Drawbridge Seminars -- Bringing Research to Practice

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• Why does so much confusion exist related to treatment for temporomandibular disorders?

Perhaps the single greatest reason for this confusion is the fact that health care curricula provide very little instruction in the normal functional anatomy and physiology of the masticatory system. The irony is that a great deal of knowledge in this subject area is available. As a result, health care providers, dentists in particular, leave their formal training with limited understanding of the normal function of the masticatory system, for which the dental profession has primary professional responsibility. Without a clear understanding of normal function, dentists and other care providers have no basis for understanding abnormal function or what might be required to return the system to something approaching normal function.

• What imaging is recommended for TMD diagnosis?

Most TMD-related problems can be diagnosed from a careful history and examination. Initial assessment of a patient with TMD-related complaints may, in most cases, involve a screening, as opposed to a comprehensive, evaluation. For this purpose, a good quality panoramic image can be very useful. However, with a panoramic image changes to the condyles are most clearly seen, but not the relationship of the condyles to the fossae, since the mandible needs to be protruded to see the condyle clearly.

Before considering other types of imaging for TMJ evaluation, a thorough history and examination is recommended. Most diagnoses of masticatory function will be made from the history and examination, not from imaging. When imaging might provide critical additional information that has not been provided by an examination, several imaging options are available. These might include tomography, arthrograms, MRI, or cone beam CT scan. The clinician must consider what information will be of greatest benefit, as each of these has strengths and limitations. For more specific information regarding the various imaging options, please see the “Imaging of the Temporomandibular Joints" page.

• Is surgery ever indicated for a temporomandibular disorder?

Most dentists will be aware that the history of TMJ surgery has not been a pretty picture. As a result, significant reservations exist in many minds as to whether TMJ surgery is ever indicated. We are not surgeons and do not wish to prescribe a specific protocol for TMJ surgery. However, we do feel that there is an appropriate place for TMJ surgery and that the primary objectives of TMJ surgery, when it is indicated, is to restore structural stability and function to the temporomandibular joints, to the degree that that can be accomplished in each case.

Our experience has clearly indicated that patients who might potentially be candidates for surgery will usually benefit from several months of non-surgical care prior to making a final determination as to whether there is truly a surgical need. This non-invasive, pre-surgical treatment might be provided by the surgeon but can also be provided by a non-surgeon when an interdisciplinary team effort is employed. Non-surgical management will often reduce or even eliminate joint and muscle pain. If this can be accomplished, reassessment of the patient’s needs regarding possible surgery is indicated. If a patient’s pain has been significantly reduced or eliminated, functional considerations may then become the primary issue involved in making a decision regarding the need for surgery. The patient’s age may also be a consideration.

When surgery is indicated, with proper pre-surgical and post-surgical management, outcomes can be very favorable in nearly all cases. For a more comprehensive review of the issues surrounding TMJ surgery, please see the “TMJ Surgery" page.

• When TMD treatment will involve an inter-disciplinary team approach, which participant should coordinate the overall treatment plan?

In an individual case, an interdisciplinary TMD team approach might require as few as two people or could involve four or five individuals with different clinical training and skills. The makeup of the interdisciplinary team for an individual patient will be determined by the nature of the patient’s needs.

A true interdisciplinary team approach (as opposed to a multi-disciplinary approach) has certain characteristics. The first of these is that all members of the team will share a common paradigm regarding treatment. Second is that each member of the team has certain clinical knowledge, skills, and experience and that all members are committed to sharing responsibility for treatment, utilizing the skills of each member to optimize the outcome for the patient. Third, interdisciplinary communication is critical for there to be an effective team effort. When this works optimally, the outcome will be greater than the sum of the parts.

When a patient presents with TMD findings that require an interdisciplinary treatment approach, the patient may originate in the practice of any of the members of the team. In other words, the need for treatment might be recognized by a general dentist, an orthodontist, a prosthodontist, a periodontist, an oral surgeon, or by a physical therapist. Any one of these portal-of-entry providers might assume responsibility to coordinate care for that individual patient. So long as each member involved in the interdisciplinary team recognizes their particular responsibility to the patient and communicates with the other members, optimal treatment is possible.

• What precautions are appropriate during routine dental visits for patients with known “TMJ” problems?

The dental responsibility regarding patients with certain symptoms of muscles and joints is not unlike the dental responsibility regarding dental caries or periodontal disease. Our responsibility is to recognize the condition in its incipient stage, if possible, and to either treat it or see to it that the patient receives care from someone with appropriate training and skills.

Although the current standard of care has yet to clearly prescribed that TMD screening should be done routinely in dental offices, this has been recommended in the American Academy of Orofacial Pain, Orofacial Pain Guidelines. We enthusiastically subscribe to these recommendation. When any symptoms of TMDs are recognized in a dental patient, the responsibility of the dental practitioner is to determine the nature of the condition that is producing those symptoms and this should become the first priority. Routine screening of all dental patients can be incorporated into a dental practice fairly easily.

