Below is a list of questions, and answers, that dentists and other health care providers
frequently do not fully understand about temporomandibular disorders:
• Why does so much confusion exist related to treatment for temporomandibular disorders?
The first reason relates to a misperception as to what TMDs really are. There is a general perception throughout health care, including dentistry, that these disorders are no more than a group of symptoms, primarily pain. The musculoskeletal dysfunction that is responsible for producing the symptoms is hardly understood at all at any level.
However, the single greatest reason for this confusion, and an irony beyond understanding, is the fact that health care curricula, especially dental curricula, provide very little instruction in the normal functional anatomy and physiology of the masticatory system. A great deal of knowledge in this subject area is available. However, due to this lack of training, health care providers, dentists in particular, leave their formal training with limited understanding of the normal function of the masticatory system, for which the dental profession has primary professional responsibility. Without a clear understanding of normal function, dentists and other care providers have no basis for understanding abnormal function (dysfunction) or what might be required to return the system to something approaching normal function. For more information, see “Information for Professionals” and also “Masticatory Pain (TMJ) and Related Headaches“.
• What imaging is recommended for TMD diagnosis?
Most TMD-related problems can be diagnosed, by an individual with appropriate training, from a careful history and examination. Initial assessment of a patient with TMD-related complaints should initially involve a screening evaluation, before considering a comprehensive assessment. For this purpose, a good quality panoramic image of the oral region can be very useful, particularly to rule out a variety of potential problems, other than the TM joints. However, with regard to assessing the TM joints with a conventional panoramic image, because only changes to the condyles can be clearly seen, the mandible needs to be protruded to see the condyles clearly, but the relationship of the condyles to the fossae cannot be seen on a traditional panoramic image. This limitation has been greatly reduced with a panoramic imaging that is derived from cone beam CT, which allows the teeth to be in occlusion, thus allowing imaging of the osseous relationships of the condyle to the fossa. A CBCT image does not, of course, provide imaging of the soft tissue within the joints, which can be critical in certain instances in determining what is occurring within the joints. So an accurate diagnosis is not made from imaging. A careful history and exam are the best source of diagnostic information.
Most diagnoses of masticatory function will be made from the history and examination, without more sophisticated imaging. Before considering other types of TMJ imaging, other than a screening panoramic image, a thorough history and examination is recommended. Imaging such as MRI or CBCT, may be considered in certain instances, when additional information is required, beyond what has been determined by an examination, to aid in determining a biologically-specific diagnosis, or to enhance decisions regarding treatment options. In the past, tomography and arthrograms were often used. With the advent of MRI and cone beam CT scanning, when indicated, we now have even better options. The clinician must consider what information will be of greatest benefit, as each of these imaging techniques has strengths and limitations. For more specific information regarding the various imaging options and protocols, please see “Imaging of the Temporomandibular Joints“ .
• Is surgery ever indicated for a temporomandibular disorder?
Most dentists will be aware that the history of TMJ surgery has not been a pretty picture. As a result, significant reservations exist in many minds as to whether TMJ surgery is ever indicated. As a non-surgeon, I do not wish to prescribe a specific protocol for TMJ surgery. However, I do feel that there is an appropriate place for TMJ surgery and that the primary objectives of TMJ surgery, when it is indicated, is to restore structural stability and function to the temporomandibular joints, to the degree that that can be accomplished in each case.
Our experience has clearly indicated that patients who might potentially be candidates for surgery will frequently benefit from several months of non-surgical care prior to making a final determination as to whether there is truly a surgical need. This protocol has been widely advocated by other authoritative sources. This non-invasive, pre-surgical treatment might be provided by the surgeon but can also be provided by a non-surgeon when an interdisciplinary team effort is employed. Non-surgical management will often reduce or even eliminate joint and muscle pain. If this can be accomplished, in each instance, reassessment of the benefits regarding possible surgery would then be indicated. If a patient’s pain has been significantly reduced or eliminated, functional considerations may then become the primary issue involved in making a decision regarding the need for surgery. The patient’s age may also be a consideration. Whether surgery is considered appropriate, the needs for long-term management of the presenting structural and functional factors should ultimately be taken into consideration in the overall treatment planning.
