Download Assessment and Treatment of Temporomandibular Disorders (TMD)

yes no Was this document useful for you?
   Thank you for your participation!

* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project

Document related concepts

Dental emergency wikipedia, lookup

Special needs dentistry wikipedia, lookup

Temporomandibular joint dysfunction wikipedia, lookup

Manitoba Public Insurance Corporation
Assessment and Treatment of Temporomandibular Disorders (TMD): Best
March 12, 2014
I. Definition of TMD and Background Information
According to the American Academy of Orofacial Pain (AAOP), the term
temporomandibular disorders (TMD) are currently viewed as a group of musculoskeletal and
neuromuscular conditions that involve the temporomandibular joints (TMJ), the masticatory
muscles, and all associated tissues. 1 Since 1934, various terms have been assigned to signs and
symptoms of musculoskeletal disorders in the jaw-face, such as Costen‟s syndrome, TMJ paindysfunction syndrome, functional TMJ disturbances, myofascial pain-dysfunction syndrome,
occlusomandibular disturbances, mandibular dysfunction, internal derangements of TMJ,
craniomandibular disorders and so on. The various terminologies reflect different concepts of
etiology (cause of the disease) and pathogenesis (mechanism of disease), as well as assumed
origin and source of these disorders over the course of nearly a century. 2, 3 The myriad of labels
applied to this condition merely enhances the confusion associated for assessment/diagnosis and
treatment rather than providing clarity.
Cardinal signs and symptoms of TMD are: pain in the temporomandibular or preauricular
regions; limitation or alteration in mandibular movement and/or masticatory functional ability;
TMJ sounds and asymptomatic radiographic changes of the TMJ. However, this is far too
simplistic as the complexity of innervations in the head and neck region provides for a dynamic
interaction between a number of cranial and cervical nerves to include the trigeminal system
thereby complicating the assessment of the TMD patient. This shared neurologic circuitry may
make the etiology of pain difficult to diagnose. 4 Confusion with regard to diagnostic and clinical
decision making is compounded by the fact that signs associated with TMD occur quite
commonly in the general population. Therefore, decisions who should and should not be treated
may be challenging. Seventy-five percent of those evaluated in a non-patient study exhibited at
least 1 sign (joint noise or palpation tenderness) and 33% exhibited at least one symptom, while
3.6% to 7% of individuals with TMD are in need of treatment. 5, 6
The most common age group found to be affected is between 15 and 45 years of age
(mean: 33.9 years). 7 Demographic data from clinically based studies indicate that TMD
symptoms are least prevalent in the young and seem to decrease after the age of 45. Interestingly,
a significant sex bias exists among patient populations of 6:1 to 9:1 with females more
commonly represented than males. 8, 9 The literature on experimentally induced pain indicates
sex differences, with females displaying greater sensitivity. 10 In epidemiological studies, sex
differences are also noted with regard to the prevalence of a number of pain syndromes, with
females reporting more severe pain, more frequent pain, and pain of longer duration. 11, 12
There are two main subdivisions within TMD based upon their primary source of pain
and dysfunction: masticatory muscle disorders (extracapsular) and joint disorders (intracapsular).
1. Muscle pain – extracapsular
Muscle related signs and symptoms are also very common in the general population and
patient-based studies indicate this to be the most common subgroup of TMD. 13, 14 Current
understanding of the complexity of masticatory muscle function and its dynamic relationship
with the cervical musculature provide ample rationale for thorough assessment of these areas in
routine TMD patient evaluation. Individual variations in muscle anatomy, biomechanics, and
fiber type/composition potentially related to muscle fatigue/overuse must be considered. The
demands on the musculature in normal function and excessive function while awake or asleep
must be appreciated. Importantly, age related decline of symptomotology may not be as great
with respect to muscular involvement as that identified with the TMJ. 15 It has to be appreciated
that not all muscle pain is the same. 2 Some individuals experience muscle pain due to simple
overuse and this may be termed “local muscle soreness”. This type of muscle pain manifests as
tenderness or pain upon palpation. Others may experience a more regional muscle condition
known as myofascial pain. It is characterized by the presence of localized, firm, hypersensitive
bands of muscle tissue called trigger points. 16 These areas create a source of deep pain input
which may lead to central nervous system excitatory effects resulting in pain referral. Referral
manifests as pain on palpation with referral of pain in the surrounding or remote tissues.
2. Joint pain – intracapsular
The most common sign of TMD has been identified as TMJ clicking. General population
based studies have reported clicking to occur in about 50% of those studied. 6 A magnetic
resonance image (MRI) study identified 33% of non-patient controls to have a disc displacement,
while 86% of the patient population also demonstrated discal displacement. 17 Therefore, we
must determine whether or not a natural course of TMD can be identified and if any intervention
is warranted. Although the concept of natural progression has been purported in the past, there
currently exists no evidence that TMJ joint clicking must progress to locking and degeneration or
that arthritic changes must develop in joints that lock.
II. Assessment of TMD
1. Principles for assessment
An etiological factor can be either necessary or sufficient. Absence of a necessary factor
implies absence of effect, while presence of a sufficient factor is enough to cause an effect. No
single cause accounts for all signs and symptoms of TMD. The etiology of TMD is considered
multifactorial and may be viewed in the light of contributing factors. 18 These factors can be
divided into predisposing, initiating, and perpetuating factors. Predisposing factors may increase
the risk of developing a condition; initiating factors may cause the onset or incidence of the
condition; while perpetuating factors may contribute to the maintenance or persistence of the
condition in focus 2, 19 Over the years a variety of etiological or contributing risk factors have
been proposed. Some of these factors are related to dental occlusion 20-22, behavioral factors such
as tooth grinding or clenching 23, micro trauma caused by repeated overloading of the jaw system
, joint hypermobility 24, 25, or external trauma 26. A series of articles have described the
functional relationship between the temporomandibular and craniocervical neuromuscular
systems 27, 28 and impaired jaw function following a whiplash trauma. 29, 30 Trauma following
endotracheal intubation 31 or third-molar extraction 32 has also been disclosed as a possible risk
factor to TMD. Furthermore, psychological factors and depression 33, social and general health
factors 34, inflammatory diseases 35, 36 and pain in the neck 37or back 38, or widespread pain 39
have all been regarded as risk or contributing factors. The importance of neurobiological
mechanisms 40, sleep disturbances 41, 42 and genetic factors has also been emphasized 43, and a
biopsychosocial model has been proposed to explain the etiology of TMD. 44, 45
Clearly, there does not exist a scientifically confirmed all-embracing hypothesis
regarding the etiology of TMD pain hence the assessment/diagnostic process relies on case
history, i.e. the description of symptoms, and clinical examination, and should be based on the
following procedures:
(1) the symptoms reported by the patient,
(2) the clinical examination,
(3) imaging, when deemed necessary and appropriate
(4) adjunctive testing, when needed
2. General considerations
a. History taking and clinical examination
The gold standard is the proven diagnostic procedure, finding or criterion accepted as the
best currently known evidence or indicator of the problem. 46, 47 The current gold standard that
can be used to identify the presence or absence of TMD, or one of its subcategories, is a
comprehensive evaluation of the patient‟s history and clinical examination supplemented, when
deemed appropriate, with imaging. 1, 2, 48-50
History taking is of the utmost importance. With pain disorders it has been estimated that
as much as 70% to 80% of the information required for a definitive diagnosis will be obtained
from a thorough history. 2 A comprehensive examination for TMD requires minimal
armamentarium. A millimeter ruler, palpation of joint and muscles and when necessary, imaging
techniques, remains the standard measures by which to diagnose TMD. This sentiment is also
endorsed by the recent “Policy Statement on Temporomandibular Disorders” published by the
American Association of Dental Research (AADR) 51 which stated the following:
“Based on the evidence from clinical trials as well as experimental and epidemiologic
studies: It is recommended that the differential diagnosis of TMDs or related orofacial
pain conditions should be based primarily on information obtained from the patient's
history, clinical examination, and when indicated TMJ radiology or other imaging
procedures. The choice of adjunctive diagnostic procedures should be based upon
published, peer-reviewed data showing diagnostic efficacy and safety. However, the
consensus of recent scientific literature about currently available technological diagnostic
devices for TMDs is that except for various imaging modalities, none of them shows the
sensitivity and specificity required to separate normal subjects from TMD patients or to
distinguish among TMD subgroups. Currently, standard medical diagnostic or laboratory
tests that are used for evaluating similar orthopedic, rheumatological and neurological
disorders may also be utilized when indicated with TMD patients. In addition, various
standardized and validated psychometric tests may be used to assess the psychosocial
dimensions of each patient‟s TMD problem.”
