u003e\n\u003cli\u003eMishra KD, Gatchel RJ, Gardea MA. The relative efficacy of three cognitive-behavioral treatment approaches to temporomandibular disorders. J Behav Med. 2000 Jun;23(3):293-309. \u003c/li\u003e\n\u003cli\u003eBernstein DN, Gatchel RJ. Biobehavioral Predictor Variables of Treatment Outcome in Patients With Temporomandibular Disorders1. J Appl Biobehav Res. 2000 Jul;5(2):101\u0026ndash;13. \u003c/li\u003e\n\u003cli\u003eGardea MA, Gatchel RJ, Mishra KD. Long-term efficacy of biobehavioral treatment of temporomandibular disorders. J Behav Med. 2001 Aug;24(4):341-59. \u003c/li\u003e\n\u003cli\u003eGlaros AG, Burton E. Parafunctional Clenching, Pain, and Effort in Temporomandibular Disorders. J Behav Med. 2004 Feb;27(1):91\u0026ndash;100. \u003c/li\u003e\n\u003cli\u003eGlaros AG, Waghela R. Psychophysiological Definitions of Clenching. CRANIO\u0026reg;. 2006 Oct;24(4):252\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eGatchel RJ, Stowell AW, Wildenstein L, Riggs R, Ellis E. Efficacy of an early intervention for patients with acute temporomandibular disorder\u0026ndash;related pain. J Am Dent Assoc. 2006 Mar;137(3):339\u0026ndash;47. \u003c/li\u003e\n\u003cli\u003eShedden Mora MC, Bleichhardt G, Weber D, Neff A, Rief W. Biofeedback bei kraniomandibul\u0026auml;ren Dysfunktionen: Vorl\u0026auml;ufige Wirksamkeit und Akzeptanz eines Biofeedback-gest\u0026uuml;tzten kognitiv-verhaltenstherapeutischen Therapiekonzepts. Psychotherapeut. 2010 May;55(3):217\u0026ndash;24. \u003c/li\u003e\n\u003cli\u003eShedden Mora MC, Weber D, Neff A, Rief W. Biofeedback-based Cognitive-Behavioral Treatment Compared With Occlusal Splint for Temporomandibular Disorder: A Randomized Controlled Trial. Clin J Pain. 2013 Dec;29(12):1057\u0026ndash;65. \u003c/li\u003e\n\u003cli\u003eBarbosa MA, Tahara AK, Ferreira IC, Intelangelo L, Barbosa AC. Effects of 8 weeks of masticatory muscles focused endurance exercises on women with oro‐facial pain and temporomandibular disorders: A placebo randomised controlled trial. J Oral Rehabil. 2019 Oct;46(10):885\u0026ndash;94. \u003c/li\u003e\n\u003cli\u003eFlorjański W, Małysa A, Orzeszek S, Smardz J, Olchowy A, Paradowska-Stolarz A, et al. Evaluation of Biofeedback Usefulness in Masticatory Muscle Activity Management\u0026mdash;A Systematic Review. \u003cem\u003eJ Clin Med\u003c/em\u003e. 2019;8(6):766. \u003c/li\u003e\n\u003cli\u003eCrider A, Glaros AG, Gevirtz RN. Efficacy of Biofeedback-Based Treatments for Temporomandibular Disorders. \u003cem\u003eAppl Psychophysiol Biofeedback\u003c/em\u003e. 2005;30(4):333\u0026ndash;46. \u003c/li\u003e\n\u003cli\u003eOrlando B, Manfredini D, Salvetti G, Bosco M. Evaluation of the Effectiveness of Biobehavioral Therapy in the Treatment of Temporomandibular Disorders: A Literature Review. \u003cem\u003eBehav Med\u003c/em\u003e. 2007;33(3):101\u0026ndash;18. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1:Databases search, created by authors.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDatabases\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSearch equation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003ePUBMED\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003e(temporomandibular disorders[MeSH Terms]) AND (biofeedback [MeSH Terms])\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eWOS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eTopic \u0026quot;temporomandibular disorders\u0026quot; AND \u0026quot;biofeedback\u0026quot;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003ePEDro\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eAdvanced search: Topic \u0026quot;temporomandibular disorders\u0026quot; AND \u0026quot;biofeedback\u0026quot;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eSCOPUS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eSearch within:Article title, Abstract, Keywords. Search Documents: \u0026ldquo;temporomandibular disorders\u0026rdquo; AND \u0026ldquo;biofeedback\u0026rdquo;.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eCOCHRANE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eSearch advances by title, summary and keywords: \u0026quot;temporomandibular disorders\u0026quot; AND \u0026quot;biofeedback\u0026quot;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Characteristics of the included studies. For each study, the aim, participants, type of intervention, outcome measures and main results are reported.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"1040\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAUTHOR / YEAR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOBJECTIVE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSAMPLE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 255px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMETHODS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 444px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRESULTS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eGlaros et al.,\u0026nbsp;(11)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1996\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eDemonstrate that people with TMD have a deficit in proprioceptive awareness\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e20 patients with TMD and 20 without pain, of the same age and sex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 255px;\"\u003e\n \u003cp\u003eMonitoring of the temporalis, masseter and frontal muscles, heart rate, and skin conductance while subjects watched a fraction of a movie and make a personal report on their physiological responses.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 444px;\"\u003e\n \u003cp\u003ePatients with TMD have better proprioceptive awareness in stressful situations and less in non-stressful ones. Even so, patients without TMD have better proprioceptive awareness.