Controversies in TMD
Greg Goddard, DDS
Copyright 1998 Journal of the California Dental Association.
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Health professionals have dealt with temporomandibular disorders, a major cause of non-dental pain in the orofacial region, by developing a broad range of treatments, ranging from
occlusal alteration to multidisciplinary self-care regimens. Research directed toward
evaluation of various TMD treatment modalities is particularly controversial due to cyclical
fluctuation of symptoms, high rates of spontaneous remission, and possibility of placebo
effect interference. Given this variety of treatments now current, dental professionals bear a
broadening responsibility to review and assess the range of diagnostic possibilities and
treatment potentials now entering into the scientific literature. |
Currently, the health professions have many different approaches to consider in the treatment
of patients suffering from temporomandibular disorders. This paper reviews and discusses
some of these approaches -- and some of the controversies aroused by them -- in the hope
that the dental profession will soon arrive at more effective, scientifically based treatments.
Temporomandibular Disorders denote a group of related disorders of the TM joint and/or the
associated musculature. Some of the more common TMD diagnoses are TMJ inflammation,
TMJ anterior displaced disc with and without reduction, and myofascial pain. These
conditions may have multiple causative factors, often without a clear understanding of what
the exact causes are. TMD can have a variety of signs and symptoms, including but not
limited to pain in the jaw joint or face, headaches, earaches, dizziness, enlarged masticatory
muscles, limited mouth opening, and noises in the jaw joints. Temporomandibular disorders
are a major cause of non-dental pain in the orofacial region. 1
It is with this background that health practitioners have responded to their patients' needs by
developing a broad range of treatments, often determined more by the specialty of the
practitioner than by scientifically-based treatment. There are practitioners claiming successful
outcomes from a diverse number of treatments ranging from education and behavioral
counseling, use of medications, occlusal therapies, surgery and splints, to a combination of
various treatments. Much of this information is anecdotal.
2-9
Historically, treatment for TMD was based on an assumption that occlusion was the primary
cause of this problem. Treatment was often focused on altering the patient's occlusion.
Treatment included splints, equilibration, reconstruction of the occlusion with orthodontics,
surgery, and restorative therapy. 10 As more research was published, diagnosis progressed to
differentiating between subsets of both joint (TMJ) and muscle conditions. Treatment altered
specific to the etiology of the problem. 11,12
The medical profession went through a similar evolution with the diagnosis and treatment of
low back pain. Medical management went from performing surgery on "ruptured discs" to a
more conservative approach of managing low back pain with self-care; anti-inflammatory
medications, muscle relaxants, physical therapy, and exercise.13 It was also recognized that
low back pain, especially if it was chronic, had to include psychological evaluation and
management because stress and somatization may play significant roles. 14,15 As a result, the
multidisciplinary approach to treatment of chronic low back pain emerged. Self-care became
an integral component in this approach. The goals of this approach are to educate the patient
to learn to manage their problem through understanding and use of proper posture and body
mechanics, exercise, weight control, stress management, and the use of over-the-counter
medications. 14,15 This approach is now accepted in the medical profession and is well-supported by research. 16,17
Today TMD may be approached in a manner similar to low back pain, i.e., using a
multidisciplinary approach to treatment. 18-20 Treatment can include many of the same
therapies included in the medical approach to low back pain; self-care, anti-inflammatory
medication, muscle relaxants, physical therapy and exercise.20-22 The clinical use of non-invasive therapy that includes the use of splints, prescription medications, biofeedback,
psychological counseling, as well as self-care techniques, is well-documented. 22-25
In the field of TMD, self-care has been mentioned in several citations as an important part of
treatment. 11,20,21 Recently de Leeuw et al.26 published a 30-year long-term follow-up of 99
TMD patients (with disc displacement) treated with mostly self-care techniques of
reassurance, exercises, and superficial heat. Satisfaction with the treatment outcome was
high. Also Toller 27 found that simple reassurance and explanation produced improvement in
over 80 percent of the TMD patients within three months. Cognitive behavioral (CB)
treatment has been shown to improve long-term outcomes for TMD patients. 28,29 Also,
minimal interventions have been used for the management of other chronic pain conditions.