These conservative, low technological measures also provide a best cost benefit ratio and
hopefully avoid unnecessary and inappropriate therapy. 2, 50, 52, 53 These approaches are further
supported by the AAOP, Royal College of Dental Surgeons of Ontario (RCDSO) and European
Academy of Craniomandibular Disorders (EACD). 1, 54, 55
b. Imaging studies
The need for imaging should be established on the basis of selection criteria. Selection
criteria represent those clinical signs and symptoms that suggest that imaging studies would
contribute to the proper diagnosis and care of the patient. 56 The type of imaging depends upon
the following factors: the specific clinical problem being investigated, whether it be hard or soft
tissue; the amount of diagnostic information produced from a particular imaging modality; cost
of the imaging examination; and the radiation dose. 57 Overall, radiographic imaging has limited
use in the identification and treatment of TMD. 58-60 It is only with collaboration with the history
and clinical examination does it gain significance. A number of imaging modalities may confirm
the presence of suspected pathology, screen for unsuspected pathology or identify staging of a
disease. Diagnostic imaging may be used to rule out dental or periodontal pathology or to rule
out pathology in areas of the head and neck other than the dentition and TMJ. If pathology is
suspected that falls outside of the scope of dental practice, appropriate medical referral should be
made for proper diagnosis. The type of imaging depends on the relevant clinical findings. 56
Panoramic imaging may be used for a general screening. Tomographic studies are used for
evaluating the hard tissues. MRI can be used to depict the soft tissues of the joint. It should be
noted that abnormal radiographic findings must be viewed with caution. In a study by Sciffman
et al., they failed to reveal a statistically significant relationship between radiographic findings
and clinical symptoms. 61 Furthermore, the information gained from radiographic interpretation
has not been demonstrated to be useful in determining the outcome of treatment. 62
c. Adjunctive testing
In certain circumstances, additional testing is required but only after more conventional
approaches such as history and examination is unable to provide adequate information to
determine a definitive diagnosis. Some of these ancillary procedures may be the use of bone
scans, psychometric testing, medication screening/testing, laboratory testing etc. An example of
where this might apply is with the use of serologic testing whereby it would only be necessary if
previous investigation (history/physical examination) has suggested a metabolic or autoimmune
disorder. Hence, the need to determine if the results of such testing are positive or negative
would then greatly influence the treatment plan as well as the decision on the need to involve
other health professionals in a multidisciplinary and multiteam approach.
3. Specific considerations
There are several key concepts that must be appreciated prior to determining whether or
not a particular diagnostic test has clinical utility. Lund et al. 63 reported there to be four major
types of diagnostic tests that may be useful in a clinical setting (Table 1). The parameters to
determine the efficacy of a diagnostic test are: reliability, validity, sensitivity and specificity,
positive and negative predictive value (Table 2). It is with these tools that the clinical usefulness
of a diagnostic test in the assessment and treatment of TMD must be measured by.
a. Extraoral photographs
Extraoral photographs are usually taken to document particular events and/or to use in a
comparative process. Therefore, if the reason for using this diagnostic aid is to document the
severity and extent of an injury then this may be applicable. Orthodontists and prosthodontists
routinely capture extraoral photographs to document facial appearances/profiles to compare
before and after treatment effects. Extraoral photographs are not routinely required for TMD as
there are often no obvious physical signs to be photographed. However, if there is a history of
trauma experienced by the patient then the practitioner may wish to capture facial profiles from
various angulations in addition to assessing asymmetries and mandibular positioning.
The subject of the relationship between head and cervical posture associated with TMD
has been discussed in the literature over the past many years. Claims have been asserted that an
altered posture of the head and neck might cause and/or predispose to painful conditions by
altering biomechanics and muscular balance of the craniocervical region, neck posture may
influence the position of the mandible and muscle activity in both the masticatory and cervical
musculature and that forward head positioning may create changes to load placed on the cervical
spine and alterations to cervical soft tissues length and strength. However, there is well
documented evidence to suggest there to be a lack of conclusive evidence to confirm these
findings. 64-67 Furthermore, in a systematic review investigating this subject, it was concluded
that “The association between intra-articular and muscular TMD and head and cervical posture is
still unclear.” 68 In a more recent systematic review, the authors concluded, based upon a
qualitative analysis rather than quantitative, that the association between TMD and head and
neck posture continues to be controversial and unclear. 69 Although, many patients complain of
concomitant cervical pain and TMDs, this should be understood as comorbidity resulting from
functional rather than structural relations. In addition, this common clinical finding may be a
result of heterotopic (referred) pain in these areas, due to the neuroanatomic and
neurophysiologic convergence of cervical and cranial sensory nerves in the brainstem nuclei. 70,
Therefore, the need to record photographs of posture or changes thereof may be of
questionable diagnostic value and may have minimal value in monitoring the condition.
b. Tomograms
As previously discussed, imaging is an important diagnostic instrument when deemed
appropriate. Essentially, tomographic studies are used for evaluating the hard tissues.
Tomography offers an evaluation of osseous structures, but is more accurate in that it can focus
on "cuts" only several millimeters thick. This modality can depict the TMJ like a loaf of bread,
evaluating one slice at a time. Information regarding condylar displacement and arthritic changes
are possible with conventional tomography. 72, 73 However, this technology has essentially been
replaced by computerized tomographic procedures.
Computerized Axial Tomography (CT) allows for thin sections of the structures of
interest to be composed in several planes and viewed under various conditions that mainly
highlight hard tissue (osseous morphology). 74 This imaging technique overcomes the distortion
and superimposition of plain film radiography and the blurring of structures outside the image
layer of conventional tomography. CT provides more information about the three dimensional
shape and internal structures of the osseous components of the TMJ by providing detailed image
slices and three-dimensional images. Conventional CT also provides images of surrounding soft
tissues; however, this is not its primary role.
Cone beam computed tomography (CBCT) is the latest advancement in radiography for
the maxillofacial region. It allows for viewing the condyle in multiple planes so that all surfaces
may be visualized. This technology allows for the three dimensional restructuring of images so
that these images can be rotated on a screen for viewing and interpretation. Because of the
reformatting capability associated with this modality, panoramic radiographs can be produced.
This technique may provide an accurate, cost- and dose-effective diagnostic tool for the
evaluation of osseous abnormalities of the TMJ. 75, 76 Its advantages over computerized axial
tomography are that it uses less radiation, is less time consuming and it has more favorable
applicability for in office use. It is for these reasons that CBCT may replace CT imaging in the
very near future for assessing TMJ. It is important to realize that either form of tomography are
incapable of producing accurate images of the articular disk as this assessment is best performed
with the use of MRI.
c. Diagnostic models/ mounted on a fully adjustable articulator
Diagnostic models do not need to be routinely acquired for the assessment or treatment of
TMD. Since occlusion is not a common etiology for TMD, their value is somewhat limited.
Hence, mounting the diagnostic models on a fully adjustable articulator must be justified as to
the purpose and additional information to be gained by doing so. 77 However, in certain
circumstances diagnostic models may have utility. They may be helpful in identifying wear
patterns and/or recording a baseline occlusion for documentation prior to the initiation of an
intervention or the monitoring of occlusal changes during active treatment. 78 Diagnostic models
may also be helpful if determining whether or not occlusal changes are related to alterations in
skeletal morphology or due to dental considerations. However, even the most accurate casts will
not, by themselves, provide enough information for an accurate diagnosis of joint or muscle
pathology. 79
d. Extraoral radiographs – panoramic radiographs
As previously stated, panoramic imaging may be used for a general screening. It provides
an overall view of the teeth and jaws, a means of comparing the left and right sides of the
mandible, a screening projection to identify odonotgenic pathology and possible other sources
for TMJ symptoms. 57 Gross osseous changes in the condyles may be identified, however, due to
limitations of this technology, there is a lack of information regarding condylar positioning
and/or function. Mild osseous changes may be obscured and only significant changes in the
articular eminence morphology can be seen due the superimposition of the skull and zygomatic
arch. Due to the angulation of image capture in a panoramic radiography (transpharyngeal or
infracanial projection) the only subarticular surface of the condyle evident in the joint space is
the medial aspect of the medial pole. The reliability and validity of the panoramic radiograph in
diagnosis of intra-articular TMD, with its fair sensitivity and very low specificity, is thus
questionable. 80 Furthermore, when panoramic imaging was used in a study (involving 55 TMD
patients) to assess its value in leading to a change of diagnosis based upon the findings from this
modality, it was determined its use did not lead to changes in clinical diagnosis in any of the
patients seen, although the findings on the radiographs did lead to requests for additional
imaging studies in 3 cases. 81
Clearly, there are several limiting factors for accurate assessment and value with this
modality and therefore it should not be used as the sole imaging modality but requires
supplementation with other techniques.
e. Cervical spine radiographs
The issues related to head and cervical posture associated with TMD has already been
discussed in a previous section (Extra-oral photographs). The issue is not the validity and utility
of cervical spine radiographs as radiographs are considered the criterion standard for measuring
cervical spine position 82-84 but rather does the practitioner have the necessary training, skills and
knowledge to interpret the information provided by the radiographs. Also, once this information
is interpreted, is the intervention to be rendered within the scope of practice of the dental
practitioner. Since TMD is a multifactorial condition which requires a multidisciplinary approach
to treatment, then the dental practitioner in certain situations may consider engaging the expertise
and knowledge from one of our many allied health colleagues. This will result in a multiteam
approach to treatment often to the benefit of all parties involved.
f. Electronic instrumentation – surface electromyography, jaw tracking, joint
vibration/sound analysis,
The use of electronic devices (also known as Biopack® instrumentation) as adjunctive
diagnostic instruments for TMD is a controversial subject. There are three main types of devices:
electromyography (EMG) machines, jaw movement trackers, and joint sound recorders
(sonography or vibratography). All of these have been utilized for many years in research studies
of normal and abnormal jaw function, in animals as well as in humans. However, attempts to use
them in a clinical situation on individuals presenting with TMD have had mixed results at best. A
large number of clinical studies and review papers have found poor discriminative qualities and
technological problems when these instruments are used in a clinical situation. Nevertheless,
some dental clinicians continue to utilize them for assessing pain patients as well as for
“discovering” problems in non-symptomatic individuals.
