Diagnosis and treatment of temporomandibular disorders

Current concepts and recommended treatment for temporomandibular disorders (TMDs) and temporomandibular joint pain and dysfunction have evolved over time. This article attempts to distill the current information for this often confusing topic into relevant clinical issues that will allow the general dental practitioner to be better able to diagnose and interpret clinical findings, and institute a therapeutic regimen that will provide needed relief to patients suffering from TMD dysfunction. Current management methods, both surgical and nonsurgical, are reviewed and discussed.     

Post-academic dental specialties 6. Gnathology: profile and competencies of the specialist in temporomandibular disorders and the general dental practitioner

The guiding principle in postgraduate programmes is to enable dentists to build on and extend the competencies acquired in the basic academic programme. This requires the examination and treatment of sufficient numbers of patients. Given the incidence and prevalence of temporomandibular disorders and orofacial pain, basic academic training will be limited to referral or to diagnosing and treating acute and non-complex cases, whereas the specialist in temporomandibular disorders(TMD) will focus especially on chronic temporomandibular disorders and orofacial pain, in a multidisciplinary setting. In case of orofacial pain, the general dental practitioner is the obvious person to determine if there may be odontogenic causes. The specialist in TMD can either advise the general practitioner or coordinate the patient's care him- or herself. In order to be able to perform well within a (partly medical) multidisciplinary setting there is a need for differentiated education, above and beyond the basic academic curriculum. The competencies of the specialist in TMD should comprise care in a broad sense, providing evidence-based care and educating patients, being able to work well within an organization, clinical reasoning and professional development through life-long learning and teaching. The specialist in TMD may either work in private practice or in special dental care clinics.     

Temporomandibular disorders: associated features

Temporomandibular disorder (TMD) encompasses a number of clinical problems involving the masticatory muscles or the temporomandibular joints. These disorders are a major cause of nondental pain in the orofacial region, and are considered to be a subclassification of musculoskeletal disorders. Orofacial pain and TMD can be associated with pathologic conditions or disorders related to somatic and neurologic structures. When patients present to the dental office with a chief complaint of pain or headaches, it is vital for the practitioner to understand the cause of the complaint and to perform a thorough examination that will lead to the correct diagnosis and appropriate treatment. A complete understanding of the associated medical conditions with symptomology common to TMD and orofacial pain is necessary for a proper diagnosis.     

Hemicrania continua presenting as temporomandibular joint pain

Patients presenting with unilateral facial pain present a unique diagnostic challenge for dental practitioners. As dentists, we routinely look for maxillofacial pathology, temporomandibular disorders, or odontogenic abscesses as the etiology of pain in these patients. However, several types of the chronic daily headaches may also produce signs and symptoms similar to dental or maxillofacial pathology. One such headache, hemicrania continua, is typically characterized by a continuous, throbbing, unilateral headache and is completely responsive to treatment with indomethacin. In this article we present 2 cases in which initial symptoms suggested temporomandibular disorders but the patients were ultimately diagnosed with hemicrania continua. A brief review of hemicrania continua and its treatment is included. Thoroughly understanding this entity and realizing that it may present as temporomandibular pain will allow us to more readily diagnose the condition and implement effective treatment.     

Diagnosis and therapy of temporomandibular disorders

Temporomandibular disorders is a collective term covering a number of related disorders affecting the temporomandibular joints, masticatory muscles, and related structures. The study reviews the recent knowledge about the diagnosis and complex therapy of temporomandibular disorders on the basis of published scientific literature. The role of general dental practitioner in management of patients with temporomandibular disorders is emphasised. Since a lot of patients turn to them for a first consultation, they should be familiar with the main diagnostic aspects of these disorders. The non-invasive conservative therapeutic possibilities are described in detail and they are suggested in the initial phase of the treatment. The disorders, which usually need further consultations with other specialist, are also described.     

Dental care for the patient with bipolar disorder

Chronic mental illness and its treatment carry inherent risks for significant oral diseases. Given the shift in treatment regimens from the traditional institutionally based approach to more community-focused alternatives, general dental practitioners can expect to see and be asked to treat patients with various forms of psychiatric disorders. One such group consists of patients with bipolar disorder (including type I bipolar disorder or manic-depressive disorder). The purpose of this paper is to acquaint the dental practitioner with the psychopathological features of bipolar disorder and to highlight the oral health findings and dental management considerations for these patients. Bipolar disorder is considered one of the most treatable forms of psychiatric illness once it has been diagnosed correctly. Through a combination of pharmacotherapy, psychotherapy and life-adjustment skills counselling, these patients are better able to understand and cope with the underlying mood swings that typify the condition and in turn to interact more positively and progressively within society as a whole. Both the disease itself and its various pharmacologic management modalities exact a range of oral complications and side effects, with caries, periodontal disease and xerostomia being encountered most frequently. It is hoped that after reading this article the general dental practitioner will feel more confident about providing dental care for patients with bipolar disorder and in turn to become a vital participant in the reintegration of these patients into society.     