Minimal interventions use information and education in the form of self-care materials
coupled with brief professional guidance at critical points and low-cost methods for patient
follow-up, such as brief telephone counseling. Most relevant to TMD, a series of studies has
shown minimal CB interventions for headache to be effective.30-32 There are three books
written for patients with self-care recommendations for TMD.33-35 There is a need for
research into the effect of self-care on TMD pain that meets today's scientific standards.
Research involving TMD treatment modalities is suspect because few research projects have
been properly controlled and blinded or use reliable and valid outcome measures.14,35,36 Most
of the research showing the high rate of clinical success in TMD therapy has evaluated
splints, either used alone or in combination with other therapies.37-45 However, many of these
reports did not follow procedures that are now considered to be essential in clinical trials.46-47
The most important of these are: the inclusion of a control group, randomization, use of
reliable outcome variables and measurement methods, data collection and analysis under
blind conditions, and adequate study sample size. The true therapeutic value of the different
treatment modalities has not been established beyond doubt. The inclusion of an appropriate
control group is particularly important in TMD research, because it has been reported that
the symptoms fluctuate cyclically, that there is a high rate of spontaneous remission, and that
the placebo effect may account for a great part of the patient's relief.38,48 The collection of
the data and their analysis under blind conditions are critical procedures that limit bias.49
Unfortunately this method has not been followed in most studies.35
Epidemiology
The epidemiological data for TMD reveals that even though large percentages of the
population have signs or symptoms, only an estimated 3.6 percent to 7.0 percent are
considered to have a problem that is serious enough to warrant treatment.50-56 Most studies
show that 60 percent - 80 percent of those presenting for treatment are women, and most of
these are between 20 and 50 years of age.
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Etiology
There is not yet a universally known cause of TMD. Most factors are not proven causal factors, but only have been shown to have associations with TMD. The masticatory system can have its dynamic balance changed so that the various components can become dysfunctional. Direct trauma as well as other anatomic, systemic, pathophysiologic, and psychosocial factors can disrupt the masticatory system's equilibrium and are associated with TMD. The dental profession historically has viewed occlusion as a primary etiologic factor for TMD. Occlusal features such as working and non-working posterior contacts and discrepancies between the retruded contact position (RCP) and intercuspid position (ICP) have been commonly identified as causes of TMD. Occlusion has long been seen as a major cause of TMD. Some have seen malocclusion as a cause, and other have seen centric relation-centric occlusion discrepancy as a cause. The literature does not explain the role of occlusion in the etiology of TMD,65-84 although many studies have tried to assess that role.71,75,81,85
Dental study casts (as well as the teeth) can give an indication of dental tooth wear over time. This can be an indicator of bruxism. Mounted casts in the presence of painful joints and/or muscles are not reliable due to joint pain, muscle pain, or joint edema.86 Even though mounted casts show the amount of tooth wear, they are not good indicators of the etiology of TMD, and should not be used specifically for the diagnosis of TMD.87
Skull studies88-90 and studies of patients with osteoarthritic change91-96 have correlated loss of molar support with bony changes in the TMJ. Both osteoarthritic changes and tooth loss increase with age; when age is controlled for, these associations disappear.85,97
Psychosocial factors also influence TMD by impacting a patient's capacity to function adaptively. There is some evidence that TMD patients experience more anxiety than healthy control groups, and also that patients with pain more than 3 months suffer more depression.73,99-103 Both anxiety and depression may not only result from and predispose patients to TMD, but also patients may present with mental disorders unrelated to TMD. A careful consideration of psychosocial factors is important for the management of TMD patients.
Diagnosis
Temporomandibular disorders first gained notoriety in the early 1930s, when James Costen, an ear, nose, and throat specialist, noticed that his patients' complaints were not limited to arthritis-like symptoms, but also included dizziness, ringing in the ears, headaches, and plugged ears.104 Costen's treatment was to provide for joint traction and stability, and it met with predictable success. This approached reinforced and firmly established the use of occlusal-biomechanical approaches as the primary method of treatment for facial pain and dysfunction problems that were collectively described as Costen's Syndrome. The occlusal-biomechanical method predominated until the 1960s.
