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Temporomandibular disorders: Standard
treatment options
Wesley E. Shankland II, DDS, MS, PhD, FAGD
Proper diagnosis is essential in all phases of health care, and dentistry certainly is no
exception. Without a proper diagnosis, effective treatment may never be rendered
and the patient’s suffering and costs will continue to escalate. Dentists who treat
patients who have temporomandibular disorders (TMDs) and orofacial pain also
must strive to stay abreast of the latest treatment options.
This article summarizes the current recommended treatment options for TMDs.
Because it would be virtually impossible to cover every type of treatment
available, only standard recognized types of treatment will be presented.
Received: September 2, 2003
Within the confines of general practice,
dentists today may be as limited or as
diverse concerning available treatment
modalities as they choose. Regardless of
the type of practice today’s dentist may
develop, the need to accurately diagnose
those disorders that affect the temporomandibular joints (TMJs) remains an
issue at the foundation of every practice. The decision to subsequently provide treatment is a second issue that
must be addressed but proper diagnosis
is most important. Otherwise, patients
will either suffer from supervised neglect or seek help from other doctors, a
quest that often results in increased
health care costs and chronic suffering
and frustration for the patient and his
or her family.
The term temporomandibular disorders (TMDs) is a collective term that includes a number of clinical diagnoses involving the TMJs, the masticatory musculature, and associated structures excluding pain of dental origin. TMDs are
considered to be a subclassification of
musculoskeletal disorders.1
This article is a general summary of
initial TMD treatment, also known as
Phase I Therapy or reversible treatment.
Specific diagnostic procedures and definitive treatment, also referred to as
Phase II Therapy (occlusal equilibration,
orthodontics, occlusal reconstruction,
overlay removable partial dentures, joint
and/or orthognathic surgery), will not be
discussed.
Accepted: September 25, 2003
Standard of care
What is the standard of care concerning
TMDs? For example, should the dentist
who limits his or her practice to esthetics
be held to the same standard as one who
actively cares for TMD patients? What
about those engaged primarily in implantology or any other type of dental
practice?
A 1982 ADA Presidential Conference
determined that all dental patients (emphasis added), not just TMD patients,
should receive a review of medical and
dental history, a thorough dental examination, and a brief screening history and
examination relating to TMDs.2 For patients whose screening history and examination result in positive findings, a second and more comprehensive assessment
also was recommended.
Eight years later, McNeill et al
strengthened the ADA’s opinion by stating that screening is an essential part of
the routine dental examination for all patients and that a TMD diagnosis is based
on evaluation of patient history, clinical
examination, and TMJ imaging, when
appropriate.3
The American Academy of Craniofacial Pain (AACP) actively established the
standard of care when screening patients
for possible TMDs. As far back as 1990,
the AACP published guidelines pertaining specifically to TMD, stating that routine examination of a dental patient
should include a basic screening for
TMD and that every dentist should be
obligated to screen all new and all reevaluated patients.4
Another influential academy, the
American Academy of Orofacial Pain
(AAOP), recommended in 1993 that
screening for TMD (consisting of a
questionnaire, brief history, and examination) should be an essential part of
the routine dental examination.5 Realizing the importance of this topic, the
AAOP embellished their earlier recommendations in 1996 by stating that a
TMD and orofacial pain screening evaluation (consisting of a questionnaire,
brief history, and examination) is appropriate for all dental patients.6
Gremillion and Reams supported these
recommendations in 1997 as “an essential component of routine dental or
medical examination.”7
As a result of these recommendations, dentists, regardless of their specialty or type of practice, will be held to
standards that include screening all patients for TMD and orofacial pain disorders, asking specific questions concerning a patient’s dental and medical
histories, and performing a brief examination. If an examination for TMDs
produces positive results, the dentist
must perform a more thorough examination or refer the patient to a colleague
who treats these disorders.8
Treatment categories
Treatment for TMDs has been discussed
in the literature for at least two centuries
but categories of treatment options have
been established only during the last two
decades.9,10 Disagreement and controversy remain among those who are active in
diagnosing and treating TMDs and orofacial pain but such disagreements have
been reduced in the last several years.