An evidence-based assessment of occlusal adjustment as a treatment for temporomandibular disorders.

STATEMENT OF PROBLEM: Occlusal adjustment therapy has been advocated as a treatment modality for temporomandibular disorders. In contrast to this position, a panel at the 1996 National Institute of Health technology assessment conference on TMD indicated that no clinical trials demonstrate that occlusal adjustment is superior to noninvasive therapies. PURPOSE: This article summarizes the published experimental studies on occlusal adjustments and temporomandibular disorders. MATERIAL AND METHODS: Eleven research experiments involving 413 subjects with either bruxism (n = 59), temporomandibular disorders (n = 219), headaches and temporomandibular disorders (n = 91), or chronic cervical pain (n = 40) were selected for critical review from the English dental literature. RESULTS: Three experiments evaluated the relationship between occlusal adjustment and bruxism. Six experiments evaluated occlusal adjustment therapy as a treatment for patients with primary temporomandibular disorders. One experiment looked at occlusal adjustment effect on headache/temporomandibular disorder symptoms; another looked at its effect on chronic neck pain. Most of these experiments used a mock adjustment or a comparison treatment as the control condition in adults who had an existing nonacute general temporomandibular disorder. Overall, the data from these experiments did not demonstrate elevated therapeutic efficacy for occlusal adjustment over the control or the contrasting therapy. CONCLUSION: The experimental evidence reviewed was neither convincing nor powerful enough to support the performance of occlusal therapy as a general method for treating a nonacute temporomandibular disorder, bruxism, or headache.     

Care of patients with temporomandibular disorders: an educational challenge

The ability to recognize, evaluate, and manage patients with temporomandibular disorders is an important component of general dental practice. Therefore, information about these disorders should be a basic part of the dental curriculum. Although most dental schools do include this subject in their educational programs, its teaching typically involves the presentation of didactic material in formal lectures or in seminars. This teaching, however valuable, rarely includes the "hands-on" clinical experience of actually caring for this patient population. To address this lack of clinical experience, the Department of Oral Diagnostic Sciences of the School of Dental Medicine at the University at Buffalo has also developed a special elective program to offer dental students in their final undergraduate year the opportunity to obtain such experience.     

Dental symptomatology associated with connective tissue anomalies

Subjects affected with inherited disorders, of the connective tissue make up an important population, carrying high risks as to distinct aspects of oral health and dental treatment. These generalized conditions may produce serious clinical symptoms in different orofacial structures, which have to be dealt with, or anticipated, when considering dental treatment. The most prevalent disorders result from deficiency of Type I collagen, an important extracellular matrix protein regulating both the structural and mechanical properties of most of the orofacial tissues. Recurrent jaw fractures, an increased liability for development of temporomandibular disorders, periodontal disease and mucosal fragility, an abnormal tooth color and/or shape, and pulp obliteration may feature as major clinical manifestations of the respective disorders. Deficiency of fibrillin, a protein providing soft tissues with elastic capacities, may produce a long face with a high and narrow palate, an increased liability for the developnet of temporomandibular disorders and periodontal disease, and root dsyplasia. Whenever present, these manifestations/risk factors have to be integrated in dental treatment strategies. In cases with high risk for cardiovascular complications, specific preventive measures, such as cardiac output monitoring and the administration of appropriate local anesthetics, have to be taken before starting any invase dental treatment. The present paper aims to provide the practitioner with an appreciation of the most prevalent inherited disorders of the connective tissue with their respective genetics, molecular aspects of pathology, medical and oral manifestations, and guidelines for dental treatment.     

Routine and emergency management guidelines for the dental patient with renal disease and kidney transplant. Part 1

The number of kidney patients is increasing in all developed countries, mainly due to the increase in patients with type II diabetes. These patients may be asked by their renal physician to attend their general dental practitioner for an oral review prior to undergoing further renal treatment. Dental surgeons working in the primary care setting will be required to manage patients who are at various stages of renal support, whether pre-dialysis patients with chronic kidney disease (CKD), dialysis patients, and also those who have had a kidney or kidney and pancreas transplant. In addition, dental practitioners may be faced with having to deal with the emergency management of such patients attending their practices in acute pain. Clinical Relevance: This paper aims to provide the general dental practitioner with the necessary knowledge to manage renal patients, and outlines the guidance regarding the criteria for referral, work up procedure and dental management of such patients.     

