Researchers make headway in defining the parameters of TMD diagnosis and treatment. This science and research can help us find resources toward collaborative care.
by Stacia Ewing, RDH, BS
Consider this scenario: A patient presents for her recall appointment with a complaint of jaw popping and pain. The dentist evaluates the patient and recommends fabrication of an occlusal splint. The patient returns in three months and reports that the splint helped for a few weeks but then the pain returned. The dentist recommends continuing use of the splint. The patient returns in another three months and tells the hygienist that she is managing the pain herself because the splint “just doesn’t work.”
Names and Variations
TMD, temporomandibular disorders - also known as TMJD, temporomandibular joint dysfunction - can no longer be considered easily treated simply by the fabrication of a splint or mouthguard. Researchers are finding that this is a much more multifaceted condition than originally thought, and many studies are taking a more holistic approach to diagnosis and treatment.1 Other names for temporomandibular disorders are Costen’s syndrome (also known as TMPD, or temporomandibular joint pain and dysfunction syndrome), MPD or myofascial pain dysfunction syndrome, CMD or craniomandibular disorders, myofacial pain dysfunction (note different spelling than MPD), facial arthromyalgia, PDS or pain dysfunction syndrome, orofacial pain, craniofacial pain, and probably more!
The TMJ Network
The TMJ network consists of the condyle of the mandible, separated by cartilage and disc joining the temporal bone, thereby comprising the joint, which directly interacts with the temporalis, masseter, medial, and lateral pterygoid muscles (plus others indirectly) and their associated nerves, tendons, ligaments, and connective tissue - all of which are linked to the teeth. This particular joint is further complicated by the fact that there are two, working in tandem. Also, the close proximity to the ear may add another layer of involvement.
Dysfunction is characterized by pain and/or immobility somewhere in the network. Symptoms may include joint pain, face pain or swelling, ear pain, joint popping or clicking, locking of the joint, stiffness, lumps in the facial musculature, headaches, neck or back pain, hearing problems, vision problems, and changes in the occlusion.
Categories of Disorders
The National Institute of Dental and Craniofacial Research (NIDCR) of the National Institutes of Health (NIH) report that there are 10 million sufferers of TMD in the United States, of which 90 percent are women of childbearing age.2 It is generally considered that TM disorders fall into three categories which may occur exclusively or in combination:
- Myofascial pain: Concerning the muscles involved in joint function and may extend to muscles in the neck and shoulders. This is the most common cause.
- Internal derangement of the joint: Displaced disc, dislocated jaw, or injury to the condyle.
- Degenerative/inflammatory conditions: Various forms of arthritis, synovial membrane inflammation.
It is possible for these conditions to exist without any symptoms.
The Systemic Link
Studies indicate that TM disorders are often linked with other health problems such as chronic fatigue syndrome, fibromyalgia, sleep disorders, irritable bowel syndrome, chemical sensitivity, chronic rhinitis, and mitral valve prolapse.2,3 These health problems, particularly in women, seem to have a connection with increased sensitivity to pain, which is leading researchers to study gender, whole nervous system mechanisms, genetics, estrogen, antidepressants, and psychological interventions. Some medical conditions such as Ehlers-Danlos syndrome, dystonia, Lyme disease, and scleroderma may affect the TMJ.3
Causes and Treatment Possibilities
The causes and treatment possibilities of TMD reflect a multidisciplinary approach. For example, the classic dental office case of the patient who bruxes at night and presents with pain symptoms may warrant a splint or guard. Some studies show that a tiny anterior splint may work better than the traditional type, while other studies have not found enough evidence to report that splint therapy is at all effective.4 If this type of therapy is considered, it may be worthwhile to have the patient try an inexpensive boil-and-bite mouthguard to first determine tolerance, since some people cannot keep a splint in the mouth.
However, this is just a singular approach. Generally, TMD has moved beyond the realm of dentistry to include rheumatology, physical therapy, acupuncture, osteopathy, otolaryngology, psychology, neurology, allergy, and more. Cause, effect, and treatments vary depending upon the specialty consulted.
To continue the example, some believe bruxism is brought on by stress, so the stress should first be addressed by a psychologist, with possible intervention by a physical therapist or massage specialist. The bruxism could be caused by malocclusion, so an orthodontist should be consulted in that case. If the bruxism is the result of a chronic pain condition, rheumatology would be the specialty of choice. It is important that primary and general health-care providers, especially dental hygienists who are often the first contact, become educated about TMD so they can provide the best direction of care for patients. In the dental office, it is particularly significant to have a complete medical/dental history. It may even be valuable to have an additional questionnaire for TMD patients, highlighting the characteristics and co-existing conditions that are unique to this disorder.