Initially, Weinberg divided TMD
treatment into three general categories:
palliative therapy, causative therapy, and
adjunctive therapy.11 Other authors have
suggested a fourth category, known as
definitive therapy.10
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349
Myofascial Pain/Occlusion
DART
Table. Examples of medications effective in palliative treatment for TMD.*
Medication
Metaxalone
Chlorzoxazone
Rofecoxib
Celecoxib
Valdecoxib
Nortriptyline
Amitriptyline
Category
Muscle relaxant
Muscle relaxant
COX-2 inhibitor
COX-2 inhibitor
COX-2 inhibitor
Antidepressant
Antidepressant
Standard use
Reduces muscle hyperactivity and pain
Reduces muscle hyperactivity and pain
Reduces inflammation and pain
Reduces inflammation and pain
Reduces inflammation and pain
Improves quality of sleep (in low doses)
Improves quality of sleep
Approximate dosage
400–800 mg every six hours
500 mg every six hours
25–50 mg every day
100–200 mg every day
10 mg every day
10–25 mg at bedtime
10–25 mg at bedtime
*These represent a random sample of available medications; this list is not inclusive.
Palliative therapy
Palliative therapy is used to reduce pain
and improve mandibular function. This
therapy includes procedures such as temporary intraoral appliances, medications,
home remedies (for example, ice, moist
heat, exercises, and a soft diet), and even
voluntary disengagement of the teeth.
TEMPORARY APPLIANCES
The temporary use of intraoral appliances can help to reduce pain and establish an accurate diagnosis. With this type
of therapy, an appliance is used to decrease symptoms, not to place the mandible in a new or therapeutic position.
For example, if a patient suffers from articular disc displacement in one or both
joints or if the pain symptoms are caused
by muscle pain, an appropriate form of
palliative therapy would involve a flat or
superior repositioning appliance that
does not alter the mandibular position
but provides neuromuscular relaxation.
MEDICATIONS
Medications are very helpful in palliative
treatment and can be the appropriate
therapy for acute cases. Unnecessary
treatments can be avoided by using
the proper medication. The newer cyclooxygenase-2 (COX-2) inhibitors can attack
inflammation aggressively and successfully. Rofecoxib (Vioxx, Merck, Whitehouse
Station, NJ; 888.637.2502), celecoxib
(Celebrex, Pfizer Inc., New York, NY;
800.223.0182), and valdecoxib (Bextra,
Pfizer Inc.) are effective for reducing pain
and swelling caused by muscle problems,
inflammation, displaced articular discs, or
degenerative arthritis (see the table).
Other medications also are effective for
the palliative treatment of TMD. Metaxalone (Skelaxin, King Pharmaceuticals,
Bristol, TN; 800.776.3637) can provide
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General Dentistry
muscle relaxation without the common
problems of sedation. Chlorzoxazone
(Parafon Forte, Ortho-McNeil Pharmaceutical, Raritan, NJ; 800.682.6532) is another effective muscle relaxant.
A tricyclic antidepressant, used in low
doses, can assist in reducing musculoskeletal spasms and pain. Nortriptyline (Pamelor, Novartis Pharmaceuticals, East Hanover, NJ; 800.257.3273) and amitriptyline
are effective in reducing TMD pain and increasing overall effectiveness of other
modalities of treatment.12,13
Prescription medications are not the
only pharmacological aids available; integrative medicine (the combination of
traditional training and alternative medicine) has had a great impact on all areas
of medicine and dentistry, including
TMD therapy. The use of herbs, supplements, vitamins, and even essential oils is
recommended and taught by many reputable institutes and continuing education sponsors. Magnesium (400 mg) is
very effective at reducing muscle pain
and tightness without the potential side
effects of prescription medication. Glucosamine and chondroitin sulfate used in
combination with vitamin C and increased water consumption are beneficial
for reducing the pain and swelling of
joint inflammation; dentists can use glucosamine sulfate, chondroitin sulfate, or
both in combination in lieu of antiinflammatory medications such as ibuprofen, thus reducing the possible side effects
of gastrointestinal irritation, decreased
platelet aggregation, and liver damage.14-16
MOIST HEAT AND ICE
Moist heat (for inflammation) and ice
(for swelling) are simple yet effective
forms of palliative therapy. Because the
effectiveness of these modalities is transitory, prolonged problems also may re-
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quire the use of anti-inflammatory medications. Moist heat opens the capillary
beds to promote increased blood flow; in
addition, it is excellent as a muscle conditioner prior to exercise or physical therapy. However, moist heat should be withheld for approximately 72 hours after an
acute injury, while ice is quite effective for
reducing muscle swelling and pain, especially in acute situations.17
ETHYL CHLORIDE
Ethyl chloride spray can reduce musculoskeletal pain and myospasms and is
very effective at reducing or eliminating
myofascial trigger points when used in
conjunction with moist heat.18 These tiny
areas of hypercontraction within muscles
produce pain and limit motion when active. A common example seen by dentists
involves a chronic clencher who, during
an episode of increased stress, develops
sudden masseteric pain, especially when
attempting to open his or her mouth for
any normal mandibular activity. Applying ethyl chloride in fine, parallel sweeps
over the skin of the muscle (followed by
the application of moist heat) often eliminates the masseteric trigger points, removing the need for further treatment.