With certain temporomandibular disorders, even routine dental care may exacerbate symptoms and/or precipitate progression of the underlying condition that is responsible for the symptoms. For patients with pain on opening and/or limited range of motion, dental procedures of all kinds should be kept to a minimum until the cause has been thoroughly diagnosed and appropriate treatment undertaken. Elective treatment should be postponed and only critical dental care should take precedence until the TMD concerns have been stabilized.  Ignoring these symptoms in hopes that nothing untoward will occur is tempting fate and is discouraged.

• What kind of occlusal appliance should I use for a “TMJ” patient?

Choosing an appropriate occlusal appliance type should be based on a biologically-specific diagnosis of the individual patient’s condition. Dawson has suggested that all occlusal appliances, regardless of their name, are of two types that he designates “permissive” or “directive”. A permissive appliance, according to Dawson’s definition, “unlocks the occlusion to eliminate contact of deflecting tooth inclines”. Another way of describing a permissive appliance would be that it masks any potentially detrimental aspects of the patient’s native dental occlusion, provides uniform occlusal stability and temporarily creates, on plastic, an occlusal environment that encourages and promotes a return of normal masticatory homeostasis and function. Many TMD patients will benefit from the use of a well-designed and properly adjusted permissive appliance. However, for certain specific conditions involving structural disorders of the temporomandibular joints, a permissive appliance may not be sufficient to definitively manage the condition.

A directive appliance, according to Dawson, “is designed to position the mandible in a specific relationship to the maxilla”. He further states that, “the sole purpose of a directive appliance is to position or align the condyle/disc assembly”. Although directive appliances do meet these criteria in most instances, this does not entirely explain when and how they might be used in specific types of temporomandibular disorders. The specific indications for this type of appliance are fairly involved and proper use will usually require a fairly sophisticated understanding of the functional anatomy of the temporomandibular joints.

For a more extensive description of appliance selection and use, please see the "Occlusal Appliances in TMD Management"  page under "Treatment".

• Does insurance cover “TMJ” diagnosis and treatment?

Insurance coverage for temporomandibular disorders is extremely variable, from no coverage at all to modest coverage in the best of circumstances. Because TMD treatment involves joints and muscles primarily, biologically these disorders should be seen as comparable to the treatment of other joints systems. In that sense, they are medical in nature rather than dental. Most insurance companies that provide benefits typically provide them under the patient’s medical insurance coverage. A few dental plans may provide some benefits.

What kinds of treatment insurance companies may cover can also vary greatly. Some will cover diagnostic procedures but nothing else. A few limit coverage to only surgical treatment. Others my cover appliance therapy but not physical therapy or surgical treatment. There does not seem to be any consistent logic behind decisions regarding benefits, except for one thing. As is true with any kind of insurance, the amount of coverage is a direct reflection of the premium that was paid for the coverage. The higher the premium, the better the coverage. One thing is very clear — decisions regarding insurance coverage are not based on patient need. 

• What constitutes an “adequate” evaluation for temporomandibular disorders?

There are two levels of evaluation of temporomandibular disorders, The first is a screening evaluation, involving a fairly brief history and an examination that is limited to a few key clinical indicators. The purpose of a screening evaluation is primarily to determine if a patient has a true temporomandibular disorder, and whether a need for a comprehensive evaluation is needed. In most cases a screening evaluation does not provide sufficient information to make a biologically-specific diagnosis nor to determine the exact needs of treatment.

A comprehensive evaluation is highly recommended prior to undertaking any treatment. This would involve taking a comprehensive history and examining the masticatory structures for not only symptoms but also to determine the adequacy or limitations of masticatory function. A comprehensive evaluation should provide indications of possible causation, the extent of the disorder, including what structures are involved and to what degree. These are the necessary ingredients for forming a true diagnosis and a patient-specific treatment plan that is focused not only on symptomatic relief but on restoration of masticatory physiologic function.

Forms for doing a screening evaluation, as well as a comprehensive history form and a comprehensive examination form, are available on the "Diagnosis" page.

• Why do women seek “TMJ” treatment more than men?

Several studies, done in different countries, have clearly shown that women seek treatment for temporomandibular disorders at an average rate of about 7 times greater than men (these studies have varied from 3:1 to 9:1, women to men). However, in studies that have examined general population groups (not patients), the predominance of symptoms among women, compared to men, is about 2:1.

The occurrence of TMDs in women, based on age, parallels the child-bearing years. This finding strongly suggests that hormonal factors may have a significant influence, perhaps related to an increased extensibility of ligamentous tissues that occur on a monthly basis with menses. Other possible hormonal effects include changes in pain perception related to the menstrual cycle have been proposed but at this time there are no firm conclusions to this intriguing question.



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