\u003c/p\u003e\n \u003cp\u003ePatients with TMD and myofascial pain may have periods of high parafunctional activity without being aware of it.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eMishra et al., \u003cstrong\u003e(12)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1999\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eDeterminate the efficacy of \u0026nbsp;TT options for chronic TMD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e94 chronic patients with TMD (more tan 6 months).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 255px;\"\u003e\n \u003cp\u003eThe patients were divided into 4 groups: BF, CBST, combination BF/CBST, and no-TT control, each group received 12 sessions of TT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 444px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eWas significant decreases in CPI and mood from pre TT to post TT among all TT conditions (p=, 000), but varying depending on the TT received. \u0026nbsp;Between the 3 TT groups and the non-TT group was a significant difference (p = .013). BF TT demonstrate the best outcomes (f= 23.903; p= .001).\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eBernstein et al., \u003cstrong\u003e(13)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eEvaluate the efficacy of two variables to predict the TT results in patients with chronic TMD.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e121 patients with chronic TMD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 255px;\"\u003e\n \u003cp\u003ewere divided into BF, CBST, combined (CBST/BFB), \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Random control (no TT), or 5 not interested in TT and were classified into 4 groups (PCG) \u0026nbsp;according to their diagnosis of TMD).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 444px;\"\u003e\n \u003cp\u003eBefore TT, CPI among groups was different . Between post-TT and 1 year later, the year later has lower CPI, being important the PCGs. The PCG 1 have the higher CPI levels.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNo significant differences were found between the different TT groups, and demonstrate the importance of biopsychosocial aspects in the TT of TMD.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eGardea et al., \u003cstrong\u003e(14)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eStudy the efficacy \u0026nbsp;of some TTs in chronic TDM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e108 patients with chronic TMD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 255px;\"\u003e\n \u003cp\u003e12 sessions of each TT, distributing the patients into the 4 groups.\u003c/p\u003e\n \u003cp\u003eBF (27), CBST (24), combined (29), no-TT (28)\u003c/p\u003e\n \u003cp\u003eEvaluated just after the TT and a year later\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 444px;\"\u003e\n \u003cp\u003ePatients who received biobehavioral TTs manifest significant betterment of subjective pain, and mandibular motion 1 year later.\u003c/p\u003e\n \u003cp\u003eCBST \u0026ndash; BFB combined produced the best improvements of all outcome measures; pain and disability. BF demonstrated a significant difference in pain. No \u0026ndash; TT group don\u0026acute;t improved.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eGlaros et al., \u003cstrong\u003e(22)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eDeterminate if the parafunctional activity increased the pain and can derivated to TMD, and if the EMG is correlated with reports of pain.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e14 persons without TMD, from 21 to 35 years old\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 255px;\"\u003e\n \u003cp\u003eWas divided into two groups: increase and decrease, who did masseter and temporalis exercises 5 days in a row (20 minutes long) and completed four Vas scales, comparing them with the prior ones.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 444px;\"\u003e\n \u003cp\u003eTwo participants of the increased group received a diagnosis of TMD at the end. The EMG activity was significantly higher in the increased group during training (p \u0026lt; 0.001). The increased group had significantly worst immediate post session pain (p \u0026lt; 0.05.), but at 24 hours pain did not significantly differences between groups.\u003c/p\u003e\n \u003cp\u003eThe EMG activity for masseters and temporalis, during training for increase group was 30 \u0026ndash; 25,2% and the decreased group were 2,4-2,3%.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAUTHOR / YEAR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOBJECTIVE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSAMPLE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 255px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMETHODS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 444px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRESULTS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eGlaros et al., \u003cstrong\u003e(16)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eStudy if the EMG activity produces by the masticatory muscles varies when they are instructed to make tooth contact.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e20 persons without TMD, from 18 to 65 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 255px;\"\u003e\n \u003cp\u003eMonitoring masseter and temporalis, a 20-minute session was \u0026nbsp;in which participants were guided to relaxing the muscles or clenching the teeth, repeating this process 3 times.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 444px;\"\u003e\n \u003cp\u003eThe participants make significantly different EMG levels throughout the three stages of the study. That is, the participants performed different EMG activities to follow the instructions given to them.