The MRI Study as a Diagnostic and Therapeutic Indicator in the Non-Surgical Management of Temporomandibular Joint Disorders: Phase I Management—A Case Report

The dental profession frequently points to occlusion, muscle disorders or psychological stress as principal causes of temporomandibular joint (TMJ) disorders. Diagnosis and management is confusing, and no general consensus exists. Recent advances in magnetic resonance imaging (MRI) have allowed a means of evaluating large numbers of patients for internal derangements in an objective non-invasive fashion. This has unequivocally confirmed prior arthrographic and surgical observation that partial or complete dislocation of the articular disk with condylar compression of sensitive superior posterior joint space neurovascular elements is the principal pathophysiologic mechanism of TMJ disorders. TMJ disorders have been shown to be a general progression of degenerative joint disease characterized by joint space compression with displacement and degeneration of articular hard and soft tissues, most commonly the result of trauma. This article illustrates how the author has combined several different dental and medical diagnostic procedures with clinical therapeutic measures to manage patients to improved function and remission of symptoms by controlling the position of the joint hard structures in an objective fashion.     

Rheumatoid Diseases and the Temporomandibular Joint: A Review

Rheumatic diseases cause patients to seek care for musculoskeletal pain or dysfunction, as well as other problems. Rheumatic diseases are musculoskeletal and connective tissue disorders demonstrating chronicity, variability, and periods of exacerbation and remission. Practitioners must be aware of the features of many of these diseases and be able to address patients' concerns, especially as they relate to the temporomandibular joint, temporomandibular dysfunction, and/or myofascial pain. Rheumatoid arthritis and systemic lupus erythematosus are sufficiently common to necessitate the dental practitioner having a working knowledge of both of these diseases. This paper presents the salient points of the general pathology of rheumatoid arthritis and systemic lupus erythematosus and specifics of temporomandibular involvement in rheumatoid arthritis.     

Specialty dentistry for the hemophiliac: is there a protocol in place?

Restorative dental care for the hemophiliac patient is of paramount importance for the fact that advanced dental conditions and subsequent treatments prove to be more complicated and risky. Quite often, dental health is neglected by hemophiliacs for fear of bleeding during procedures. Surprisingly, even dental specialists avoid these candidates and contribute to the conversion ofa simple dental patient to an oral surgical patient. The complexities involved in diagnosing a bleeding disorder and the rarity of a standardized protocol to handle such patients contribute to this problem. This article prescribes a simple protocol to diagnose bleeding disorders and a modified scheme for endodontic and periodontal therapy in a hemophiliac patient.     

The gap between dental education and clinical treatment in temporomandibular disorders and orofacial pain

Implementation of research findings in patient care ideally will follow in a continuous cycle, and clinical questions from practitioners should stimulate research. Even in the most optimal situations, there will be a gap between the steady flow of new findings from research and their eventual implementation in clinical practice. In the clinical practice of temporomandibular disorders and orofacial pain (TMD/OFP) simple cases outnumber the more complex cases by far. Therefore, research implications for the general dental practitioner, whose patients are rarely represented in research populations, may differ from what is published and taught. Treatment options like counselling, occlusal treatments (reversible as a rule and irreversible by exception) and physiotherapy can be very successful in the hands of the general dental practitioner. European dental schools should define additional amendments to the recently proposed profile and competencies for the European dentist, in order to focus on the relevant and current knowledge on temporomandibular disorders and orofacial pain. These amendments should address the adequate diagnosis and management of non-complex TMD cases and the need to refer to a TMD/OFP specialist in complex cases. Professional organizations such as the European Academy of Craniomandibular disorders can endorse better TMD/OFP education and training.     

