Clinical Experiences and Findings of the Etiologies of TMD and the Global Health Care System

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I was invited by Dr. Sushil Koirala, Founder and Coordinator – MiCD Global Academy, Chief- Editor of MiCD Clinical Journal, as one of many globally renowned clinicians, academicians and researchers to answer 15 exclusive interview question for their clinical e-journal sharing my experience, clinical and research findings on the subjective of “TMDs – Confusion & Consensus: Expert’s Advice“. The following is the second of 15 responses to their questions.

 2. What are your clinical experiences/research findings of the etiologies of TMDs and, how do you perceive its global burden in the health care system?

In my dental TMD practice, patients come because they are looking for a better answer to their unresolved paining problems.  They have experienced various therapies and modalities, appliances including upper splints, lower splints, day-time wear and night-time wear, anterior discluders, deprogrammers and even neuromuscular orthotics.  They may have also had orthodontic treatment that has retracted or collapsed their dental arches.  Some present with previous unsuccessful jaw joint surgeries, arthrocentesis, orthognathic surgeries or may have even had various forms of equilibration/ occlusal bite adjustments, physio therapy, acupuncture, botox, various types of chiropractic’s and even neurologic oblation surgeries.  Others come with previous failing full mouth porcelain rehabs or failing orthodontics that did not adequately address their bite concerns, straining jaw problems or the simple complaint of:  “My doctor can’t find my bite”.

I have discovered that there are not enough dentists in this world who have been adequately been educated and trained in the field of TMD and dental occlusion. Dentist in general recognize there is this topic of dental occlusion or TMD that subconsciously bothers them. But they also realize they don’t feel confident in pursing the matter because they know their training or understanding about it was inadequate. So, they try to ignore it and move on to other things in dentistry that interests them.

TMD problems exist, just like dental occlusion exists in every dental practice whether one acknowledges this fact or not.  Without a firm physiologic basis and understanding to the etiologies of the numerous musculoskeletal occlusal signs and symptoms it is impossible for today’s clinician to adequately address the seemingly mysterious TMD/myofascial/orofacial pain problems, let alone the dental occlusal dilemmas faced in every dental practice world-wide.  From my clinical experience, a great majority of the time, TMD pain, joint derangement and masticatory problems are actually occlusal problems. A majority of dentists do not  fully recognize this fact.  Most dentists are trained to believe that TMD pain is separate from occlusal issues.  It really is not!

The educational burden lies on those who have some understanding of these matters and to inspire the younger generation of dentists to dig deeper, beyond the operative, adhesive dentistry, endodontic, restorative/ prosthetics, implant approaches and even digital dentistry to see into the realm that is not so easily seen by radiographic imaging alone.  There is a greater need to put all the pieces of the TMD/ orofacial pain/ occlusion puzzle together in a manner that makes the most logical sense to the dental professional. De-mystifying occlusion and removing the mysteries of TMD pain problem is what is needed today.  TMD problems simply exists when the principles of occlusion in each discipline of dentistry are not acknowledge, properly applied nor understood correctly by the dental profession. 

Theoretical concepts about the temporomandibular joint are not sufficient to effectively diagnose or treat the underlying causes of the multi-faceted pains, masticatory dysfunctions and temporomandibular joint derangement problems that exist in every clinical practice.  Just ask yourself, “How stable are my dental patients.”

TMD pain problems are far more common than most dentist will actually acknowledge. Comprehending this fact coming out of dental school is even less.  After 10 years doing clinical wet-fingered dentistry one may begin to realize these clinical complaints are actually part of every dental procedure.  The more seasoned dentist begins to realize the importance of occlusion and how important it is to optimally relate the mandible to the maxillary teeth for optimal function in a detailed manner.  If every dental student and graduate understood the importance of implementing good occlusion to their patient’s they would avoid the unwanted pains and discomforts of the masticatory system. Then, TMD would no longer be mysterious. 

The teeth (cusps to fossae), the muscles of mastication (unstrained) including the cervical muscles that support the head are innervated by the trigeminal nerve and their nerve branches.   Dentists cannot say they have reached maximum dental improvement (MDI) unless dental occlusion (teeth, muscles and the temporomandibular joints) are physiologically balanced. The terminal contact of occlusion must be free of any noxious afferent and efferent stimuli as the mandible enters and exits from its terminal contact position. Unstable temporomandibular joints that have displaced disc must be reduced.  Muscles that operate the movement of the lower jaw and head positioning must be free of muscle tenderness and pains.  Teeth must be free of teeth sensitivities, periodontal ligamentous  strains, abnormal occlusal forces that contributes to bone loss and periodontal gum recession.

As long as the dental professional overlooks and or ignores the gnathic and neuromuscular principles of objectively measuring and quantifying dental occlusion, TMD will exist and continue within this world of dentistry. We will not fully understand clinical outcomes within our dental practice.  The unwanted, undesirable complaints will always exist as long as each dentist chooses to refer out these problems to other colleagues who also have limited knowledge and awareness in solving these problems. Without measuring the parameters that are necessary achieve stable dental occlusal health in the dental practice, new strategies for effective treatment outcomes will be difficult and challenging.

How to find a physiologic jaw relationship is fundamental and crucial especially, when dentists want to implement advanced dental procedures and techniques in their practice.  First, asking “How stable is our patient’s dental health?” is a simple, yet fundamental question every clinician should ask when researching the etiologies of occlusal/TMD problems within the health care system?  Secondly, understand, synthesize and critically assess what objectively measured and quantified data means when recording the status of a patient’s physiologic jaw health.  Measuring the resting modes, functional muscle recruitment quality, functional joint health, speed and positional mandibular relationships in six-dimensions are all part of today’s comprehensive diagnosis. This has been my clinical experience and the way I do my own research searching for the etiologies of TMD.  Without having this type understanding, I am quite certain that TMDs will continue to baffle the minds of our health care system.  Dentistry will never fully understand what is required in establishing true physiologic health and stability of their dental patients without taking a scientific real-time measured approach.  This kind of awareness goes beyond the daily mechanical application of dental procedures and services. It has to start grass roots in every dental practice. This will require a different mind-set by the dentist along with a need to enhanced their training to acquire the necessary GNM occlusal skills to master occlusion in the TMD patient.

Clayton A. Chan, D.D.S. – Founder/Director

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Leader in Gneuromuscular Dentistry