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Transcript
Manitoba Public Insurance Corporation
Assessment and Treatment of Temporomandibular Disorders (TMD): Best
Practices
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
1
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
2
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
3
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
2
, 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,
4
(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
5
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
6
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
7
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
8
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,
71
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
9
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
10
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.
11
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.
12
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
13
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
14
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.
15
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
16
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,
17
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
18
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
treatment.
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.
19
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
20
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
21
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.
22
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
23
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
24
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
25
Table 1. Diagnostic tests and applications.
Category
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
26
Table 2. Efficacy of a diagnostic test.
Term
Definition
Reliability
Measurement of a phenomenon that can be
repeated (degree of consistency)
Validity
The means that the phenomenon being
measured was truthful (accuracy of
measurements)
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
diagnose
Sensitivity
The ability to correctly detect the presence
of a condition in patients who actually have
the condition
Specificity
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
result
27
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