How to Treat TMD Effectively

UNDERSTAND THE UNDERLYING PHILOSOPHY OF YOUR TMD DOCTOR

by Clayton A, Chan, D.D.S. – Founder/Director of Occlusion Connections™

“Caring for the TMD/ GNM patient is like a journey, where we may uncover things along the way (journey) that we cannot see at this moment”. Let’s remember, “It’s a journey, not a sprint”.

Educated guesses, subjective feelings and speculation does not produce effective, reliable, lasting results. Addressing the source of the problems rather than just treating the symptoms is crucial if one desires to reach maximal dental improvement. To date, there is no clear method that has been agreed upon regarding what is TMJ. Research has been promised, yet our patients who are suffering can’t wait any longer! There lives are at stake and they are looking for answers. Many of the dentists who are familiar with these conditions have discovered effective, objective means to treat the TMD patient, but researchers have not shown a willingness to work with the clinicians who actually contend with these problems daily.

The Council on Dental Care of American Dental Association (ADA) Guidelines for initial TMJ treatment recommends a phase I (reversible) treatment approach for those cases that are not stable; proving the jaw relationship with time and implementing a reversible appliance is highly recommended to prevent further harm. A phase II level of necessary therapy may be required after the patient is pain free (3 to 6 months). [Ref: The Council on Dental Care of American Dental Association (ADA). Guidelines for TMJ Treatment (2004). http://www.cda.org/library/cda_member/policy/quality/tmj_mpd.pdf. Accessed: December 3, 2007].
Many within our profession recognize that a majority of individuals with internal derangement and associated myofacial pain will respond favorably to orthotic and functional jaw orthopedic appliance therapy. [Broadbent JM. TMJ in your practice. Funct Orthod. 2006;23:38-45. Simmons HC 3rd. Guidelines for anterior repositioning appliance therapy for the management of craniofacial pain and TMD. Funct Orthod. 2006;23:22-31 [republished from Cranio. 2005;23:300-305]].

TWO PHILOSOPHIES/PERSPECTIVES TO TREATING TMD

Within the dental profession there are two prominent philosophies and perspectives to addressing TMD:

Bio-Psychosocial Perspective
Bio-Physiologic Neuromuscular Perspective

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 as well is an over-site which only exemplifies its intent to ignore the bio-physiologic factors of the stomatognathic system and posture of the upper quarter of the bodies systems.

It suggests that medicine is the solution to TMD problems.
It suggests that TMD often resolves itself and is self healing.
It emphasizes that TMD is a self-limiting disease and occlusal (bite) changes are to be avoided.
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 that TMD is both innocuous and unaffected by preventative therapy 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 one support the use of flat splints presumably to avoid parafunction?

To convey that jaw joint X-rays (transcranial/ tomographic radiographs) are not generally useful in diagnosing TMJ disorders is unconscionable and confused as to the understanding and appreciation of the TM joint. Not having an ability to distinguish normal from abnormal, pathologic from physiologic affords the doctor no possible way to diagnose nor render treatment to people without a clear picture of the patient’s condition. It is not customarily used as a first radiographic procedure, but rather for conditions of long-standing pain and limitation of jaw movement that have not been responsive to conservative treatment. MRI may be indicated in cases of direct trauma to the joints as an early diagnostic modality.

No mention of the American Dental Association’s granted Seal of Acceptance to three computerized measurement devices that aid in the management of TMD are mentioned in this philosophy.

Bio-Physiologic Gneuromuscular (GNM) Perspective

This approach focuses on not only the subjective patient complaints, but also on objective assessment of the musculoskeletal occlusal signs and symptoms of TMD.

Measuring technology and instrumentation are used and include: 1) computerized mandibular tracking, 2) surface electromyography and 3) electrosonography of the TMJ.
The US Food and Drug Administration (FDA) approved the sale of these devices for these purposes of measuring activity that directly relates to the TMJ. The medical necessity of their use for each patient must be documented by the treating dentist and certainly are non invasive approaches to document medical necessity.
These devices have been found to be extremely useful in aiding the clinician to arrive at a diagnosis for conservative treatment. NIDCR fails to even recognize such.
The use of objective quantifiable diagnostic procedures should be implemented to quantify and qualify a patient’s dysfunction. This certainly adds essential, accurate information in the effective diagnostic and treatment process especially for patients with trauma episodes to the head and neck regions.