The main argument offered for using technologic diagnostic devices to diagnose TMD is
an appeal for the dentist to be contemporary with electronic advancements. Analogies are made
to our medical colleagues with their use of electrocardiography, echo(ultra) sonography, or
ballistocardiography in the diagnosis of heart problems. However, it must be remembered that
TMD is more comparable to orthopedic disorders and headaches, which are medical conditions
where imaging technology has become somewhat useful, but other technologies have failed to
add much to the enhancement of differential diagnosis.
In 1989, eleven prominent Canadian neuroscientists delivered a position statement
regarding the use of electronic devices in the diagnosis and treatment of TMDs as follows:
“In our opinion, these instruments do not yet have a proven value in the diagnosis and
treatment of TMD, and their use for purposes other than research could lead to
misdiagnosis and overtreatment of patients.” 85
In 1996, the National Institute of Health investigated the use of electronic instrumentation in the
management of TMD and proclaimed the following:
“Validated diagnostic methods for identification and classification of TMD patients are
needed. The diagnostic value of these assessment techniques should be established with
respect to the criteria of sensitivity, specificity, reliability and cost effectiveness.” 86
The Royal College of Dental Surgeons of Ontario, in their guidelines related to the diagnosis and
management of TMD, make no mention on the need for electronic instrumentation. 54 The
AADR, as previously discussed, regarding their position on the use of technological diagnostic
devices for TMDs commented that “except for various imaging modalities, none of them
(electronic instrumentation) shows the sensitivity and specificity required to separate normal
subjects from TMD patients or to distinguish among TMD subgroups .” 51
1. Surface electromyography
The purpose of this instrument is to diagnose certain pathologic or dysfunctional
conditions based upon abnormal activity of the masticatory muscles. However, several studies
have reported the inability of this instrumentation to distinguish between healthy and patient
populations. 87, 88 Furthermore, there are a multitude of biological factors as well as technological
factors that make the results generated by these instruments to be somewhat inaccurate and
unreliable. 89 There have also been a number of well designed systematic reviews which have
questioned the validity, reliability and utility of this instrumentation for the purposes of
diagnosing TMD. 90-94 Interestingly and somewhat worrisome is that a recent study investigating
the diagnostic accuracy of surface electromyography for myofascial pain, reported this device
should not be used clinically to diagnose or monitor the course of TMD in an individual patient
due to the potential risk for overdiagnosis and/or overtreatment. 92 Unfortunately, this would not
be in the best interest of either the practitioner or the patient whom entrust us with their health.
2. Jaw tracking
The concept for the use of jaw tracking devices is based upon the concept that
impairment of jaw mobility and function are signs or symptoms of TMDs, therefore various
parameters of jaw movement have diagnostic value. The measurements usually include the
following: amplitude of jaw movement in all three planes of space, reproducibility or consistency
of jaw movements and velocity and smoothness of jaw trajectories. However, the significance of
these measurements for diagnostic purposes remains unclear. 95-99 Furthermore, the use of these
devices in the diagnosis of muscle pain as either a stand-alone measurement or an adjunct to
clinical decisions fail to meet the standards of reliability and validity for their usage. 92 Another
study evaluated the usefulness of this device to assess whether treatment related changes in pain
levels and chewing ability coincided with measurements taken with this technology. The
conclusions from the study indicated that if pain variables are the primary outcome in the
assessment of TMJ osteoarthritis the recordings from this device are not useful. 100 From an
economic perspective, there does not appear to be any more information garnered by the
mandibular movement measurements obtained with use of jaw tracking devices as compared to
those measurement provided by a traditional millimeter ruler and a visual assessment.
3. Joint vibration/sound analysis
The purpose of this technology is to measure the sound or vibration characteristics
produced during jaw movements to a specific pathological state within the TMJ. Firstly, it should
be noted that vibration analysis is similar to sonography in that both technologies rely upon joint
sounds to assist in the diagnosis of an intracapsular TMD condition. 101, 102 Even though there are
studies that have provided evidence for vibration analysis in accurately identifying certain TMJ
conditions 103 other studies have found that sensitivity and specificity is less than desired with
many false negatives and positives. 104-106 Interestingly, studies have also reported on the day to
day variability of joint sounds within the same individual and the artifacts (contamination of
collected data) associated with the recordings 107, the common finding of joint noises found in
random population samplings 15, 108 and the finding that many intracapsular disorders do not
consistently produce any noises at all. 109, 110 In a recent systematic review investigating the
reliability and diagnostic validity of joint vibration analysis for the diagnosis of TMD, the
authors concluded that “the literature is unable to provide evidence to support the reliability and
diagnostic validity of the JVA (joint vibration analysis) for diagnosis of TMD.” 111 Therefore the
question to be raised is whether or not the use of this technology can be justified when compared
to the use of a stethoscope and palpation in recording joint sounds.
g. Acoustic reflection technology
The relationship between pain and sleep is complex and it appears to be bidirectional.
Hence, pain can influence sleep and disturbances in sleep can influence pain. 112 The literature
has indicated a relationship between TMD and sleep disorders. 41, 42, 113 There are many
conditions within the classification of sleep disorders and one of the subgroups is “Sleep Related
Breathing Disorders (SRBD)” which is defined as breathing abnormalities that occur during
sleep as a result of increased airway resistance or obstruction. Obstructive sleep apnea (OSA) is a
condition that would be considered a SRBD. There also appears to be an association between
SRBD and TMD. 114-116 It has been suggested that due to these interrelationships that patients
presenting with sign and symptoms of TMD who concomitantly complain of sleep disturbances
should engage in a sleep study.
According to the American Academy of Sleep Medicine, the gold standard for the
evaluation of sleep and SRBD is the polysomnogram (PSG). 117 A position paper produced by a
group of Canadian sleep medicine professionals recommended that dentists who suspect their
patients‟ of experiencing SRBD must refer the patient to a sleep medicine physician who will be
responsible for assessing the risk and severity of the sleep apnea. 118 The role of the dentist
should be to screen for SRBD and perform a comprehensive evaluation. 119
The role of the nose in the etiology of OSA is somewhat controversial. In studies
investigating the relationship between OSA and nasal obstruction, the authors concluded that that
the nose may not play a significant role in the pathogenesis of OSA nor is it the main
contributing factor in the majority of patients. 120, 121 However, other studies have found that
nasal obstruction plays a modulating, but not causative, role in SRBD as nasal interventions may
improve subjective aspects of snoring and OSA but do not improve objective indicators of
disease. 122 Therefore, even though evaluation of the nose is suggested as a component for
comprehensive evaluation, its utility may be in question.
Acoustic reflection technology (also known as Ecovision®) also known as
pharyngometry is a modality that emits a sound wave through the mouth that is used to identify
the sites of narrowing from the oropharyngeal junction to the hypopharynx. This technique may
have some utility in assisting the practitioner in determining the potential for success of oral
appliance therapy. 123 A companion device is called the rhinometer which provides acoustic
imaging from the external nasal valve to the posterior choanae. The issues related to both of
these devices are that the data is collected when the patient is awake rather than asleep and the
patient is in an upright position rather than a lying down position that occurs during sleep. The
current apparatus suggested for a nasal evaluation is a nasal speculum. 124 The utility of these
devices might be applicable as a screening tool but further research and evaluation are warranted.
h. Lateral cephalograms
Lateral cephalograms have been utilized for many years to assess the impact on the
airway as it relates to SRBD. The standards of practice related to oral appliances does not
specifically recommend this imaging modality as part of the treatment, but the standards do
indicate that cephaolmetrics may be used as an option if the practitioner deems it necessary. 125
Currently, the use of cephalometrics appears to have a limited role in the diagnosis of SRBD.