When surgery is indicated, with proper pre-surgical and post-surgical management, outcomes can be very favorable in nearly all cases.
• When TMD treatment will involve an inter-disciplinary team approach, which participant should coordinate the overall treatment plan?
In an individual case, an interdisciplinary TMD team approach might require as few as two people or could involve four or five individuals with different clinical training and skills. The makeup of the interdisciplinary team for an individual patient will be determined by the nature of the patient’s overall needs.
A true interdisciplinary team approach (as opposed to a multi-disciplinary approach) has certain characteristics. The first of these is that all members of the team will share a common paradigm regarding treatment. Second is the recognition that each member of the team has certain clinical knowledge, skills, and experience and that all members are committed to sharing responsibility for treatment, utilizing the skills of each member to optimize the outcome for the patient. Third, interdisciplinary communication is critical for there to be an effective team effort. When this works optimally, the outcome will consistently be greater than the sum of the parts.
When a patient presents with TMD findings that require an interdisciplinary treatment approach, the portal-of-entry may be the practice of any of the members of the team. In other words, the need for treatment might be recognized by a general dentist, an orthodontist, a prosthodontist, a periodontist, an oral surgeon, or by a physical therapist. Any one of these portal-of-entry providers might assume responsibility to coordinate care for that individual patient, assuming that this individual has sufficient knowledge and experience to serve that purpose. So long as each member involved in the interdisciplinary team recognizes their particular responsibility to the patient and communicates with the other members, optimal treatment is possible.
• What precautions are appropriate during routine dental visits for patients with known “TMJ” problems?
The dental responsibility regarding patients with certain symptoms of muscles and joints is not unlike the dental responsibility regarding dental caries or periodontal disease. Our responsibility is to recognize the condition in its incipient stage, if possible, and to either treat it or see to it that the patient receives care from someone with appropriate knowledge, training and skills.
TMD screening should be done routinely in all dental offices. This has been recommended by several organizations for at least two decades, including the ADA, the Academy of General Dentistry, the American Academy of Orofacial Pain, and the Amearican Academy of Craniofacial Pain. We enthusiastically subscribe to these recommendation.
When any symptoms of TMDs are recognized from a screening evaluation, the responsibility of the dental practitioner is to either undertake a comprehensive evaluation or to refer the patient to a knowledgeable colleague for appropriate comprehensive workup and treatment. Routine screening of all dental patients can be incorporated into a dental practice fairly easily. Screening forms and instructions for doing routine screening, are available to be downloaded from this website. See “Screening for TMDs in Dental Practice“.
With certain temporomandibular disorders, even routine dental care may have the potential to exacerbate symptoms and/or precipitate progression of the underlying condition that is responsible for the symptoms. For patients with pain on opening and/or limited range of motion, dental procedures of all kinds should be kept to a minimum until the cause has been thoroughly diagnosed and appropriate treatment undertaken. Elective treatment should be postponed and only critical dental care should take precedence until the TMD concerns have been stabilized. Ignoring these symptoms in hopes that nothing untoward will occur is tempting fate, is abdicating professional responsibility, and is strongly discouraged.
• What kind of occlusal appliance should I use for a “TMJ” patient?
Choosing an appropriate occlusal appliance type should be based on a biologically-specific diagnosis of the individual patient’s condition. (see Diagnosis of Temporomandibular Disorders) Dr. Peter Dawson has suggested that all occlusal appliances, regardless of their name, are of two types that he designates “permissive” or “directive”.
A permissive appliance, according to Dawson’s definition, “unlocks the occlusion to eliminate contact of deflecting tooth inclines”. Another way of describing a permissive appliance would be that it masks any potentially detrimental aspects of the patient’s native dental occlusion, provides uniform occlusal stability and temporarily creates, on plastic, an occlusal environment that encourages and promotes a return of normal masticatory homeostasis and function. Many TMD patients will benefit from the use of a well-designed and properly adjusted permissive appliance. However, for certain specific conditions involving structural disorders of the temporomandibular joints, a permissive appliance may not be sufficient to definitively manage the condition.
