When medical insurers toss those `weird` cases back to the dental office, are you the first person attempting to explain temporomandibular disorders to pain-maddened patients?
Ann-Marie C. DePalma, RDH, BS
Your first patient this morning is a 33-year-old female. You have seen her several times previously as a six-month recall patient. This morning, while reviewing her medical history, she informs you that she has been experiencing headaches and earaches for the past several months. She recently went to her physician who, upon examination, could find nothing obviously wrong. He suggested that she see an ENT because of the ear symptoms. She did, and he diagnosed that she may have TMD. She had never heard of it. Since the ENT explained it was a "dental situation," she wanted to know your opinion and explanation of it. Since you work in a state where general supervision is allowed, and today just happens to be the day the doctor is attending a continuing education seminar out of town, the patient cannot ask him. What would you do?
As hygienists, many of us are not aware of the signs, symptoms, and treatments available for patients who may have TMJ (the more appropriate terminology is TMD - Temporomandibular disorders). TMJ refers primarily to the jaw joint proper, while TMD is the disease process. TMD is an area of dentistry fraught with controversy. This article briefly will try to answer some of the more common questions asked regarding TMD.
What is TMD?
Temporomandibular disorders are a group of conditions, often painful, that affect the temporomandibular joint (jaw joint) and/or the muscles of mastication. The temporomandibular joint is composed of the temporal bone of the skull and the mandible (lower jaw). Separating the two is a cartilaginous material known as the meniscus or disc. The disc allows for movement of the joint in several positions.
The disc separates the joint into upper and lower joint spaces. The upper joint space is the area between the temporal bone and the disc and is where translation of the joint occurs (the gliding forward motion of the joint at approximately 25 mm of opening). The lower joint space, the area between the disc and the mandible, is where rotation of the joint occurs (the rotating motion of the joint). Not only does the joint rotate and translate, it moves in a lateral, side-to-side movement known as excursion. The disc itself is avascular, dense, fibrous connective tissue.
The primary muscles of mastication involved in the TMD process are the Masseter, Ptyergoids (internal and external) and the Temporalis. Other muscles of mastication are involved in the process, but not as intensively.
What is the patient population for TMD?
It has been estimated by the National Institutes of Health that some form of TMD affects approximately 10 million people. The most predominately affected are women between the ages of 20 and 40, although many men and older patients also suffer from it.
What are the symptoms of TMD?
A variety of symptoms is one of the reasons TMD is such a difficult disorder to diagnose and treat. Two patients may exhibit an entirely different set of symptoms. TMD also is known as the "imposter disease," since a lot of the signs and symptoms mimic other disorders.
The most obvious symptoms involve the function of the joint, such as in chewing or talking. Pain from the joint proper or from the muscles usually is elicited upon wide opening, chewing hard on crunchy foods (although any chewing can bring about a pain episode), and/or prolonged talking. It also can be seen as a limitation of opening (a normal opening range is approximately 40-50mm of opening) and as a deviation in opening (normal opening pathways usually are straight).
Nonfunctional symptoms can relate to muscle pain of the face, neck and upper back/shoulders, grating and ringing noises in the ears, and a feeling of fullness or itchiness in the ears.
What are the types of TMD?
TMD can be grouped into basic categories, all of which may have subsets and a variety of dental/medical treatments. TMD can be classified as a myofasical pain dysfunction (MPD), an internal derangement (with a reducing or non-reducing disc), an inflammatory disorder or a growth disorder. An MPD patient may exhibit with muscle inflammation and guarding/splinting, a chronic contracture of the elevator muscles or a fibrous ankylosis of the muscles. An inflammatory-disorder patient may have other joints that are affected by a generalized or localized inflammatory disorder, such as lupus, synovitis or arthritis. A patient with a growth disorder could possibly have a developmental or an acquired growth disorder or a tumor/neoplasm.
The most common types of TMD are MPD and internal derangement. Internal-derangement patients are divided into two categories: reducing joint or non-reducing joint.
