Prevalent Philosophies Advocating the Treatment of TMD
“Experts estimate that 75 percent of all headaches are caused by muscle tension, which may be related to the bite.”
- AGD/Oral Health Resources, Temporomandibular Joint Disorder (TMD), March 30, 2007
Today, there are two growing and evolving principle schools of thought regarding the cause and optimal treatment of temporomandibular disorders (TMJD) within the TMJ-TMD community that the layperson needs to be aware of. It is these two schools or philosophies of thought that drives the influencing process of the TMJ public as to their approaches, diagnosis and treatment. Both believe and practice within the predefined standards or parameters which have been established by the dental profession. One philosophy focuses on the bio psychosocial perspective of TMJ and the other focuses on the physical/functional aspects, bio patho-physiologic neuromuscular model of TMJ.
- 1. Bio Psychosocial Model
- 2. Bio Patho-physiologic Neuromuscular Model
Every TMJ pain patient who experiences pain, masticatory dysfunction and joint dysfunction problems and the associated ailments (sufferings) that comes with these issues should know which philosophy their treating dentist is approaching their case. The two philosophies and those dentist who practice to help the TMJ patients may have different mindsets, beliefs, methodologies and views as to how best to treat your case. Depending on which school of philosophy and training your doctor has learned will naturally lead to different mindsets and treatment outcomes.
The initial TMD diagnosis is based on patient’s history, physical and clinical assessment/examination and imaging, if indicated, psychosocial cursory evaluation, a pharmacological assessment, but additionally an evaluation of the patient’s physiologic resting and functional body responses that go beyond subjective complaints. Diagnosis is greatly enhanced with physiologic measurement devices, providing objective measurements of the functional status of the masticatory system: TMJs, muscles and dental occlusion.
The American Alliance of TMD organizations represent thousands of clinicians involved in the treatment of TMD. The ten basic principles of the Alliance include the following statement: “Dental occlusion may have a significant role in TMD; as a cause, precipitant and /or perpetuating factor. Therefore, it can be stated that the overwhelming majority of dentists treating TMD believe dental occlusion plays a major role in predisposition, precipitation and perpetuation. While clinicians who believe that occlusal treatments most frequently resolve TMD, it is recognized that TMD can be multi-faceted and may exist with co-morbid physical or emotional factors that may require therapy by appropriate providers.” <2>
Bio Psychosocial Model
Those within the bio psychosocial arena of TMD site “literature produced during the past 25 to 30 years has pointed the profession in the direction of a medically based model for diagnosis and treatment. They have noted that, “Finally, it has become clear that a minority segment of patients with TMDs will prove resistant to therapy and become patients with chronic pain problems; as a result, the focus of much research has been directed at unraveling the complexities of such outcomes. These conclusions about TMDs are accepted widely by those in the clinical research community, but arguments persist within the practice community, leading to an unacceptable gap between science and practice in many instances. Obviously, the people primarily affected by this situation are the patients themselves, because their fate is determined largely by whomever they consult about their problems.”<1>
In addition, it has become accepted widely among pain experts in the medical and dental professions that these types of pain conditions must be managed within a bio psychosocial framework, in which behavioral
approaches supplement conservative medical care.” <1> Pain management via pharmocology medicines, self help therapies, splints or dental orthotic appliances along with physical therapy are often implemented with no clear understanding or theory as to what causes TMD. If no adequate resolution is found this philosophy will often indicate that surgery is rare, but indicated for TMD patients who have 1) TMJ inflammation, 2) acute TMJ disc displacement without reduction (closed lock), and 3) TMJ ankylosis (painless severe limited opening).
Although, teeth, muscles, joints and the central nervous system are discussed there is a significant de-emphasis on occlusion, since this school of thought does not believe that the occlusion or bites have anything to do with the multi-faceted TMD issues involved, thus a need to implement a pain management medical model of therapy.
The National Institute of Health (NIH), the American Academy of Dental Reserach (AADR) along with other small organizational groups taughting “Orofacial” or “Craniofacial” are of this philosophy.
Bio Patho-physiologic Neuromuscular Model
Clinicians who acknowledge the bio-physiologic neuromuscular approach are composed of academic and clinical dentists who believe that TMD has a primary physical/functional basis associated with the teeth, muscles, joints and the central nervous system. Initial conservative and reversible TMD treatment employing a therapeutic neuromuscular orthosis that incorporates relaxed, healthy masticatory muscle function and a stable occlusion is most often successful. This is accomplished using objective measurement technologies and ultra low frequency transcutaneous electrical neural stimulation (TENS) along with all the prudent implementation of all aspects of TMJ management guidelines.