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eGatchel et al., \u003cstrong\u003e(17)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eDetermine the effectiveness of a biopsychosocial intervention in patients with acute TMD and high risk of developing chronic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e101 patients from 18 to 70 years, who present facial pain for les tan six months.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 255px;\"\u003e\n \u003cp\u003eThe subjects randomly were divided in \u0026nbsp;a group with CBST \u0026nbsp;/ BF (EI) or no intervention (NI)). Six sessions of a one hour long, and some assignments to realized between sessions\u003c/p\u003e\n \u003cp\u003eEvaluation a year later.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 444px;\"\u003e\n \u003cp\u003eBoth groups scores on the self reported IPC scale improved at the year, but the EI group had significantly less pain, more adaptive and coping abilities and had less anxiety.\u003c/p\u003e\n \u003cp\u003eThe NI group had more pain disorders and significantly higher rates of the DSM \u0026ndash; IV, significantly more anxiety, somatoform and affective disorders and received significantly more sought professional help to treat pain outside of the study.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eMora \u0026nbsp; \u0026nbsp; et al., \u003cstrong\u003e(18)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eDevelop a manual for CBT-BFB and compare it with other dental TTs.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e26 patients with chronic TMD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 255px;\"\u003e\n \u003cp\u003eThey were randomly designated to a group: one received 8 sessions of CBT-BFB and the other group take a discharge splint\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 444px;\"\u003e\n \u003cp\u003eBoth TTs significantly reduced pain (p\u0026lt;0,001) and mandibular deterioration (p\u0026lt;0,05), in addition to reducing disability due to pain (p\u0026lt;0,05).\u003c/p\u003e\n \u003cp\u003eThe CBT-BFB group showed an improvement in mood (p=0,051)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eMora et al., \u003cstrong\u003e(19)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eCompare the effectiveness of CBT-BFB \u0026nbsp;vs. OS and analyze changes in nocturnal masseter muscle activity (NMMA).\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e58 patients with chronic TMD between 18 and 70 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 255px;\"\u003e\n \u003cp\u003eThey were randomly designated in two groups, the CBT-BFB group receives 8 sessions (1/week) and the OS group use it for 8 weeks. Evaluation 6 months after the end of the TT.\u003c/p\u003e\n \u003cp\u003eNMMA was analyzed at home 3 consecutives nights\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 444px;\"\u003e\n \u003cp\u003eBoth groups make significant improvements in pain, pain related disability, jaw use limitations, depressive symptoms, anxiety, symptoms of TMD, somatoform symptoms and with clinically significant improvements (48% for OS and 45% for BFB-CBT). There were no significant differences but the BFB-CBT obtained a longer-term effect and greater general satisfaction. The NMMA did not suffer significant changes.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003eBarbosa et al., \u003cstrong\u003e(20)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eAnalyze the effectiveness of an 8-week protocol of local resistance exercises of the muscles of mastication\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e46 women with orofacial pain and TMD between 18 and 45 years old, but only 34 completed the TT.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 255px;\"\u003e\n \u003cp\u003eThe subjects were randomly divided into: intervention group (protocol of bite resistance exercise controlled with BF) and placebo group.\u003c/p\u003e\n \u003cp\u003eThe 16 sessions (2 / week), consisted in resistance exercises.\u003c/p\u003e\n \u003cp\u003eThey were evaluated before, at 4 weeks and at 8 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 444px;\"\u003e\n \u003cp\u003eBetween groups, some significant differences were noted. The intervention group showed less pain at 8 weeks, higher values in muscle efficiency \u0026nbsp; \u0026nbsp; weeks 4 and 8, and a longer time to fatigue.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAlthough temporal muscle excitation was higher in the intervention group at 8 weeks, but for the algometry, force response and muscle excitation no differences was observed.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: TMD: temporomandibular disorders; TT: treatment; BF: biofeedback; CBST: cognitive-behavioral skills training; CBT-BFB: combination of cognitive \u0026nbsp; behavioral treatment and biofeedback; OS: \u0026nbsp;occlusal splint; CPI: Characteristic Pain Intensity; EMG: electromyography activity\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"465\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3:\u003c/strong\u003e Ranking table of interventions and time measurements.