A reducing joint is one that exhibits a click or pop on opening. The disc is abnormally placed on closure, the patient opens and hears the click or pop. This means the disc has returned to its normal functioning position on the condyle. Upon closure, the patient feels or hears the disc "pop off" thus resuming its abnormal position.
However, in a non-reducing joint, the disc is abnormally placed on closure and, upon opening, the patient "hits" into the disc and the condyle cannot navigate around it, thus producing a limited opening and often pain. The presence of clicking and popping in and of itself is not an indication for treatment. Treatment is begun only if there is pain and limited range of motion.
How is TMD diagnosed?
Looking, listening, and feeling are the three hallmarks of TMD diagnosis. Listening to the patient, both clinically and through a thorough medical and dental history, can elicit much information.
If a patient tells you that he or she has a vague pain running down the cheek, it possibly could be an MPD situation. However, if the patient says that there is a sharp, shooting pain in front of the ear, then this could possibly be an internal derangement. This is by no means a definitive diagnosis, but it can guide you in a direction.
Next, a full clinical exam is performed including evaluation of the opening, closing and excursive range of motions (ROM), and any pain that may or may not be elicited. Palpation of the joint for crepitus (the rubbing together of two bones) and the muscles for spasming or trigger points (focused areas of hyperirritability within muscles and/or fascia) also can be performed.
Radiographs ranging from panorex to transcranials to tomographs also can be helpful in determining if there are any osseous changes. Within the last several years, CT scans (computed tomography) and MRI (magnetic resonance imaging) have been useful in diagnosis of both the hard and soft tissue structures of the joint. Both have a variety of pros and cons for their usage varying from cost, to radiation (CT), to claustrophobic conditions (MRI). The MRI, however, currently is the "gold standard" of non-invasive diagnostic techniques. There also are many high tech diagnostic modalities used that may or may not be helpful.
How is TMD treated?
Depending on the actual diagnosis, there are a variety of treatment options available. These, however, should be done in the most conservative manner possible, proceeding from least invasive procedures to the more complex invasive procedures. Since TMD is fraught with controversy and even the so-called experts really don`t know the best method of treatment, patients should proceed with caution.
Treatment can and should involve a multi-disciplinary team approach involving several different specialties. Treatments should continue for a period of three to six months before giving up on a chosen method. TMD patients, many times, worsen when treatments are initiated before they see any improvements. Conservative non-invasive treatments should be pursued for one year without substantial improvement before invasive procedures are initiated.
Initial therapy can include limitation of the diet to soft food, limiting talking and/or faulty habits (excessive singing, gum chewing, cradling the phone), anything that allows the jaw and the muscles to rest.
Medications also can be used. These can include analgesics (non-opiates and opiates), NSAIDS, muscle relaxants, anti-depressants and anti-anxiety medications. The anti-anxiety and anti-depressants should be used only in conjunction with psychological counseling. Use of heat and ice to the joint and muscles also is helpful (patients often favor one approach or prefer a combination).
Physical therapy and chiropractic therapy also can be used. Non-traditional healing, such as acupuncture and holistic medicine have helped some patients. Psychological counseling for various issues can be helpful along with the use of biofeedback and relaxation therapies. Nutritional counseling can be beneficial.
The use of dental appliances can be used alone or in combination with other therapies. Appliances or splints are as varied as practitioners and patients, ranging from upper to lower appliances, hard or soft appliances, repositioning splints or night guards for bruxing. No one appliance has been proven to be definitely better than another. It all depends on the patient`s diagnosis and the practitioner`s biases. They can, if worn extensively over a long period of time, cause occlusal changes such as open bites. Therefore, they are considered somewhat controversial and invasive. But most TMD patients use them with good results.
