Key Areas Dentists Should Look into When Diagnosing TMD: Criteria, Tools and Protocols

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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 thirteenth of 15 responses to their questions.

13. Research on the TMD field is considered tedious and has become controversial due to the lack of a globally accepted TMD diagnosis protocol or criteria. In these global situations, if clinicians and young academicians desire to conduct quality clinical research in the field of TMD management, what are the key areas they should look into, and which TMD diagnostic criteria/tools or protocol do you suggest they use?

Educated guesses, subjective feelings and speculation do not produce effective, reliable, lasting results. Controversy is mainly due to a lack of global consensus as to what is TMD. Addressing the source of the problems rather than just treating the symptoms is crucial if one desires to reach maximal dental improvement (MDI). There are three areas that are overlooked by most dentist when treating and researching TMD/TMJ (Myofascial Pain Dysfunction): 1) Structural imbalance, 2) Bio-chemical/nutritional imbalance, and 3) Emotional/psychological imbalance.

I believe TMD is result of our dental professions failure to understand, educate, learn, diagnose and effectively treat the underlying developmental (etiologic) issues of upper respiratory collapse and its impact on the maxillo-mandibular dental arches.  Failure to recognize poor tongue repose and how it interferes with posterior tooth eruption (deep bites) or (creates an open bite with a steep mandibular plane angle) leads to narrow arch development and changes to tooth angulation (lingual tipping of posterior teeth).  Malocclusion leads to mandibular lateral and posterior displacement and a decrease in physiologic intra oral volume for the tongue.  Airway obstruction by the dorsum of the tongue against the posterior pharyngeal walls leads to snoring, obstructive sleep and dysphagia. Airway obstruction also leads to chronic mouth breathing.  All of these factors lead to COR pulmonale as well as craniomandibular dysfunctions (which to many are called TMD (temporomandibular dysfunctions).

Within the dental profession, there are two prominent philosophies and perspectives that attempt to address TMD.  The bio-physiologic neuromuscular (structural/functional) perspective and the bio-psychosocial perspective (Orofacial). Two different paths of focus with two different clinical outcomes result when entering the world of TMD.  Some TMD experts believe in objectively measuring and quantifying their patient’s physiologic responses when diagnosing and treating, while another group of orofacial pain experts believe that measuring instrumentation is not relevant or important in their diagnostic and treatment process of “managing pain.”  One group recognizes the teeth/occlusion plays a role in TMD while the other believes the teeth/occlusion play a lesser role in orofacial pain.

Bio-Physiologic Neuromuscular (Structural/Functional) Perspective

This approach focuses not only on the subjective patient complaints, but also on objective assessment of the musculoskeletal occlusal signs and symptoms of TMD research (etiology). Measuring technology and instrumentation are used as part of research and include: 1) computerized mandibular tracking, 2) surface electromyography and 3) electrosonography of the TMJ. These devices have been found to be extremely useful in aiding the clinician to arrive at a diagnosis for conservative treatment based on objective physiologic measured data.

The U.S. Food and Drug Administration (FDA) approved the sale of these electro-diagnostic devices for the purposes of measuring bio-physiologic activity that directly relates to the TMD. The medical necessity of their use for each patient is documented by the treating dentist.  Certainly, this scientific, methodical and non-invasive approach to documentation of medical necessity is a fundamental criterion to eliminate controversies. The use of objective quantifiable diagnostic procedures should be implemented to quantify and qualify a patient’s dysfunction if reasonable and scientific consensus is to be established. This approach certainly adds essential, accurate information and credibility in the effective diagnostic and treatment process especially for patients with trauma episodes to the head and cervical regions.

Bio-Psychosocial Perspective

The National Institute of Dental and Craniofacial Research (NIDCR) ignores that TMD may have not only a muscular component to this disease/dysfunction, but that it also may have an occlusal component.  This over-site which only exemplifies this perspectives intent, to diminish the bio-physiologic factors of the stomatognathic system and posture of the upper quarter of the bodies systems only adds to its purposefully created controversy and perpetuated use of legalized pharmaceutical therapeutics in an attempt to “manage” the underlying pains and dysfunctions.  A non interest in scientific measuring protocols continues to be promoted internationally with more of a focus on academic analysis and reliance on academic designed co-horted studies that keeps the dental and medical professionals circling in a maze of mystery as to how best to “manage” TMJ/TMD and orofacial pain problems. An emphasis to credentialing those with a “specialty” status who have espouse this approach seems to enhance a circular path of analysis with no consensus to how best to resolve the underlying issues. This perspective continues to be advocated by a small group of academics who prefer not to recognize objective measurements as a reasonable and logical progression in scientific investigation as to the patient’s muscle or occlusal complaints. To be the “specialists” of orofacial pain seems to be a significant focus.