III. Treatment of TMD
1. Principles for treatment
The importance of utilizing an evidenced based and scientifically derived approach to
TMD assessment/diagnosis and treatment cannot be overemphasized. However, others have
criticized this approach as being „ivory tower” thinking and they argue for more subjective,
experience-based paradigms of treatment. Unfortunately, this has resulted in a variety of clinical
treatment approaches for TMD based upon the educational background and/or theoretical
disposition of treating practitioners. Therefore, unsuspecting patients may be exposed to simple,
conservative and relatively inexpensive treatments or to invasive, irreversible and costly
treatments by another – both for the same set of symptoms. In light of these contrasting
philosophies, it has been strongly recommended that a conservative approach to the treatment of
TMD following a low technological and high prudence approach be followed. 126 These authors
argue that this is the ethical choice when the etiology of the condition is uncertain, and risks of
aggressive treatment are considerable. Greene and Laskin 127 have described the evolution of the
TMD field from a dental mechanical model to a more complex medical model, and concluded
that this change requires initial use of a conservative medical approach to management of those
disorders. Furthermore, a large number of articles about long-term outcomes of conservative
TMD treatment approaches have reported that patients respond at least as well to these as to
various irreversible therapies. 128, 129 As those conservative treatment approaches are, by
definition, reversible and non-invasive, this implies that the ethical choices for clinicians treating
TMD should be discussed in terms of those findings. Furthermore, it suggests that practitioners
have a moral obligation to justify the use of invasive treatments by demonstrating that they are
better for TMD patients than non-invasive treatments.
2. General considerations
a. Extracapsular versus intracapsular
A very important concept to understand is that different diagnoses require different
treatment approaches. Furthermore, a practitioner should only prescribe a treatment based upon a
definitive diagnosis with justification for the intervention based upon the best available scientific
evidence. Extracapsular conditions are quite different than intracapsular conditions and as such
each much be treated quite differently. It should be noted that TMD should be treated within a
medical orthopedic framework and ought to be managed by the same conservative modalities as
other musculoskeletal disorders. It is important for practitioners to avoid the problem of
misdiagnosis/incomplete diagnosis thereby resulting in misdirected/incomplete or inappropriate
b. Surgical approaches
According to the Royal College of Dental Surgeons of Ontario:
“The guiding principle of any treatment must be “primum non nocere” or, freely
translated, “above all, do no harm.” Irreversible and invasive procedures should only be
considered after attempts at treatment with more conservative measures have failed, and
only if the severity and/or persistence of the patient‟s symptoms warrant it. However, it
cannot be overemphasized that failure to respond to conservative treatment is not a priori
an indication to proceed to irreversible or invasive therapies. In this regard, there must
still be clear indications that in and of themselves point to the need for a specific invasive
or irreversible treatment approach. Hence, the relative risks and benefits of the treatment
versus the untreated symptoms must always be weighed.” 54
A surgical approach has few indications for the treatment of extracapsular issues and greater
indications involving those of intracapsular origin. Furthermore, it must be appreciated that
where conservative therapy has failed to modify the TMD complaint, it does not necessarily
follow that surgical intervention will result in a positive therapeutic effect. Moreover, it must be
recognized that surgical intervention is generally part of a process of management rather than a
cure in most circumstances.
3. Specific considerations
a. Oral appliances
i. Maxillary versus mandibular
Generally, oral appliances are fabricated for the maxillary arch. Alternatively, some
practitioners have argued that for reasons of enhanced esthetics and less effect on speech, this
type of appliance should be fabricated for the mandibular arch. The evidence from various
studies suggests no differences in reduction of symptoms between either of these two designs. 130
There is evidence that use of a maxillary oral appliance, in some patients with OSA, may have a
risk of aggravating obstructive events thus negating the use of this type of appliance. It is
suggested that these patients be considered for a mandibular oral appliance or a mandibular
repositioning device (MRD). 131-133
The question on use of an oral appliance on a 24 hour basis or for use only while asleep is
a controversial subject. The main concern regarding use on a 24 hour basis is associated with the
potential for greater adverse events such as alterations to the dentition and maxillo-mandibular
relationships. In the situation whereby the practitioner utilizes a MRD during sleep for the
treatment of a diagnosed SRBD and also feels the use of oral appliance will assist in
diminishment of TMD signs and symptoms then the need for these different designed oral
appliances may be a consideration.
ii. Flat plane design
The flat plane stabilization appliance (also known as the Michigan splint, muscle
relaxation appliance or gnathologic splint) is probably the most commonly used oral appliance in
the treatment of TMD (both extracapsular and intracapsular) and when properly fabricated it has
the least potential for adverse effects to the oral structures. The appliance is most often designed
with the use of hard acrylic and is fabricated so that the opposing dentition occludes uniformly,
evenly and simultaneously with the occluding surface of the appliance. Preferably, they are used
while asleep only, whereas behavioral modification strategies may be used to increase the
patient‟s awareness and reduce the impact of daytime parafunctional habits on TMD.
Observational studies suggest that OAs are effective in reducing sleep muscle activity, but only
for a variable period of time, and only in certain individuals. It must be recognized that sleep
bruxism (SB) is not eliminated with oral appliances as to date there is no “cure” for SB. 134-137
iii. Anterior repositioning design
The anterior repositioning appliance (also known as an orthopedic repositioning
appliance) purposefully alters the maxillo-mandibular relationship so that the mandible assumes
a more anterior position. This is accomplished with the addition of an acrylic guiding ramp to the
anterior 1/3 of the maxillary appliance which, upon closing, forces the mandible into a more
forward position. Originally, this type of appliance was supposed to be used to treat patients with
internal derangements (usually anterior disk displacements with reduction). It was thought that
by altering the mandibular position in this manner, anteriorly displaced disks could be
“recaptured”, after which the new condyle-disk relationship could be “stabilized” through
comprehensive dental or surgical occlusal procedures. 138 Currently it is recommended that
repositioning appliances should be used primarily as a temporary therapeutic measure to allow
for symptomatic control of painful internal derangements, but not to “permanently” recapture the
TMJ disk. Full-time, short-term wear of the anterior repositioning appliance should be limited to
cases with acute disc displacement without reduction (acute closed lock), only if the practitioner
is able to reduce the disc (unlock the jaw). In such cases, restoring the disc-condyle relationship
full-time for 5 to 7 days may reduce or prevent additional locking episodes and encourage
adaptation. Once joint pain and dysfunction are decreased, the appliance use may be gradually
reduced to be worn only during sleep and, if needed, eventually replaced with a flat plane
appliance. The potential dangers with long term use of this appliance are permanent and
irreversible occlusal and even skeletal changes. Therefore, this type of appliance should be used
with discretion, and only for short periods of time.
b. TMD and Motor Vehicle Collision
The association between TMD symptoms following motor vehicle collisions (MVC), and
specifically associated with whiplash injury is certainly complex and is associated with much
controversy. Whiplash-associated disorders (WAD) are commonly associated with MVC,
usually when the vehicle experiences a rear-end collision. The Quebec Task Force (QTF) on
Whiplash-Associated Disorders defined whiplash as an acceleration-deceleration mechanism of
energy transfer to the neck resulting from a rear end or side impact MVC but may also occur
during diving or other mishaps. They also indicated the impact may result in bony and soft tissue
injuries which in turn may lead to a variety of clinical manifestations such as WAD and include
reduced and/or painful jaw movement. 139 It should be noted when discussing this subject that
there is strong evidence that the prevalence and incidence of TMD are greater in patients with
WAD compared to control groups. Additionally, data suggests a less favorable treatment
outcome for this patient population compared to TMD patients without a history of neck injury
as TMD pain after whiplash trauma may have a different pathophysiology compared to localized
TMD pain. 140 An understanding of the prognosis of WAD is complex because TMD symptoms
may be associated with WAD or present as an independent manifestation as a result of MVC.
Regardless, both WAD and TMDs share a number of common physical and psychological
features which greatly influence, either alone or in combination, the prognosis of these disorders.
In a recent narrative literature review of 32 papers that assessed the possible relationship
between TMDs and WAD, it was concluded that a low to moderate incidence and prevalence of
TMDs was associated with whiplash. 141 Studies have indicated a significant risk for delayed
onset of TMDs following whiplash trauma (up to 1 year following the initial trauma) making this
an important consideration for patient evaluation, diagnosis, prognosis, management and
medico-legal issues. 142
From a treatment perspective, patients with post-injury TMDs do not respond as well to
treatment as non-trauma cases. 143-146 Patients who do not recover and return to work prior to
settlement of claims appear to continue to have symptoms. 147 The treatment approach for
patients with post-MVC TMD should be one that follows an interdisciplinary philosophy
following general principles of physical medicine (including sleep medicine), physical therapy,
and behavioral medicine, employing physical therapies and directed medications for
musculoskeletal pain and chronic pain due to the regional and potentially widespread nature of
the pain. 148-152
c. Sleep Bruxism and Sleep Related Breathing Disorders
A relationship between SB and SRBD has been previously suggested; 153 however, it is
yet to be demonstrated whether both entities are just coincidental, causally related, linked to
some arousal reactivity, or that SRBD and SB are, under some physiological state, involve the
triggering of one or the other.