If the conservative treatments do not work within a reasonable amount of time or if there are definitive osseous changes seen on radiographs or MRI, surgery may be considered. Only 5 to 10 percent of TMD patients should seek surgical options. Surgery, as in general treatment options, should be considered in stages. These include muscle and joint injections (which can be both diagnostic and therapeutic), arthrocentesis (flushing of the joint), and arthoscopic and arthrotomy (open joint) surgical procedures. Each carries risks and benefits and should be carefully considered before being undertaken.
In the 1980s, surgical intervention of displaced and deformed discs was widely performed. Discs were removed and replaced with several different types of silicone-based implants. Since the TMJ is a load-bearing joint, time has proven these replacement materials were placed in error. Patients who have had the silicone-based discs or total joint replacements are now faced with problems similar to those confronting women who have had breast-implants. Further research is being undertaken to find the best materials and types of implants to help patients facing similar situations.
Is TMD covered under dental or medical insurance?
Temporomandibular disorders are medical conditions and should be treated as such. The TM joint is similar to every other joint in the body and is subject to the same medical conditions. However, medical insurance companies feel that, since there is a dental component and since the primary treatment practitioner is the dentist, it should be covered under dental. Dental insurance usually denies coverage and the patient is then caught in a vicious cycle.
Fortunately, this is beginning to change, albeit slowly. Many medical insurers now are providing some TMD coverage. Approximately 13 states have mandated insurance coverage for TMD. However, insurance companies only have to provide coverage for services that would be covered for other joints - surgery only, for example. Since coverage for TMD varies widely, patients must be as informed about their policies as soon as possible. If a claim is rejected, the patient should investigate the insurer`s claim-review process and appeal the case.
As a hygienist, what can I do for my TMD patients?
As a hygienist, you can play a vital role in the treatment of TMD patients. First, having a thorough understanding of the disease process is important. Armed with that information, you can educate your patients so that they will have a better understanding of their own situation. Educated TMD patients are often the best patients, because, with more knowledge, they are more in control of their disease. Also, patients often share information with the hygienist that they feel uncomfortable discussing with the dentist.
All new patients and recall patients can be evaluated for TMD. A simple evaluation can be done as part of the regular head and neck exam. This can include palpation of the joint and muscles, observing ROM and evaluating parafunctional habits, bruxism, tooth-wear patterns, facets, mobility patterns and malocclusions. During a detailed exam, evaluation of the ROM, determination of the overjet/overbite presence and midline positions can be done along with the above. Notation of the coordination and symmetry of opening, closing and lateral excursive movements also can be accomplished as well as evaluation of skeletal symmetries of the cranial/facial complex.
For TMD patients who are in active treatment, the hygienist can obtain the names, addresses and phone numbers of all of the patient`s treatment providers in order to contact them as needed during treatment. Progress notes as to the patient`s symptoms and ROM can be noted in the treatment record for comparison as treatment progresses.
In terms of actual hygiene therapies for TMD patients, there really are no set guidelines. The treatment is varied according to the patient`s needs. Some patients like to use heat after dental treatment while others prefer ice. Limiting the length of the appointment and the time the patient is open and the use of a mouth prop often help. However, some patients prefer longer appointments.
Recommendation of the use of pre/post-operative medications, such as analgesics or anti-inflammatories as the patient needs and is allowed, also is beneficial. Many patients find the use of stress-reduction techniques and cervical/lumbar supports helpful during dental treatments.
For home-care instruction, pedo brushes, floss holders, oral irrigators and electric toothbrushes can be recommended for use as needed. Removable oral appliances can be cleaned with commercial denture cleaners and brushed daily. The patient may have difficulty with home care so a three- to four-month recall program should be established.
Temporomandibular disorders are varied and clouded in controversy. The best that we can offer our patients is to be informed about TMD and help educate and support them so that they can manage their disease. There are no true experts in the TMD field. Only the patient can be the true and final judge of all of the controversies.
Anne-Marie C. DePalma, RDH, BS, is the founder of the TMJ Network. The network is composed of TM patients, families, and professionals who exchange information. For more information, contact Ms. DePalma at (781) 279-1146 in Stoneham, Mass.