An update on the controversies in bacterial endocarditis of oral origin

OBJECTIVES: The aim of this review was to evaluate the evidence implicating dental procedures in bacterial endocarditis (BE) development and the basis for antimicrobial prophylaxis (AP). STUDY DESIGN: In this article, the literature is reviewed and meaningful findings about epidemiology, pathogenesis, and AP guidelines for BE of oral origin are highlighted. Available results are used to formulate clinical recommendations for the dental practitioner. RESULTS: The nature of dental procedures that cause bacteremia, patients at risk for BE, and the effectiveness of AP guidelines, continue to be points of controversy. There appears to be further evidence to support the important role of oral health status in the prevention of BE of dental origin. CONCLUSIONS: One objective of the dental practitioner in caring for patients at risk for BE should be to promote oral health care. There are no hard data on which to scientifically base the need for AP in patients at risk for BE. However, it would appear prudent, at least from the medicolegal perspective, to provide AP, at least to persons with previous BE or prosthetic heart valves and to those undergoing oral surgery, periodontal treatment, or implant placement.     

Insurance coverage for the treatment of craniomandibular disorders

The successful dental practitioner must be knowledgeable in all aspects of insurance claims administration. The efficient management of insurance claims for the treatment of temporomandibular joint disorders (TMJ) and myofascial pain dysfunction syndromes should not be considered an exception. The information presented in this article is intended to provide dental practitioners who treat TMJ disorders and myofascial pain dysfunction syndromes with a practical, efficient, and proved method of maximizing insurance reimbursement for their patients' TMJ and myofascial pain therapy.     

Prevention of endocarditis: communication between doctors and dentists.

Successful implementation of guidelines to prevent infective endocarditis (IE) depends upon the dental practitioner being aware of which of his patients are at risk. This was studied by sending a questionnaire to at risk patients and their dentists in the Grampian area. Of 145 respondents (53% response rate) with predisposing cardiac disorders, only 63 reported having seen their dentist in the past 2 years, although for dentate patients 47/61 had seen a dentist in the past 2 years. The dentists of 59 of these cases were then surveyed and replies received in 53 cases. Nineteen had no record of the patient having a cardiac disorder. In only 17 of the remaining cases was information on the cardiac disorder well enough recorded to warrant prophylaxis for at risk procedures. The dentist was usually told of the disorder only by the patient. Sixty-three per cent of dentists felt that communication between them and the patient's doctor was unsatisfactory. It is necessary to improve doctor/patient/dentist communication so that current recommendations on prophylaxis can be implemented to the full. This should be done through the patient's GP or consultant, who should communicate directly with the dentist. Details could also be inserted on warfarin cards and 'cardiac alert cards' expanded.     

Long-Term Results of Appliance Therapies in Anterior Disk Displacement with Reduction: A Review of the Literature

The diagnosis and management of temporomandibular disorders (TMD) have been a source of controversy in the dental community for decades. This controversy has been especially acute in the management of patients with anteromedial disk displacement (ADD) with reduction. This article presents a review of the literature specifically concerning the long-term results of appliance therapy in ADD with reduction patients. The literature review identified the failure of many past investigators to conduct scientifically well-designed studies or to use comparable criteria. However, from the evidence examined, both appliances seem to be able to decrease muscle and joint pain and increase mandibular function. The anterior repositioning splint seems to be superior to the flat-plane occlusal splint in eliminating reciprocal clicking and palpatory tenderness of the temporomandibular joint, The recapture of the disk is permanent in only a small percentage of patients suggesting that the use of irreversible procedures must be carefully evaluated.     

Longitudinal Changes in Temporomandibular Disorders in Young Adults: Indication for Systematic Temporomandibular Joint Screening

OBJECTIVE: The aim of this study was to investigate longitudinal changes in temporomandibular joint function in young adults in terms of clinical and subclinical temporomandibular disorders (TMD), and to identify patients at risk for clinically manifest TMD. SUBJECTS AND METHODS: Ninety-one consecutive dental students were surveyed over a mean period of 2.4 years. The temporomandibular joint and masticatory muscles were analyzed by means of the Manual Functional Analysis. Examinations took place during the first (T1) and sixth (T2) terms of dental training. RESULTS: The prevalence of subclinical TMD decreased from 16.5% to 15.4%, while that of clinical TMD rose from 19.8% (T1) to 24.2% (T2). Subjects with subclinical TMD at T1 showed the most pronounced fluctuation, and were about equally likely to improve, remain stable or deteriorate. The incidence of clinical TMD in the subclinical TMD-group was 28.6%, that is, almost every third subject developed clinical TMD over a 2.4-year period. CONCLUSIONS: Should clinical TMD become apparent during orthodontic treatment, the patient might attribute it to the therapy, rather than to the subclinical disorder at baseline. It thus makes therapeutic and forensic sense to carry out systematic TMJ-screening in all adult patients prior to orthodontic treatment, in order to identify patients at risk.