  1. It suggests that medicine is the solution to TMD problems.
  2. It suggests that TMD often resolves itself and is self-healing.
  3. It emphasizes that TMD is a self-limiting disease and occlusal (bite) changes are to be avoided.
  4. It does not acknowledge that TMD is a major component in the scope of dental practice nor does it recognize that the dentist has a major role in dealing with muscles, joints and teeth as it pertains to temporomandibular joint disorder and all the associated signs and symptoms that relate to the trigeminal system.

Taking a “wait and see” approach to disease based on unfounded, conflicting opinions lacks responsibility to the public. A support for pain medications that can lead to dependency and drug abuse in dealing with chronic pain rather than a philosophy of support toward prevention is irresponsible. To improperly suggest that occlusion is not even remotely related to TMD when it has been well demonstrated that loss of posterior occlusal support and parafunction have a role, even if an indirect one, is fatuous.  If the latter is an unfair criticism, why then would such an approach support the use of flat splints presumably to avoid parafunction?

Where are the clinicians/doctors today who understand the importance of muscle physiology and dental occlusion?  Where are those clinicians who are conducting clinical research based on objective measured criteria, recognizing its impact on dental occlusion, body structural alignment, its impact on the central nervous system and relevance to the trigeminal nerve (dental ) system?  Where are those clinicians who truly have the desire to be the “Physicians of the Trigeminals System” helping their patients and also are willing to conduct scientific investigations, rather than perpetuate pharmaceutical drugs to mask the pains of their patients and do the much-needed work in dentistry?  Who is best qualified to address the TMD/occlusal problems? The TMD pain patients will ultimately decide who is qualified to treat their problems – Credential academic “specialists” or treating clinicians who value objective measurements and understand the occlusal issues?

To date there is no clear method that has been agreed upon regarding what is TMD – temporomandibular joint dysfunction and its associated craniomandibular and neuro-muscular occlusal issues). Because of these controversies, I decided to take the bio-physiologic approach and do my own clinical research and measure each and every one of my TMD pain patients for the past 25 years.

To all my colleagues within our profession who are serious about acknowledging that TMD problems exist and want to fully research how to best treat and avoid the controversies, I would suggest using computerized K7x technology to define, objectively measure, quantify and record the quality and level of dysfunctions of your patients who have TMD/orofacial pain.

Measure, research and gather the following data:

  1. Speed of Mandibular Opening/Closing Before TENS in Sagittal/Frontal/Velocity Mode.
  2. Freeway Space Before TENS using CMS to document 3 dimensional movements of the mandible (in real time) from physiologic rest to C.O. BEFORE TENsing.
  3. Freeway Space After TENS using CMS to document three-dimensional movement (relative to time) of the mandible from physiologic rest to C.O. After TENsing.
  4. Bite Registration in Sweep, Sagittal/Frontal Mode to document the physiologic trajectory of closure (Myo-pulse) and habitual movement of the mandible from rest to C.O.
  5. Swallow Patterns in Sagittal/Frontal Mode  to document mandibular movement during swallowing to identify tongue thrust.
  6. Speed of Mandibular Opening/Closing in Velocity Frontal Mode to document the speed of mandible during opening and closing AFTER pulsing.
  7. Chewing Patterns in Sagittal/Frontal Mode to document Dimensional movements of the mandible during chewing.
  8. EMG Resting Levels Before TENS in EMG Raw Mode to document EMG muscle activity with the patient at rest Before TENSing.
  9. EMG Resting Levels After TENS in EMG Raw Mode to document EMG muscle activity with the patient at rest After TENsing.
  10. EMG Clench Test in EMG Processed Mode to document the amount of muscle activity during clenching.
  11. First Tooth Contact in EMG Processed Mode to document the firing order of the muscles to determine first contact.
  12. Mandibular Range of Motion to document patients range of motion.
  13. Joint Sound Tracings with Corresponding CMS Tracings to document bilateral joint sounds simultaneously with jaw tracing (vertical and velocity).

Research has been promised by those in academia and organized dentistry for years, yet patients around the world are still suffering daily. They can no longer wait.  My patient’s lives are at stake and they are looking for clinical answers and solutions to their TMD/orofacial pain dilemmas.  I as well as many of my colleagues are familiar with these debilitating conditions all around the world.  We have discovered affective; objective means to treat these TMD patients with results.  At the present, many researchers and orofacial pain doctors have not shown a willingness to work together with the clinicians who actually contend with these problems using a scientific objectively measured approach.

Some within our profession are willing to measure and record the bio-physiologic evidence of their patients to discover what they didn’t know, while others rather chose the easier and convenient route to ignore the truths and facts about these matters.

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

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Leader in Gneuromuscular Dentistry