Currently, there is no evidence to support the association or causality between SB and
OSA. However, there do appear to be clinical commonalties between SB and OSA. SB is a
complex process that may have a role in maintaining normal physiology or perhaps, being a
component of pathophysiology not yet fully elucidated. However, there appears to be an
association between SB and sleep position. 154 Furthermore, an association between OSA, sleep
position and parafunctional activities (clenching) has been expressed in some patients. 155 A link
between OSA and those individuals manifesting SB is a possibility as these entities share the
common finding of an alteration in muscle activity/tone. 156-158
Vulnerability or predisposition to SRBD and SB respectively needs to be identified given
that indirect evidence is now emerging that perhaps SB may be serving as a “reactive or
protective mechanism” against upper airway obstruction. It appears that when patients with SB
and/or painful TMD complain about insomnia, snoring and/or cessation of breathing during
sleep, sleepiness of unidentified causes or uncontrolled blood pressure, it is prudent to screen for
the presence of SRBD.
IV. Summary
The mandate of this document was to provide guidance to support best practices in
relation to the assessment and treatment of TMJ/TMD disorders following motor vehicle
accident/collision. The guiding principle for this document was “primum non nocere” or, freely
translated, “above all, do no harm.” This statement regarding non-maleficence or stated in
another way such as, "given an existing problem, it may be better not to do something, or even to
do nothing, than to risk causing more harm than good." is the manner by which all health
practitioners must consider patient assessment and treatment decisions. In light of this, the
method chosen to achieve the task at hand was to utilize and deliver an evidence based approach
from the existing scientific literature regarding various subjects and to specifically address
certain questions as presented. This document also contains numerous references, tables and an
annotated appendix which will assist and aid in the review and perhaps revision of existing
policies and procedures or in developing and implementing new policies and procedures based
upon the presented materials. It was beyond the scope of this document to critique individual
books, book chapters and various articles. The goal of this document should be to enable the
reader(s) of this document to utilize the materials contained here within so as to provide
guidance to the practitioner who is assessing/diagnosing and treating the patient and ultimately to
the benefit of the patient who deserves the highest and most scientifically based quality of care.
Respectfully submitted,
Gary D. Klasser, DMD, Cert. Orofacial Pain
Associate Professor
Table 1. Diagnostic tests and applications.
Predictive tests
To identify individuals at risk/not at risk of
developing a specific disease
Screening tests
To identify individuals who have/do not
have a disease or category of disease
Discriminatory tests
For differential diagnosis
Monitoring tests
To describe changes in the disease process
and/or effects of therapy
Table 2. Efficacy of a diagnostic test.
Measurement of a phenomenon that can be
repeated (degree of consistency)
The means that the phenomenon being
measured was truthful (accuracy of
a. technical validity
The procedure or device measures what it
claims to measure
b. diagnostic validity
The resultant information can actually help
to diagnose what it claims to be able to
The ability to correctly detect the presence
of a condition in patients who actually have
the condition
The ability to correctly detect the absence
of a condition in patients who actually do
not have the condition
Positive Predictive Value
The measure of the probability that patients
have the disease given a positive result
Negative Predictive Value
The measure of the probability that patients
do not have the disease given a negative
American Academy of Orofacial Pain. In: De Leeuw R, Klasser GD., editors. Orofacial
Pain: Guidelines for Assessment, Diagnosis, and Management. 5th ed. Chicago:
Quintessence; 2013. p. 129-30.
Okeson JP. The Clinical Management of Temporomandibular Disorders and Occlusion,
7th ed. St. Louis: Mosby; 2013.
Wanman A. Craniomandibular disorders in adolescents. A longitudinal study in an urban
Swedish population. Swed Dent J Suppl 1987;44:1-61.
Sessle BJ, Hu JW, Amano N, Zhong G. Convergence of cutaneous, tooth pulp, visceral,
neck and muscle afferents onto nociceptive and non-nociceptive neurones in trigeminal
subnucleus caudalis (medullary dorsal horn) and its implications for referred pain. Pain
De Kanter RJ, Truin GJ, Burgersdijk RC, Van 't Hof MA, Battistuzzi PG, Kalsbeek H, et
al. Prevalence in the Dutch adult population and a meta-analysis of signs and symptoms
of temporomandibular disorder. J Dent Res 1993;72(11):1509-18.
Schiffman EL, Fricton JR, Haley DP, Shapiro BL. The prevalence and treatment needs of
subjects with temporomandibular disorders. J Am Dent Assoc 1990;120(3):295-303.
LeResche L. Epidemiology of temporomandibular disorders: implications for the
investigation of etiologic factors. Crit Rev Oral Biol Med 1997;8(3):291-305.
LeResche L. Gender Considerations in the Epidemiology of Chronic Pain. In: Crombie
IK., editor. Epidemiology of Pain. Seattle: IASP Press; 1999. p. 43-52.
Levitt SR, McKinney MW. Validating the TMJ scale in a national sample of 10,000
patients: demographic and epidemiologic characteristics. J Orofac Pain 1994;8(1):25-35.
Sarlani E, Garrett PH, Grace EG, Greenspan JD. Temporal summation of pain
characterizes women but not men with temporomandibular disorders. J Orofac Pain
Robinson ME, Riley JL, Brown FF, Gremillion H. Sex differences in response to
cutaneous anesthesia: a double blind randomized study. Pain 1998;77(2):143-9.
Riley JL, Robinson ME, Wise EA, Myers CD, Fillingim RB. Sex differences in the
perception of noxious experimental stimuli: a meta-analysis. Pain 1998;74(2-3):181-7.
Manfredini D, Arveda N, Guarda-Nardini L, Segu M, Collesano V. Distribution of
diagnoses in a population of patients with temporomandibular disorders. Oral Surg Oral
Med Oral Pathol Oral Radiol 2012;114(5):e35-41.
Manfredini D, Guarda-Nardini L, Winocur E, Piccotti F, Ahlberg J, Lobbezoo F.
Research diagnostic criteria for temporomandibular disorders: a systematic review of axis
I epidemiologic findings. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
Dworkin SF, Huggins KH, LeResche L, Von Korff M, Howard J, Truelove E, et al.
Epidemiology of signs and symptoms in temporomandibular disorders: clinical signs in
cases and controls. J Am Dent Assoc 1990;120(3):273-81.
Simons DG, Travell JG, Simons LS. In: Simons DG, Travell JG, Simons LS., editors.
Travell & Simons‟ Myofascial pain and dysfunction: The trigger point manual. 2nd ed.
Baltimore: Williams and Wilkins; 1999.
Tallents RH, Katzberg RW, Murphy W, Proskin H. Magnetic resonance imaging findings
in asymptomatic volunteers and symptomatic patients with temporomandibular disorders.
J Prosthet Dent 1996;75(5):529-33.
Greene CS. The etiology of temporomandibular disorders: implications for treatment. J
Orofac Pain 2001;15(2):93-105; discussion 06-16.
De Boever JA, Carlsson GE. Etiology and differential diagnosis. In: Zarb GA, Carlsson
GE., editors. Management of temporomandibular disorders and occlusion. Copenhagen:
Munksgaard; 1994. p. 171-87.
Egermark I, Magnusson T, Carlsson GE. A 20-year follow-up of signs and symptoms of
temporomandibular disorders and malocclusions in subjects with and without orthodontic
treatment in childhood. Angle Orthod 2003;73(2):109-15.
Mohlin B, Ingervall B, Thilander B. Relation between malocclusion and mandibular
dysfunction in Swedish men. Eur J Orthod 1980;2(4):229-38.
Mohlin B, Thilander B. The importance of the relationship between malocclusion and
mandibular dysfunction and some clinical applications in adults. Eur J Orthod
Magnusson T, Egermark I, Carlsson GE. A longitudinal epidemiologic study of signs and
symptoms of temporomandibular disorders from 15 to 35 years of age. J Orofac Pain
Hirsch C, John MT, Stang A. Association between generalized joint hypermobility and
signs and diagnoses of temporomandibular disorders. Eur J Oral Sci 2008;116(6):525-30.
Westling L. Craniomandibular disorders and general joint mobility. Acta Odontol Scand
Pullinger AG, Seligman DA. Trauma history in diagnostic groups of temporomandibular
disorders. Oral Surg Oral Med Oral Pathol 1991;71(5):529-34.