The Multifaceted Nature Of TMD
Practitioners need to accurately evaluate these patients with a sensitivity to the multifaceted nature of TMD. Think outside the box of dentistry. Consider referring and consulting with other disciplines. In addition to the history, physical examination (with thorough palpation) should include evaluation of tissues, musculature, neurological functions, auditory performance, speech, swallowing, pain, functional range of motion, occlusion, periodontal status, and parafunctional habits. Radiographic and other imaging diagnostics may be indicated. Pyschosocial assessment may be helpful and referred as necessary. Any obvious dental needs - such as prophylaxis, periodontal, and/or restorative - should be addressed only with consideration for the TMD diagnosis and treatment, since the effects of doing dental work may exacerbate the TMD.
Science-based research is basically in its infancy concerning the multifaceted aspects of TMD, but a few points are generally accepted:
- TMD is not caused by orthodontics.
- An injury, such as whiplash, can trigger TMD.
- Disease, such as arthritis, can be a causative agent.
- Wide opening of the mouth, such as during certain dental procedures, and chewing hard foods can cause or exacerbate TMD.
- Intubation during surgery can cause or exacerbate TMD.
- The majority of TMD treatment seekers are women, and the problem is usually myofascial pain dysfunction rather than a joint disorder.5
Myofascial vs. Myofacial
It is crucial that clinicians understand the different terminology of myofascial vs. myofacial. “Myo” means muscle, and “fascia” refers to the connective tissue that sheaths skeletal muscles. Myofascial pain is defined as the sensory, motor, and autonomic symptoms caused by myofascial trigger points.6 A myofascial trigger point is defined as a hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a tight band (the spot is painful on compression and can give rise to characteristic referred tenderness, motor dysfunction, and autonomic phenomena).6 Trigger points may be active (characterized by pain) or latent (characterized by tension, stiffness, and restricted range of motion).6 Myofacial refers to pain in facial musculature, but is actually an outdated term for TMD.
As stated earlier, the majority of patients seeking treatment for TMD have been determined to have myofascial pain syndrome. Much of the scientific literature for the past 10 years supports this finding. Even in cases where the joint is deranged or malfunctioning, it has been proposed that the first line of treatment should be to inactivate the trigger points.7 Skeletal muscle is the largest organ in the body and is a significant source of pain, but historically, this has been a neglected area of medical training and care. A good introduction to the explanation and treatment modalities of trigger point therapy is Myofascial Pain and Dysfunction: The Trigger Point Manual by David G. Simons, MD, Janet G. Travell, MD, and Lois S. Simons, MS, PT. Patients interested in this type of treatment should look for physicians, dentists, physical therapists, and massage therapists with specialized training in trigger point or myofascial therapy. Accredited programs are available through the National Association of Myofascial Trigger Point Therapists, www.myofascialtherapy.org. An intriguing aside that may have interest to dental hygienists is how this type of therapy impacts repetitive motion pain, which commonly plagues those in the dental field.
Begin With Conservative Treatment
In many cases, TMD is temporary and will go away on its own. It is best to begin with conservative treatments such as ice packs, moist heat, soft foods, avoiding extreme jaw movements, analgesics (such as ibuprofen), relaxation techniques (such as meditation and yoga), and gentle exercises. Over-the-counter appliances are not recommended. In the case of chronic TMD, it is most important to get the correct diagnosis and best identification of the cause(s) via properly executed evaluation procedures. If the TMD is ascertained to be fundamentally dental in nature, treatment may include occlusal adjustment or a splint. Splints can be either for stabilization (usually worn at night) or for repositioning (worn 24 hours). Professional and research consensus seems to indicate that stabilization splints can, in some cases, be helpful for pain management of TMD, but repositioning splints generally are not.3
Treatments Outside of Dentistry
Other treatments outside the field of dentistry include surgery, joint implants, acupuncture, physical therapy, massage (including specialized bodywork such as rolfing or the Alexander technique), trigger point therapy, biofeedback, cognitive behavioral therapy, psychotherapy, and different types of prescription medication such as for arthritis, depression, neuralgia, pain, and muscle spasm. Many clinical trials are currently underway to investigate the efficacy of these treatments. Currently, research indicates that most of these treatment modalities are not effective, with the exceptional of physical therapy,8 even in the case of osteoarthritis.9 Interestingly, a few studies indicate the positive effects of postural training on TMD.10,11 Many studies also have shown that patients who have reported ear problems, such as tinnitus or vertigo, have actually developed those symptoms from TMD.12 Clearly, there is symptomatic overlap with TMD and the surrounding structures, which strongly supports the multidisciplinary approach to treatment. Due to the difficulty of definitive diagnosis of underlying cause, it is recommended that conservative, reversible treatments are given first priority.