In the 1960s and 1970s the psychophysiological theory became popular. This theory advocated that, except for obvious degenerative arthritic conditions, temporomandibular disorders were not due to occlusal abnormalities but had a psychological factor as a primary etiology. These symptoms were referred to as myofascial pain dysfunction syndrome. In the late 1970s and 1980s, the intracapsular problems associated with the TM apparatus were more clearly defined by a series of anatomic and radiographic studies. This led to the conclusion that patients did not have a single syndrome, but had many different problems, including internal derangements, osteoarthritis, and myogenesis disorders, chronic pain, and other orofacial sensory disturbances.
The American Academy of Orofacial Pain has established a classification system based on the International Headache Society (IHS) classification of head, neck, and neuralgic pain.105 Clinical diagnostic criteria are included for each diagnostic disorder. Even though examination findings can vary from doctor to doctor, a commonly used method for diagnosing TMD is a thorough history and examination.106
Electrodiagnostic devices measure signs, not symptoms. A click and an abnormal opening pattern can be measured whether symptomatic or not. Asymptomatic clicks are common to the general population.107-109 Imaging, in the form of axially corrected tomographic radiographs, and magnetic resonance imaging (MRI) of the TMJs can both give additional important information in the diagnosis of TMD.
Treatment
All of the above controversies come down to the most important one, how do we treat our patients? Some practitioners state that there is a high prevalence of TMD, and if not treated will progress to more degenerative and debilitating levels of disease. Some practitioners say that occlusion is the etiology of TMD and that the occlusion must be treated. Other clinicians recommend a combination of clinical treatment such as medications, physical therapy, interocclusal appliance therapy, and self-care instruction to the patient. Joint lavage is the most common surgical recommendation.
Science is not absolute, and what we thought was good, scientifically based treatment at a given period in time may be shown to be incorrect at a later period of history. It is in this light that the ethical issue of "do no harm" comes into play. There is the concept of conservative (reversible) versus invasive or irreversible treatments. Studies show that many TMD patients achieve good pain relief with reversible therapy such as behavior modification, physical therapy, medication, and orthopedic appliances. 20,110-112 These conservative therapies also provide good long-term results.113-115
If good results can be demonstrated with these conservative therapies, then other therapies such as orthodontics, full-mouth reconstruction, and orthognathic surgery need to be evaluated as to their risk and benefit to the patient.116 Ethics would seem to dictate that treatment can benefit some patient equally with less risk, then that would be the preferred choice.
Management
Management of TMD has been primarily based on treatments selected by the clinician's specialty or personal bias, rather than on science.117,118 However, there are few prospective clinical trials providing guidance, yet there is the need for further research for the benefit of our patients.
The scientific literature seems to support that TMD can be a self-limiting disorder that affects patients mostly between 30 and 50 years of age.48-54 For TMD patients, the model of low back pain management has been proposed.32 An accurate diagnosis, counseling the patients to reassure them that the disorder is manageable, and good medical support to reduce pain using medications, splints, and physical therapy, as well as a home care program that instructs the patients on what they can do for their problem will allow the doctor and patient to manage the disorder in many cases.
In the United States, it is becoming more common for prosthodontists, oral surgeons, and orthodontists (especially those graduating in the past 10 years from accredited specialty programs) to refer TMD patients to dentists that have special education and experience in TMD, although some patients may eventually need those other services. The dental profession has the responsibility for the diagnosis and treatment of TMD. Keeping abreast of the current scientific literature on TMD will help raise our standards.
Author / Greg Goddard, D.D.S., is Dental Director of the Native American Health Center in
San Francisco, California, and Assistant Clinical Professor in the Center for
Temporomandibular Disorders and Orofacial Pain at the University of California, San
Francisco. He has been a Diplomate of the American Board of Orofacial Pain since 1995.
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