Eriksson PO, Haggman-Henrikson B, Nordh E, Zafar H. Co-ordinated mandibular and
head-neck movements during rhythmic jaw activities in man. J Dent Res
Haggman-Henrikson B, Nordh E, Zafar H, Eriksson PO. Head immobilization can impair
jaw function. J Dent Res 2006;85(11):1001-5.
Eriksson PO, Haggman-Henrikson B, Zafar H. Jaw-neck dysfunction in whiplashassociated disorders. Arch Oral Biol 2007;52(4):404-8.
Gronqvist J, Haggman-Henrikson B, Eriksson PO. Impaired jaw function and eating
difficulties in whiplash-associated disorders. Swed Dent J 2008;32(4):171-7.
Martin MD, Wilson KJ, Ross BK, Souter K. Intubation risk factors for
temporomandibular joint/facial pain. Anesth Prog 2007;54(3):109-14.
Huang GJ, Rue TC. Third-molar extraction as a risk factor for temporomandibular
disorder. J Am Dent Assoc 2006;137(11):1547-54.
Slade GD, Diatchenko L, Bhalang K, Sigurdsson A, Fillingim RB, Belfer I, et al.
Influence of psychological factors on risk of temporomandibular disorders. J Dent Res
Johansson A, Unell L, Carlsson G, Soderfeldt B, Halling A, Widar F. Associations
between social and general health factors and symptoms related to temporomandibular
disorders and bruxism in a population of 50-year-old subjects. Acta Odontol Scand
Helenius LM, Hallikainen D, Helenius I, Meurman JH, Kononen M, Leirisalo-Repo M, et
al. Clinical and radiographic findings of the temporomandibular joint in patients with
various rheumatic diseases. A case-control study. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2005;99(4):455-63.
Wenneberg B, Kopp S. Clinical findings in the stomatognathic system in ankylosing
spondylitis. Scand J Dent Res 1982;90(5):373-81.
Ciancaglini R, Testa M, Radaelli G. Association of neck pain with symptoms of
temporomandibular dysfunction in the general adult population. Scand J Rehabil Med
Wiesinger B, Malker H, Englund E, Wanman A. Back pain in relation to musculoskeletal
disorders in the jaw-face: a matched case-control study. Pain 2007;131(3):311-9.
John MT, Miglioretti DL, LeResche L, Von Korff M, Critchlow CW. Widespread pain as
a risk factor for dysfunctional temporomandibular disorder pain. Pain 2003;102(3):25763.
Svensson P, Graven-Nielsen T. Craniofacial muscle pain: review of mechanisms and
clinical manifestations. J Orofac Pain 2001;15(2):117-45.
Smith MT, Wickwire EM, Grace EG, Edwards RR, Buenaver LF, Peterson S, et al. Sleep
disorders and their association with laboratory pain sensitivity in temporomandibular
joint disorder. Sleep 2009;32(6):779-90.
Edwards RR, Grace E, Peterson S, Klick B, Haythornthwaite JA, Smith MT. Sleep
continuity and architecture: associations with pain-inhibitory processes in patients with
temporomandibular joint disorder. Eur J Pain 2009;13(10):1043-7.
Diatchenko L, Slade GD, Nackley AG, Bhalang K, Sigurdsson A, Belfer I, et al. Genetic
basis for individual variations in pain perception and the development of a chronic pain
condition. Hum Mol Genet 2005;14(1):135-43.
Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC. The biopsychosocial approach to
chronic pain: scientific advances and future directions. Psychol Bull 2007;133(4):581624.
Suvinen TI, Reade PC, Kemppainen P, Kononen M, Dworkin SF. Review of aetiological
concepts of temporomandibular pain disorders: towards a biopsychosocial model for
integration of physical disorder factors with psychological and psychosocial illness
impact factors. Eur J Pain 2005;9(6):613-33.
Glazer A. High-yield biostatistics. Baltimore: Williams and Wilkins; 1995.
Hulley SB, Cummings SR. Planning the Measurements: Precision and Accuracy. In:
Hulley SB, Cummings SR., editors. Designing Clinical Research: An Epidemiologic
Approach. Baltimore: Williams and Wilkins; 1988. p. 31-41.
McNeill C, Mohl ND, Rugh JD, Tanaka TT. Temporomandibular disorders: diagnosis,
management, education, and research. J Am Dent Assoc 1990;120(3):253, 55, 57 passim.
Laskin DM, Greene CS. Diagnostic methods for temporomandibular disorders: what we
have learned in two decades. Anesth Prog 1990;37(2-3):66-71.
Goulet JP, Clark GT. Clinical TMJ examination methods. J Calif Dent Assoc
American Association of Dental Research TMD Policy Statement Revision (2010). Accessed December 27,
Clark GT, Tsukiyama Y, Baba K, Simmons M. The validity and utility of disease
detection methods and of occlusal therapy for temporomandibular disorders. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 1997;83(1):101-6.
Goulet JP, Clark GT, Flack VF, Liu C. The reproducibility of muscle and joint tenderness
detection methods and maximum mandibular movement measurement for the
temporomandibular system. J Orofac Pain 1998;12(1):17-26.
Royal College of Dental Surgeons of Ontario, Guidelines, Diagnosis & Management of
Temporomandibular Disorders & Related Musculoskeletal Disorders, Revised July 2009.
De Boever JA, Nilner M, Orthlieb JD, Steenks MH. Recommendations by the EACD for
examination, diagnosis, and management of patients with temporomandibular disorders
and orofacial pain by the general dental practitioner. J Orofac Pain 2008;22(3):268-78.
Brooks SL, Brand JW, Gibbs SJ, Hollender L, Lurie AG, Omnell KA, et al. Imaging of
the temporomandibular joint: a position paper of the American Academy of Oral and
Maxillofacial Radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
White SC, Pharoah MJ. Oral Radiology: Principles and Interpretation. 6th ed. St. Louis:
Mosby; 2009.
Bezuur JN, Habets LL, Jimenez Lopez V, Naeije M, Hansson TL. The recognition of
craniomandibular disorders--a comparison between clinical and radiographic findings in
eighty-nine subjects. J Oral Rehabil 1988;15(3):215-21.
Muir CB, Goss AN. The radiologic morphology of asymptomatic temporomandibular
joints. Oral Surg Oral Med Oral Pathol 1990;70(3):349-54.
Muir CB, Goss AN. The radiologic morphology of painful temporomandibular joints.
Oral Surg Oral Med Oral Pathol 1990;70(3):355-9.
Schiffman EL, Anderson GC, Fricton JR, Lindgren BR. The relationship between level of
mandibular pain and dysfunction and stage of temporomandibular joint internal
derangement. J Dent Res 1992;71(11):1812-5.
Eliasson S, Isacsson G. Radiographic signs of temporomandibular disorders to predict
outcome of treatment. J Craniomandib Disord 1992;6(4):281-7.
Lund JP, Widmer CG, Feine JS. Validity of diagnostic and monitoring tests used for
temporomandibular disorders. J Dent Res 1995;74(4):1133-43.
Hackney J, Bade D, Clawson A. Relationship between forward head posture and
diagnosed internal derangement of the temporomandibular joint. J Orofac Pain
Darlow LA, Pesco J, Greenberg MS. The relationship of posture to myofascial pain
dysfunction syndrome. J Am Dent Assoc 1987;114(1):73-5.
Armijo Olivo S, Magee DJ, Parfitt M, Major P, Thie NM. The association between the
cervical spine, the stomatognathic system, and craniofacial pain: a critical review. J
Orofac Pain 2006;20(4):271-87.
Armijo-Olivo S, Rappoport K, Fuentes J, Gadotti IC, Major PW, Warren S, et al. Head
and cervical posture in patients with temporomandibular disorders. J Orofac Pain
Olivo SA, Bravo J, Magee DJ, Thie NM, Major PW, Flores-Mir C. The association
between head and cervical posture and temporomandibular disorders: a systematic
review. J Orofac Pain 2006;20(1):9-23.
Rocha CP, Croci CS, Caria PH. Is there relationship between temporomandibular
disorders and head and cervical posture? A systematic review. J Oral Rehabil
Sessle BJ. Sensory and Motor Neurophysiology of the TMJ. In: Laskin DM, Greene CS,
Hylander WL., editors. Temporomandibular Disorders. An Evidence-Based Approach to
Diagnosis and Treatment. Chicago: Quintessence; 2006. p. 69-88.
Tal M, Devor M. Anatomy and Neurophysiology of Orofacial Pain. In: Sharav Y,
Benoliel R., editors. Orofacial Pain and Headache. Edinburgh: Elsevier; 2008. p. 19-44.