A directive appliance, according to Dawson, “is designed to position the mandible in a specific relationship to the maxilla”. He further states that, “the sole purpose of a directive appliance is to position or align the condyle/disc assembly”. Although directive appliances do meet these criteria in most instances, this does not entirely explain when and how they might be used in specific types of temporomandibular disorders. The specific indications for this type of appliance are fairly involved and proper use will usually require a fairly sophisticated understanding of the functional anatomy of the temporomandibular joints, as well as clear clinical indications of certain functional parameters in the individual patient. For more discussion, see “Two-Phase Treatment for Temporomandibular Disorders“.
• Does insurance cover “TMJ” diagnosis and treatment?
Insurance coverage for temporomandibular disorders has always been extremely variable, from no coverage at all to modest coverage in the best of circumstances. Because TMD treatment involves joints and muscles primarily, biologically these disorders should be seen as comparable to the treatment of other joints systems. In that sense, they are medical in nature rather than dental. Most insurance companies that provide benefits typically provide them under the patient’s medical insurance coverage. A few dental plans may provide some benefits.
What kinds of treatment insurance companies may cover can also vary greatly. Some will cover diagnostic procedures but nothing else. A few limit coverage to only surgical treatment. Others may cover appliance therapy but not physical therapy or surgical treatment. There does not seem to be any consistent logic behind decisions regarding benefits, except for one thing. As is true with any kind of insurance, the amount of coverage is a direct reflection of the premium that was paid for the coverage. The higher the premium, the better the coverage. One thing is very clear — decisions regarding insurance coverage are not based on patient need. For more information, see “Insurance Benefits for TMDs“
• What constitutes an “adequate” evaluation for temporomandibular disorders?
There are two levels of evaluation of temporomandibular disorders, The first is a screening evaluation, involving a fairly brief history questionnaire and an examination that is limited to a few key clinical indicators. The purpose of a screening evaluation is primarily to determine if a patient has a true temporomandibular disorder, and whether a need for a comprehensive evaluation is needed. A screening evaluation can be done in a very limited period of time, thus making it quite easy to introduce into any dental practice. In most cases a screening evaluation does not provide sufficient information to make a biologically-specific diagnosis nor to determine the exact needs of treatment. However, a tentative, working diagnosis should result from a proper screening evaluation. Please see “Screening for TMDs in Dental Practice“
A comprehensive evaluation is highly recommended prior to undertaking any treatment. This would involve taking a comprehensive history and examining the masticatory structures for not only symptoms but also to determine the adequacy or limitations of masticatory function. A comprehensive evaluation should provide indications of possible contributing factors, the extent of the disorder, including what structures are involved, and to what degree. These are the necessary ingredients for forming a true diagnosis and a patient-specific treatment plan that is focused not only on symptomatic relief but on restoration of masticatory physiologic function.
Forms for doing a screening evaluation, as well as a comprehensive history form and a comprehensive examination form, are available on the “Diagnosis of Temporomandibular Disorders” page.
• Why do women seek “TMJ” treatment more than men?
Several studies, done in different countries, have clearly shown that women seek treatment for temporomandibular disorders at an average rate of about 7 times greater than men (these studies have varied from 3:1 to 9:1, women to men). However, in studies that have examined general population groups (not patients), the predominance of symptoms among women, compared to men, is about 2:1. The reason for this apparent discrepancy is usually attributed to the fact that women are much more inclined to seek treatment than men for many conditions and disorders.
The occurrence of TMDs in women, based on age, parallels the child-bearing years. This finding strongly suggests that hormonal factors may have a significant influence, perhaps related to an increased extensibility of ligamentous tissues that occur on a monthly basis with menses. Other possible hormonal effects that have been proposed include changes in pain perception related to the menstrual cycle, but at this time there are no firm conclusions to this intriguing question.