TMJ

Diagnostic Tools and Instrumentation

There is a variety of common diagnostic modalities employed by the health care practitioners to confirm (or deny) an initial diagnosis of TMJ which is based upon objective physical findings and subjective complaints. Some of these diagnostic modalities are more reliable than others. The following is a list of some of the most common ones.

Radiography

• Conventional Radiography (plain x-rays, including Panorex) is quick, painless, and relatively inexpensive. However, since they only show just the bony structure of the joint, they are generally useful for ruling out obvious pathological changes and disease processes.
• Transcranial and tomographic x-rays shows “slices” through the joint. When done properly and interpreted accurately, tomograms give a better view than plain x-rays. Tomography are more accurate unlike plain x-rays. They show the status of the bone. The tomogram provides a precise view of the temporomandibular joint by taking eight postage stamp serial views of the joint, slice by slice. Each view is taken at a slightly different level, thereby allowing the health care practitioner to view the condyle and temporal bone in great detail. In addition, the advantage of a “corrected cut” is the accuracy of the subject anatomy, without artifacts, and its reproducibility before, during and after treatment. The tomogram provides an accurate picture of joint functions and is useful for evaluating evidence of deformity, tumor, osteoarthritis or a previously healed condylar fracture. It does not provide a picture of the soft tissues of the joint.
• Computed Tomography (CT or CAT Scan) provides superb detail of bone in multiple directional planes, with a minimal dose of radiation. They are fairly expensive and provide a somewhat limited view of the disc and soft tissue. They also do not image the cartilaginous disc, ligaments and muscles. The CAT scan is considered one of the least effective tests for diagnosisng TMJ because it is extremely difficult to see the meniscus on a CAT scan.
• Magnetic Resonance Imaging (MRI) produces brilliantly detailed and accurate images of bone as well as soft tissue, and is widely considered the best single way to study the TMJ. No radiation is used; however, since sophisticated equipment is needed, MRIs are expensive and can be cost prohibitive — sometimes over a $1,000 for both sides.
• Arthrography allows the study of the position and function of the joint, including the disc. It involves the injection of contrast dye into the joint, followed by imaging using plain x-rays, tomograms, videotape, or a combination. A skilled examiner is a must, and the procedure can be very uncomfortable, but if done properly, arthrography can be an extremely accurate diagnostic tool.

Thermography    

The thermogram is a test that records heat and is allegedly used to locate areas of pain in suspected TMJ patients. The thermogram produces a dramatic, high-color, high-tech picture of the pain. The validity of thermograms in diagnosing any condition is hotly debated. A review of the medical literature indicates a clear lack of peer review support for this diagnostic technique and it should be viewed with a great deal of suspicion when it serves as a basis for diagnosing a TMJ injury.   

Filed under: Chronic Pain and TMJ, Cosmetic Dentistry, Dental Education, Diagnosis and Treatment, Diagnostics, Joint Imaging, Neuromusular Dentistry, Occlusion Connections, TMJ, tmj neuromuscular dentistry forum, TMJ Neuromuscular Forum, tmj neurouscular dentistry forum, TMJ Pain, TMJ Treatment, Tomography by Clayton A. Chan, D.D.S.
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The American Dental Association’s Council on Scientific Affairs has awarded surface electromyography (SEMG), Computer Mandibular Scanning (CMS), and Sonography its “Seal of Acceptance”, as diagnostic aids in the management of temporomandibular disorders.

The American Dental Association initially recognized the use of the Electromyographic and Computerized Mandibular Scanning Jaw Tracking Systems in January, 1986.  The equipment was manufactured by Myotronics-Normed, Inc., and carried the recognition seal of the American Dental Association.  These bio-instruments are recognized as safe and effective as aids in the diagnosis and treatment of muscle tension and pain associated with TMJ and MPD.  This recognition was never withdrawn or rescinded.  The recognition program, however was discontinued.  On June 16, 1993, the Seal of Acceptance was granted to the Jaw Tracking (EMG-CMS) and TMJ Sonography modalities.  They are now authorized and approved to carry the acceptance seal with the following statement:

“The ADA Council on Scientific Affairs Acceptance of K7/EMG ELECTROMYOGRAPH, K7/CMS JAW TRACKING and K7/ESG ELECTROSONOGRAM is based on its finding that the products are effective for measuring physiologic or anatomic parameters of the temporomandibular musculoskeletal complex, when used as directed”.