Major PW, Kinniburgh RD, Nebbe B, Prasad NG, Glover KE. Tomographic assessment
of temporomandibular joint osseous articular surface contour and spatial relationships
associated with disc displacement and disc length. Am J Orthod Dentofacial Orthop
Pullinger AG, Seligman DA. Multifactorial analysis of differences in temporomandibular
joint hard tissue anatomic relationships between disk displacement with and without
reduction in women. J Prosthet Dent 2001;86(4):407-19.
Westesson PL, Katzberg RW, Tallents RH, Sanchez-Woodworth RE, Svensson SA. CT
and MR of the temporomandibular joint: comparison with autopsy specimens. AJR Am J
Roentgenol 1987;148(6):1165-71.
Honda K, Larheim TA, Maruhashi K, Matsumoto K, Iwai K. Osseous abnormalities of
the mandibular condyle: diagnostic reliability of cone beam computed tomography
compared with helical computed tomography based on an autopsy material.
Dentomaxillofac Radiol 2006;35(3):152-7.
Hussain AM, Packota G, Major PW, Flores-Mir C. Role of different imaging modalities
in assessment of temporomandibular joint erosions and osteophytes: a systematic review.
Dentomaxillofac Radiol 2008;37(2):63-71.
Rinchuse DJ, Kandasamy S. Articulators in orthodontics: an evidence-based perspective.
Am J Orthod Dentofacial Orthop 2006;129(2):299-308.
Pullinger AG, Seligman DA. The degree to which attrition characterizes differentiated
patient groups of temporomandibular disorders. J Orofac Pain 1993;7(2):196-208.
Alexander SR, Moore RN, DuBois LM. Mandibular condyle position: comparison of
articulator mountings and magnetic resonance imaging. Am J Orthod Dentofacial Orthop
Schmitter M, Gabbert O, Ohlmann B, Hassel A, Wolff D, Rammelsberg P, et al.
Assessment of the reliability and validity of panoramic imaging for assessment of
mandibular condyle morphology using both MRI and clinical examination as the gold
standard. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102(2):220-4.
Epstein JB, Caldwell J, Black G. The utility of panoramic imaging of the
temporomandibular joint in patients with temporomandibular disorders. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 2001;92(2):236-9.
Harrison DE, Haas JW, Cailliet R, Harrison DD, Holland B, Janik TJ. Concurrent
validity of flexicurve instrument measurements: sagittal skin contour of the cervical spine
compared with lateral cervical radiographic measurements. J Manipulative Physiol Ther
van Niekerk SM, Louw Q, Vaughan C, Grimmer-Somers K, Schreve K. Photographic
measurement of upper-body sitting posture of high school students: a reliability and
validity study. BMC Musculoskelet Disord 2008;9:113.
Grimmer-Somers K, Milanese S, Louw Q. Measurement of cervical posture in the
sagittal plane. J Manipulative Physiol Ther 2008;31(7):509-17.
Lund JP, Lavigne G, Feine JS, Goulet JP, Chaytor DV, Sessle BJ, et al. The use of
electronic devices in the diagnosis and treatment of temporomandibular disorders. J Can
Dent Assoc 1989;55(9):749-50.
Management of Temporomandibular Disorders. National Institutes of Health Technology
Assessment Conference Statement. J Am Dent Assoc 1996;127(11):1595-606.
Mohl ND, Lund JP, Widmer CG, McCall WD. Devices for the diagnosis and treatment of
temporomandibular disorders. Part II: Electromyography and sonography. J Prosthet
Dent 1990;63(3):332-6.
Majewski RF, Gale EN. Electromyographic activity of anterior temporal area pain
patients and non-pain subjects. J Dent Res 1984;63(10):1228-31.
Klasser GD, Okeson JP. The clinical usefulness of surface electromyography in the
diagnosis and treatment of temporomandibular disorders. J Am Dent Assoc
Suvinen TI, Kemppainen P. Review of clinical EMG studies related to muscle and
occlusal factors in healthy and TMD subjects. J Oral Rehabil 2007;34(9):631-44.
Armijo-Olivo S, Gadotti I, Kornerup M, Lagravere MO, Flores-Mir C. Quality of
reporting masticatory muscle electromyography in 2004: a systematic review. J Oral
Rehabil 2007;34(6):397-405.
Manfredini D, Cocilovo F, Favero L, Ferronato G, Tonello S, Guarda-Nardini L. Surface
electromyography of jaw muscles and kinesiographic recordings: diagnostic accuracy for
myofascial pain. J Oral Rehabil 2011;38(11):791-9.
Manfredini D, Castroflorio T, Perinetti G, Guarda-Nardini L. Dental occlusion, body
posture and temporomandibular disorders: where we are now and where we are heading
for. J Oral Rehabil 2012;39(6):463-71.
Al-Saleh MA, Armijo-Olivo S, Flores-Mir C, Thie NM. Electromyography in diagnosing
temporomandibular disorders. J Am Dent Assoc 2012;143(4):351-62.
Widmer CG, Lund JP, Feine JS. Evaluation of diagnostic tests for TMD. J Calif Dent
Assoc 1990;18(3):53-60.
Baba K, Tsukiyama Y, Yamazaki M, Clark GT. A review of temporomandibular disorder
diagnostic techniques. J Prosthet Dent 2001;86(2):184-94.
Feine JS, Hutchins MO, Lund JP. An evaluation of the criteria used to diagnose
mandibular dysfunction with the mandibular kinesiograph. J Prosthet Dent
Theusner J, Plesh O, Curtis DA, Hutton JE. Axiographic tracings of temporomandibular
joint movements. J Prosthet Dent 1993;69(2):209-15.
Tsolka P, Preiskel HW. Kinesiographic and electromyographic assessment of the effects
of occlusal adjustment therapy on craniomandibular disorders by a double-blind method.
J Prosthet Dent 1993;69(1):85-92.
Manfredini D, Favero L, Michieli M, Salmaso L, Cocilovo F, Guarda-Nardini L. An
assessment of the usefulness of jaw kinesiography in monitoring temporomandibular
disorders: correlation of treatment-related kinesiographic and pain changes in patients
receiving temporomandibular joint injections. J Am Dent Assoc 2013;144(4):397-405.
Christensen LV. Physics and the sounds produced by the temporomandibular joints. Part
II. J Oral Rehabil 1992;19(6):615-27.
Paiva G, Paiva PF, de Oliveira ON. Vibrations in the temporomandibular joints in
patients examined and treated in a private clinic. Cranio 1993;11(3):202-5.
Wabeke KB, Spruijt RJ, van der Weyden KJ, Naeije M. Evaluation of a technique for
recording temporomandibular joint sounds. J Prosthet Dent 1992;68(4):676-82.
Christensen LV, Donegan SJ, McKay DC. Temporomandibular joint vibration analysis in
a sample of non-patients. Cranio 1992;10(1):35-41; discussion 41-2.
Ishigaki S, Bessette RW, Maruyama T. Vibration analysis of the temporomandibular
joints with meniscal displacement with and without reduction. Cranio 1993;11(3):192201.
Tallents RH, Hatala M, Katzberg RW, Westesson PL. Temporomandibular joint sounds
in asymptomatic volunteers. J Prosthet Dent 1993;69(3):298-304.
Widmer CG. Temporomandibular joint sounds: a critique of techniques for recording and
analysis. J Craniomandib Disord 1989;3(4):213-7.
Gross A, Gale EN. A prevalence study of the clinical signs associated with mandibular
dysfunction. J Am Dent Assoc 1983;107(6):932-6.
Westesson PL, Eriksson L, Kurita K. Reliability of a negative clinical
temporomandibular joint examination: prevalence of disk displacement in asymptomatic
temporomandibular joints. Oral Surg Oral Med Oral Pathol 1989;68(5):551-4.
Kircos LT, Ortendahl DA, Mark AS, Arakawa M. Magnetic resonance imaging of the
TMJ disc in asymptomatic volunteers. J Oral Maxillofac Surg 1987;45(10):852-4.
Sharma S, Crow HC, McCall WD, Gonzalez YM. Systematic review of reliability and
diagnostic validity of joint vibration analysis for diagnosis of temporomandibular
disorders. J Orofac Pain 2013;27(1):51-60.
International Association for the Study of Pain. Lavigne G, Sessle BJ, Chorniere M, Soja
PJ., editors. Sleep and Pain. Seattle: IASP Press; 2007.
Yatani H, Studts J, Cordova M, Carlson CR, Okeson JP. Comparison of sleep quality and
clinical and psychologic characteristics in patients with temporomandibular disorders. J
Orofac Pain 2002;16(3):221-8.
Cunali PA, Almeida FR, Santos CD, Valdrighi NY, Nascimento LS, Dal'Fabbro C, et al.
Prevalence of temporomandibular disorders in obstructive sleep apnea patients referred
for oral appliance therapy. J Orofac Pain 2009;23(4):339-44.