Subjective feelings and educated guesses when treating the mandible, masticatory muscles of the head and neck, and the temporomandibular joints will not produce cost effective results and treatment times!

A Word of Caution:

Total agreement as to conservative treatment and / or no surgery is to be applauded, but to exclude or limit proper and needful data gathering is certainly going to result in inaccuracies of treatment, diagnosis, increased treatment time, frustration and greater costs.

How can any qualified treating clinician (when treating TM Joint degeneration) be limited to diagnosing a joint disease condition from only a panoramic X-ray, which is merely a surveying film and not specific for the TM Joints? Obscure data and documentation will result in obscure and unpredicatable results!

Note: The NIDCR statement says not to use splints long-term, but criticizes the lack of long-term studies on effectiveness. These are contradictory statements.

Their position states one-sidedly “Research has disproved the popular belief that a bad bite or orthodontic braces and headgear can trigger TMJ”. To the contrary, research and documented clinical evidence has shown the opposite is true. Bad bites that are poorly misaligned can be contributory to masticatory dysfunction leading to intolerable muscle pain and discomfort which are components of TMD. Retractive orthodontics has been shown to lead to numerous signs and symptoms of TMD. These very same conditions have also been shown to be resolved with reversible splint therapy, as documented with tomography and ADA/FDA approved devices that objectively measure such conditions, before and after treatment.

The NIDCR publications states, “Irreversible treatments are of no proven value and may make the problem worse”. This is absolutely false and misleading leading. It causes the reader to believe that orthodontics to improve the bite or restorative dentistry using crown and bridge work to enhance the bite or occlusal adjustment (re-shaping teeth to bring the bite into balance) is impossible which totally undermines professional ethics.

Their perspective on intraoral splints is contradictory.

Many clinicians nationally who are well versed in treating TMD patients with either acute or chronic conditions have found orthodontic treatment, restorative therapy and/or occlusal adjustments to balance the bite excellent remedies after a thorough investigation and a reversible approach has been taken first. Only after all other conservative means have been exhausted, may the clinician implement these later methods for final stabilization of the TMD patient.

This is totally contrary to the pharmacological approach which seems to be endorsed in NIDCR publications. This supposed “quick-fix” approach fails to recognize the long-term, irreversible, pathologic state medications and drug addiction leaves a chronic, paining, TMD-suffering patient with no final resolution, but rather long term drug/ medication dependency and pain.

To make a blanket statement, “Avoid treatments that cause permanent changes in the bite or jaw”… most certainly is an inflammatory statement that undermines doctor/patient relationships. These types of treatments should only be performed by the clinician after need has been demonstrated.

Because there is no American Dental Association (ADA) recognized specialty for TMD and none in medicine, finding the right care can be difficult. Look for a health care provider who understands musculoskeletal disorders (affecting muscle, bone and joints) and who is trained in treating pain conditions should be the focus of the NIDCR in assisting the TMD to find help. Specially trained dentists with expertise in this field can be helpful in diagnosing and treating TMD.

Discussion

If the National Institute of Dental and Craniofacial Research (NIDCR), supports an active research program on TMD and is truly interested in learning more about the cause, symptoms, process and etiology of this disorder, it would seem quite reasonable that they should listen to the too numerous dentists treating in this country – doctors who are in the trenches treating their TMD patients with first-hand knowledge and experience diagnosing and rendering care to patients with TMD. These very same doctors employ these modalities in order to pinpoint the factors that lead to chronic or persistent temporomandibular pain. Identifying medications is only one avenue out of many others that should be thoroughly investigated for conservative and effective long-term help. Research performed by experts in the field should be acknowledged and further investigated when trying to understand the etiology of TMD.

Clinical research using dental practitioners, who actually treat the overwhelming majority of TMD patients must be encouraged, mentored and supported by NIDCR.

Patients suffering from TMD should not be denied their illness, but rather they should understand the nature of the illness and the available remedies for it.

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