Extensive literature substantiates the scientific validity of the physical/functional basis of TMD, efficacy of measurement devices and TENS and their use as aids in diagnosis and in establishing a therapeutic neuromuscular dental occlusion. Clinical Implications: A scientifically valid basis for TMD diagnosis and treatment is presented aiding in therapy. “The dental profession accepts certain predefined standards or parameters of function/ dysfunction. Electronic instrumentation provides objective measurement of many of these biological phenomena, and thus can be used throughout treatment for critical analyses that monitors and enhances treatment efficacy.” The bio physiologic neuromuscular clinicians recognize that this aspect of diagnostic care in addition to the classical standards of TMJ care should also be recognized and considered.
The International College of Craniomandibular Orthopedics (ICCMO) supports this bio physiologic neuromuscular philosophy along with other prominent organizations that comprise the American Alliance of TMD organizations.
The American Alliance of TMD Organizations is comprised of the following 9 organizations:
• The American Academy of Gnathological Orthopedics
• The American Academy of Pain Management
• The American Association of Functional Orthodontics
• The American College of Prosthodontics
• The American Equilibration Society
• The American Prosthodontic Society
• The American Society of Temporomandibular Joint Surgeons
• The International College of Cranio-Mandibular Orthopedics
• The Society of Occlusal Studies
Conclusion:
It is clear that those of the Bio psychosocial/ Orofacial TMJ model proponents are really not serious about scientific objective measurements and the related instrumentations associated with quantifying physiologic jaw and masticatory muscle function to be included in their methodology and “research”. Those leaders who are advocating an anti-instrumentation agenda against the use of proven instrumentation devices and trying to persuade the dental profession and TMJ public that the psychosocial medical model is the method that is most scientific and literature based is misleading and unfounded in their biased research. These Orofacial pain doctors tend to found their perspectives on academia, take pride in referencing their biased articles as truth, but fail to recognize that science has moved on. Those of the physiologic/functional bio pathophysiologic neuromuscular belief tend to be more clinically oriented and endorse great value in the use of scientific objective measurement protocols in addition to implementing sound TMJ guidelines that are endorsed by the American Dental Association.
History does not need to be re-written when severe scrutiny has already been done at the highest levels of the FDA. Is it necessary for those of the bio-physiologic neuromuscular perspective re-open history and re-expose those who are of the anti-instrumentation, psychosocial agenda of TMD once again? History should be a reminder to all in the TMD community and not be forgotten that these anti-instrumentation/orofacial pain advocates were embarrassingly exposed and publically reprimanded at the Congressional hearings regarding an FDA Office of Internal Affairs inquiry, the U.S. House Commerce Oversight Committee and the U.S. Department of Health and Human Services Inspector General. The TMJ layperson should not be fooled by their deceptive and persistent subvertive agenda.
- 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. January 1986.
- “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”. June 16, 2005.
To Read More Related Articles:
The Controversy – What to Call this Problem?
Diagnostic Classification Confusion
The Neuromuscular Approach to Dentistry - Computerized Electro-diagnostic Instrumentation – the Missing Link
Neuromuscular Dentistry – Inspired Attach on Truth, Justice and Professional Freedom
Scientific Studies Supporting – Neuromuscular Instrumentation
References:
Greene, C S: Managing the Care of Patients with Temporomandibular Disorders A New Guideline for Care. JADA 141(9) http://jada.ada.org September 2010.
Cooper, B: Temporomandibular Disorders: A Position Paper of the International, College of Cranio-Mandibular Orthopedics (ICCMO), 2007
Kuwahara, T, Miyauch S, Maruyama T: Clinical classification of the patterns of mandibular movements during mastication in subjects with TMJ disorders. Int J Prosthod 1992; 5:122-129.
Tsolka P, Fenion M, McCullock A, Preiskel H: A controlled clinical, electromyographic and kinesiographic assessment of craniomandibular disorders in women. J Orofacial Pain 1994;8(1):80-89.
Tsolka P, Preiskel H: Kinesiographic and electromyographic assessment of the effects of occlusal adjustment therapy on craniomandibular disorders by double-blind method. J Prosthet Dent 1993;69(1)”85-92.
© 2009 Clayton A. Chan, DDS. All Rights Reserved.
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