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eP-score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterventions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eOcclusal splint\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.609\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNo intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.517\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eParafunctional clenching\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBiofeedback\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.309\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePlacebo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.011\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime meaurement\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFollow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.919\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePost-treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.774\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 567px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eTable 4:\u003c/strong\u003e Outcome variables effect.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 567px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePairwise comparisons\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 402px;\"\u003e\n \u003cp\u003eOcclusal Splint vs.\u0026nbsp;No intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003e-0.057 (-0.771, 0.657)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 402px;\"\u003e\n \u003cp\u003eOcclusal Splint vs.\u0026nbsp;Placebo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003e-0.424 (-1.291, 0.442)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 402px;\"\u003e\n \u003cp\u003eOcclusal Splint vs.\u0026nbsp;Parafunctional Clenching\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003e-0.153 (-1.184, 0.878)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 402px;\"\u003e\n \u003cp\u003eNo intervention vs.\u0026nbsp;Placebo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003e-0.367 (-1.053, 0.318)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 402px;\"\u003e\n \u003cp\u003eNo intervention vs.\u0026nbsp;Parafunctional Clenching\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003e-0.096 (-0.847, 0.654)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 402px;\"\u003e\n \u003cp\u003ePlacebo vs.\u0026nbsp;Parafunctional Clenching\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003e0.271 (-0.081, 0.623)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 567px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime meaurement\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 402px;\"\u003e\n \u003cp\u003eFollow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003e-0.465 (-1.357, 0.426)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 402px;\"\u003e\n \u003cp\u003ePost-treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 165px;\"\u003e\n \u003cp\u003e-0.259 (-0.699, 0.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 402px;\"\u003e\n \u003cp\u003eEstimates and their 95% confidence intervals are shown.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 165px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 402px;\"\u003e\n \u003cp\u003eSignificant differences shown in red.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 165px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"temporomandibular disorders, biofeedback, meta-analysis, education, systematic review","lastPublishedDoi":"10.21203/rs.3.rs-6388848/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6388848/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e To evaluate the effectiveness of biofeedback (BF) as an educational treatment for temporomandibular disorders (TMD) through a systematic review and a network meta-analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A systematic search was conducted across five electronic databases (PubMed, WOS, PEDro, Scopus, and Cochrane), select clinical trials using BF as a therapeutic intervention in patients diagnosed with TMD based on RDC/TMD or DC-TMD criteria. A frequentist fixed-effects network meta-analysis was conducted with robust variance estimation to adjust for within-study correlations in repeated measures. Sensitivity analyses were performed using an autoregressive lag-1 (AR1) model at varying correlation levels (0–0.8). Model fit was assessed via likelihood ratio tests (LRT) and Akaike Information Criterion corrected for small samples (AICc).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Ten studies (n = 758) were included. No statistically significant differences in pain intensity were found between the interventions at post-treatment or follow-up. The model without autocorrelation showed a superior fit (AICc = 54.293) compared to models adjusted for covariates or random effects. Ranking analyses revealed higher P-scores for occlusal splints and parafunctional clenching. The Egger’s test and funnel plot suggested no publication bias.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e BF demonstrated effectiveness comparable to that of established TMD treatments, with no significant differences in pain outcomes. However, its educational role may offer added value by improving psychological factors, such as anxiety and stress. These findings support BF as a valuable component of a biopsychosocial approach to TMD rehabilitation.\u003c/p\u003e","manuscriptTitle":"Usefulness of Biofeedback as an Educational Treatment of Temporomandibular Disorders: A Systematic Review and Network Meta-analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-08 09:04:36","doi":"10.21203/rs.3.rs-6388848/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"02260512-3c73-44e7-806b-d7481233de0e","owner":[],"postedDate":"April 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":46790592,"name":"Physical Medicine \u0026 Rehab"},{"id":46790593,"name":"Psychology"}],"tags":[],"updatedAt":"2025-04-08T09:04:36+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-08 09:04:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6388848","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6388848","identity":"rs-6388848","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}