Researchers are beginning to make headway in defining the parameters of TMD diagnosis and treatment. We can look at the science and prevalence of this research to help us recognize and find resources toward collaborative care. Dental hygienists are in a distinctive position to be the first health-care providers in whom a TMD sufferer confides, and as such, can do a great service for these patients.
About the Author
S. Stacia Ewing, RDH, BS, has 26 years’ experience in dental hygiene, with diverse experience in private practice, public health, research, clinical instruction, recruitment, and continuing education. Currently, she does independent contracting, writing, proofreading, and is pursuing yoga teacher training. She can be contacted at [email protected].
1 Sarlani E, Balciunas BA, Grace EG. Orofacial pain - part II: Assessment and management of vascular, neurovascular, idiopathic, secondary, and psychogenic causes. AACN Clin Issues Jul-Sept 2005; 16(3):347-58.
2 National Institute of Dental and Craniofacial Research, part of the National Institutes of Health. Available at: www.nidcr.nih.gov. Accessed May 11, 2007.
3 The TMJ Association. Available at: www.tmj.org. Accessed May 11, 2007.
4 Al-Ani MZ, Davies SJ, Gray RJM, Sloan P, Glenny AM. Stabilization splint therapy for temporomandibular pain dysfunction syndrome. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD002778. DOI:10. 1002/14651858. CD002778.pub2.
5 Bermejo-Fenoll A, Saez-Yuguero R. Differential diagnosis of temporomandibular disorders (TMD). Med. Oral patol. Oral cir. Bucal (Ed.impr.).[online]. 2005; 10(5) [cited 2007-05-18], pp. 468-469. Available from: http://wwwscielo.isciii.es/scielo.php?script=sci_arttext&pid=S1698-4447200500014&1ng=en&nrm=iso. ISSN 1698-4447.
6 Simons DG, Travell JG, Simons LS. Myofascial pain and dysfunction: the trigger point manual. Vol.1. Upper Half of Body. 2nd Ed. Atlanta, Ga: Emory University 1998; 5.
7 Simons DG, Travell JG, Simons LS. Myofascial pain and dysfunction: the trigger point manual. Vol.1. Upper Half of Body. 2nd Ed. Atlanta, Ga: Emory University 1998; 252.
8 Furto ES, Cleland JA, Whitman JM, Olson KA. Manual physical therapy interventions and exercise for patients with temporomandibular disorders. Cranio Oct 2006; 24(4):283-91.
9 Nicolakis P, Erdogmus CB, Kollmitzer J, Kerschan-Schindl K, Sengstbrati M, Nuhr M, Crevenna R, Fialka-Moser V. Long-term outcome after treatment of temporomandibular joint osteoarthritis with exercise and manual therapy. Cranio Jan 2002; 20(1):23-7.
10 Wright EF, Domenech MA, Fischer JR Jr. Usefulness of posture training for patients with temporomandibular disorders. J Am Dent Assoc Feb 2000; 131(2):202-10.
11 Nicolakis P, Erdogmus CB, Kopf A, Nicolakis M, Piehslinger E, Fialka-Moser V. Effectiveness of exercise therapy in patients with myofascial pain dysfunction syndrome. J Oral Rehabil Apr 2002; 29(4):362-8.
12 Wright EF, Syms CA 3rd, Bifano SL. Tinnitus, dizziness, and nonotologic otalgia improvement through temporomandibular disorder therapy. Mil Med Oct 2000; 165(10):733-6.
Resources for Further Interest or Study
- www.nidcr.nih.gov - National Institute of Dental and Craniofacial Research (part of the National Institutes of Health)
- www.tmj.org - The TMJ Association; loads of information plus brochures titled “Dental Hygiene Considerations for Patients With Temporomandibular Joint Diseases and Disorders” and “What TMJ Patients Should Know About Dental Hygiene and Self Care.”
- www.tmjoints.com - Jaw Joints & Allied Musculo-Skeletal Disorders Foundation, Inc.
- Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 1. Upper Half of Body, Second Edition
- www.rolf.org - About rolfing bodywork
- www.oea.umaryland.edu/communications/magazine/2005/05Magazine_features.pdf - Article titled “Understanding Pain: Gender, Genetics, and Treatment” by Regina Lavette Davis about current research at the University of Maryland.