The U.S. Food and Drug Administration has granted 510k status to each of these mentioned devices for use in the diagnosis and management of TMD in my practice.  The U.S. Food and Drug Administration in July 1994 indicated that the following indications and uses are the only uses for the model K7/ EMG-CMS-ESG currently accepted:

CMS (computerized Mandibular Scanning) – Jaw Tracking

• Tracks mandibular movement and position.
• For the diagnosis of functional disorders such as TMJ/MPD syndrome, muscle tension, bruxing and instability of occlusion.
• Identification of interocclusal distance and freeway space.
• Monitors the position of the jaw in three dimensions.
• Represents the spatial position of the mandibular incisal edge relative to the skull.

Electromyography

• Intended for use for muscles of mastication, especially temporalis, masseter and digastric.
• Designed to perform a limited number of functions in dental diagnosis.
• For use as a stand alone system for clinical monitoring or up to eight different muscles.  It is ideally suited for diagnosis and treatment evaluation by recording function/ dysfunction of the muscles of the stomatognathic system.
• Determination of the degree of relaxation of a particular muscle or muscle groups at rest.
• The precise measurement of relative levels of contraction of several muscles during a functional act.

Electrosonography

• The Electrosonogram (ESG) is a computer controlled, noninvasive temporomandibular joint sound recorder.  Using sensitive transducers, the ESG captures and displays the sound patterns emanating from the right and left TM Joints simultaneously.
• The Electrosonogram evaluation provides a “hard documentation” of course of therapy, the appropriateness of orthotic therapy and a measurement of the patient’s relative muscle dysfunction and pain.

Therefore, any comments that the validity of Electromyography, Computerized Mandibular Scan and Electrosonogram testing has not been established is erroneous.

This technology has undergone tremendous scrutiny and analysis by the United States F.D.A. (Federal Drug Agency Dental Advisory Panel), the Dental Products Advisory Panel of the Center for Devices and Radiologic Health (C.D.R.H.) as well as the American Dental Associations (A.D.A.)  Council on Scientific Affairs granting these technologies its’ Seal of Recognition to Myotronic’s neuromuscular instrumentation (1988-1994).  Because of these breakthroughs it has given 1000′s of clinicians further personal confidence in using these technologies and concepts in their own dental practices throughout North America and the world.

T.E.N.S. (Transcutaneous Neural Stimulation) – Low Frequency TENS

Safety of TENS devices has been scrutinized by the medical community over the past 40 years.   The scientific literature is unanimous in validating the safety of TENS devices.   This is an excerpt from an FDA publication titled “An Introduction to Electrical Nerve Stimulation: TENS” dated August 1986, published by Center for Devices and Radiological Health branch of the FDA:

“The approximately one hundred publications from the most recent years are virtually unanimous in TENS safety.  The notable exception is a necessary awareness of potential fetal stimulation during labor pain.  In all other aspects, TENS risk is limited to minor and easily remedied skin irritations from electrodes and electrode gels in a rather small number of reported cases.”

The U.S. Food and Drug Administration has very specific guidelines for all manufacturers in listing of FDA’s  Indications.  Contraindications, warnings, adverse effects and precautions (see pages 1-3 of J4/J5/BNS-40 Operating Guide).  “ Shorting out” or injuring the nervous system is not a listed adverse effect or precaution of TENS devices and can not be attributed to TENS therapy.

One other issue, J4/J5 Myomonitor TENS units and the BNS-40 are one of only few TENS devices that are equipped with a “Patient Fail-Safe Circuit”.  The delivery of current to the patient will be automatically interrupted if the Fail-Safe circuitry is activated.

These bio-instruments are unequivically recognized as safe and effective as diagnostic aids in the diagnosis and treatment of muscle tension and pain associated with TMJ and MPD (Myofacial Pain Dysfunction.

The American Dental Association’s Council on Scientific Affairs has awarded surface electromyography (SEMG), Computer Mandibular Scanning (CMS), and Sonography its “Seal of Acceptance”, as diagnostic aids in the management of temporomandibular disorders.

(Report on Acceptance of TMD Devices, ADA Council on Scientific Affairs, JADA, Vol. 127, November 1996).

For more detailed information see: Computerized Electro-diagnostic Instrumentation

Read more on the Scientific Studies Supporting Electronic Instrumentation

Filed under: Chronic Pain and TMJ, Clayton Chan, Dental Education, Diagnosis and Treatment, Dr. Clayton Chan, Ear Congestion, Electromyography, Electronic Instrumentation, FDA, Jaw Tracking, LVI, Neuromuscular dentistry, Neuromuscular Dentistry LVI, Neuromuscular Dentistry Treatment, Neuromuscular Instrumentation, Neuromuscular Treatment, Neuromusular Dentistry, NM instrumentation, NMD, Occlusion Connections, TMJ, TMJ Neuromuscular Forum, tmj neurouscular dentistry forum, TMJ Pain, TMJ Treatment by Clayton A. Chan, D.D.S.
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