Sanders AE, Essick GK, Fillingim R, Knott C, Ohrbach R, Greenspan JD, et al. Sleep
apnea symptoms and risk of temporomandibular disorder: OPPERA cohort. J Dent Res
2013;92(7 Suppl):70S-7S.
Hoffmann RG, Kotchen JM, Kotchen TA, Cowley T, Dasgupta M, Cowley AW.
Temporomandibular disorders and associated clinical comorbidities. Clin J Pain
Kushida CA, Littner MR, Morgenthaler T, Alessi CA, Bailey D, Coleman J, et al.
Practice parameters for the indications for polysomnography and related procedures: an
update for 2005. Sleep 2005;28(4):499-521.
Gauthier L, Almeida F, Arcache JP, Ashton-McGregor C, Cote D, Driver HS, et al.
Position paper by Canadian dental sleep medicine professionals on the role of different
health care professionals in managing obstructive sleep apnea and snoring with oral
appliances. Can Respir J 2012;19(5):307-9.
Bailey DR, Attanasio R. Screening and comprehensive evaluation for sleep related
breathing disorders. Dent Clin North Am 2012;56(2):331-42.
Kohler M, Bloch KE, Stradling JR. The role of the nose in the pathogenesis of
obstructive sleep apnea. Curr Opin Otolaryngol Head Neck Surg 2009;17(1):33-7.
Georgalas C. The role of the nose in snoring and obstructive sleep apnoea: an update. Eur
Arch Otorhinolaryngol 2011;268(9):1365-73.
Meen EK, Chandra RK. The role of the nose in sleep-disordered breathing. Am J Rhinol
Allergy 2013;27(3):213-20.
Viviano JS. Acoustic reflection: review and clinical applications for sleep-disordered
breathing. Sleep Breath 2002;6(3):129-49.
Bailey D. Oral and Nasal Airway Screening by the Dentist. Sleep Med Clin 2010;5(1):18.
Kushida CA, Morgenthaler TI, Littner MR, Alessi CA, Bailey D, Coleman J, et al.
Practice parameters for the treatment of snoring and Obstructive Sleep Apnea with oral
appliances: an update for 2005. Sleep 2006;29(2):240-3.
Stohler CS, Zarb GA. On the management of temporomandibular disorders: a plea for a
low-tech, high-prudence therapeutic approach. J Orofac Pain 1999;13(4):255-61.
Greene CS, Laskin DM. Temporomandibular disorders: moving from a dentally based to
a medically based model. J Dent Res 2000;79(10):1736-9.
Turp JC, Jokstad A, Motschall E, Schindler HJ, Windecker-Getaz I, Ettlin DA. Is there a
superiority of multimodal as opposed to simple therapy in patients with
temporomandibular disorders? A qualitative systematic review of the literature. Clin Oral
Implants Res 2007;18 Suppl 3:138-50.
Fricton J. Current evidence providing clarity in management of temporomandibular
disorders: summary of a systematic review of randomized clinical trials for intra-oral
appliances and occlusal therapies. J Evid Based Dent Pract 2006;6(1):48-52.
Turp JC, Komine F, Hugger A. Efficacy of stabilization splints for the management of
patients with masticatory muscle pain: a qualitative systematic review. Clin Oral Investig
Gagnon Y, Mayer P, Morisson F, Rompre PH, Lavigne GJ. Aggravation of respiratory
disturbances by the use of an occlusal splint in apneic patients: a pilot study. Int J
Prosthodont 2004;17(4):447-53.
Nikolopoulou M, Ahlberg J, Visscher CM, Hamburger HL, Naeije M, Lobbezoo F.
Effects of occlusal stabilization splints on obstructive sleep apnea: a randomized
controlled trial. J Orofac Pain 2013;27(3):199-205.
Nikolopoulou M, Naeije M, Aarab G, Hamburger HL, Visscher CM, Lobbezoo F. The
effect of raising the bite without mandibular protrusion on obstructive sleep apnoea. J
Oral Rehabil 2011;38(9):643-7.
Hiyama S, Ono T, Ishiwata Y, Kato Y, Kuroda T. First night effect of an interocclusal
appliance on nocturnal masticatory muscle activity. J Oral Rehabil 2003;30(2):139-45.
Yap AU. Effects of stabilization appliances on nocturnal parafunctional activities in
patients with and without signs of temporomandibular disorders. J Oral Rehabil
Holmgren K, Sheikholeslam A, Riise C. Effect of a full-arch maxillary occlusal splint on
parafunctional activity during sleep in patients with nocturnal bruxism and signs and
symptoms of craniomandibular disorders. J Prosthet Dent 1993;69(3):293-7.
Solberg WK, Clark GT, Rugh JD. Nocturnal electromyographic evaluation of bruxism
patients undergoing short term splint therapy. J Oral Rehabil 1975;2(3):215-23.
Farrar WB. Differentiation of temporomandibular joint dysfunction to simplify treatment.
J Prosthet Dent 1972;28(6):629-36.
Spitzer WO, Skovron ML, Salmi LR, Cassidy JD, Duranceau J, Suissa S, et al. Scientific
monograph of the Quebec Task Force on Whiplash-Associated Disorders: redefining
"whiplash" and its management. Spine 1995;20(8 Suppl):1S-73S.
Haggman-Henrikson B, List T, Westergren HT, Axelsson SH. Temporomandibular
disorder pain after whiplash trauma: a systematic review. J Orofac Pain 2013;27(3):21726.
Fernandez CE, Amiri A, Jaime J, Delaney P. The relationship of whiplash injury and
temporomandibular disorders: a narrative literature review. J Chiropr Med
Sale H, Isberg A. Delayed temporomandibular joint pain and dysfunction induced by
whiplash trauma: a controlled prospective study. J Am Dent Assoc 2007;138(8):1084-91.
Poorbaugh K, Brismee JM, Phelps V, Sizer PS, Jr. Late whiplash syndrome: a clinical
science approach to evidence-based diagnosis and management. Pain Pract 2008;8(1):6587; quiz 88-9.
Schofferman J, Bogduk N, Slosar P. Chronic whiplash and whiplash-associated
disorders: an evidence-based approach. J Am Acad Orthop Surg 2007;15(10):596-606.
Williams M, Williamson E, Gates S, Lamb S, Cooke M. A systematic literature review of
physical prognostic factors for the development of Late Whiplash Syndrome. Spine
Scholten-Peeters GG, Verhagen AP, Bekkering GE, van der Windt DA, Barnsley L,
Oostendorp RA, et al. Prognostic factors of whiplash-associated disorders: a systematic
review of prospective cohort studies. Pain 2003;104(1-2):303-22.
Kolbinson DA, Epstein JB, Burgess JA. Temporomandibular disorders, headaches, and
neck pain following motor vehicle accidents and the effect of litigation: review of the
literature. J Orofac Pain 1996;10(2):101-25.
Epstein JB. Temporomandibular disorders, facial pain and headache following motor
vehicle accidents. J Can Dent Assoc 1992;58(6):488-9, 93-5.
Klobas L, Tegelberg A, Axelsson S. Symptoms and signs of temporomandibular
disorders in individuals with chronic whiplash-associated disorders. Swed Dent J
Grushka M, Ching VW, Epstein JB, Gorsky M. Radiographic and clinical features of
temporomandibular dysfunction in patients following indirect trauma: a retrospective
study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104(6):772-80.
Goldberg MB, Mock D, Ichise M, Proulx G, Gordon A, Shandling M, et al.
Neuropsychologic deficits and clinical features of posttraumatic temporomandibular
disorders. J Orofac Pain 1996;10(2):126-40.
Romanelli GG, Mock D, Tenenbaum HC. Characteristics and response to treatment of
posttraumatic temporomandibular disorder: a retrospective study. Clin J Pain
Okeson JP, Phillips BA, Berry DT, Cook YR, Cabelka JF. Nocturnal bruxing events in
subjects with sleep-disordered breathing and control subjects. J Craniomandib Disord
Miyawaki S, Lavigne GJ, Pierre M, Guitard F, Montplaisir JY, Kato T. Association
between sleep bruxism, swallowing-related laryngeal movement, and sleep positions.
Sleep 2003;26(4):461-5.
Phillips BA, Okeson J, Paesani D, Gilmore R. Effect of sleep position on sleep apnea and
parafunctional activity. Chest 1986;90(3):424-9.
Yoshida K. A polysomnographic study on masticatory and tongue muscle activity during
obstructive and central sleep apnea. J Oral Rehabil 1998;25(8):603-9.
Hollowell DE, Bhandary PR, Funsten AW, Suratt PM. Respiratory-related recruitment of
the masseter: response to hypercapnia and loading. J Appl Physiol (1985)
Hollowell DE, Suratt PM. Activation of masseter muscles with inspiratory resistance
loading. J Appl Physiol (1985) 1989;67(1):270-5.