EXERCISES
Home exercises are an excellent method
for treating a patient’s symptoms, getting
the patient and family members actively
involved in the patient’s therapy. Fast, active, aerobic exercises should be avoided;
passive stretching—that is, keeping the
muscle fibers relaxed while slowly stretching the muscle, preventing it from tightening via the stretch reflex—in conjunction with moist heat (followed by the
application of ice) is beneficial for decreasing muscle and joint pain and for
improving ranges of motion.
Causative therapy
Eliminating the etiological factors that
contribute to TMDs is the goal of
causative therapy. For most dentists,
such therapy involves treating intra-articular disorders (for example, capsulitis,
displaced articular discs, and osteoarthritis) or one of the various muscle disorders that affect the mastication muscles.
ANTERIOR REPOSITIONING APPLIANCE
Anterior repositioning appliances have
been advocated by the scientific, peer-reviewed literature for more than 50 years.19
These appliances are used to treat TMJ
internal derangements, which Dolwick
defined as “an abnormal relationship of
the articular disc to the mandibular
condyle, fossa, and articular eminence
with the disc usually displaced in an anteromedial direction.”20 Since these types
of orthopedic devices were popularized
by Farrar in 1977 and Gelb in 1983, the
theory behind this appliance has been
taught in continuing education programs.21,22 The recent literature is replete
with articles and studies concerning the
use and efficacy of anterior repositioning
appliances for treating anteriorly displaced articular discs of the TMJs.10,23-35
Based upon clinical experience and the
literature, anterior repositioning appliances appear to be more effective than
the flat-plane occlusal splint in eliminating joint clicking, joint and headache
pain, and muscle pain from a dislocated
joint.25,33,34,36,37
TMJ clicking generally indicates discal
dislocation.38 Dislocations that do not require treatment include those that have
developed very slowly over a period of
years, those that do not lock, and those
that do not produce headaches, TMJ
pain, ear pain (and occasional ear pressure), reduced range of mandibular motion, and masticatory muscle pain.
A reciprocal click is a click in the joint
that occurs upon opening and closing.
This type of clicking (compared to an
opening click with no closing click) can
be treated successfully with an anterior
repositioning appliance, especially if the
clicking occurs early in the opening
phase. It appears that such therapy offers
more success to younger patients.39
The diagnosis of an anteriorly displaced articular disc usually is confirmed
by medical history, various imaging techniques, and successful reduction of the
dislocation by placing the mandible in an
anterior position. Historically, joint
clicking occurs most often after a traumatic episode, such as blunt trauma to
the mandible or head, intubation during
general anesthesia, prolonged opening in
the dental office, or even indirect trauma
during a motor vehicle accident.25 In addition, many young females have developed a displaced articular disc with no
known cause and ligament laxity—a condition that affects load-bearing joints as
well as the TMJ—as the only common
factor.40-42
Some type of joint image is necessary
to confirm an anterior discal displacement with subsequent posterior and superior displacement of the mandibular
condyle. Magnetic resonance imaging
(MRI) is the finest method for viewing
the position of the articular disc, although the cost often is prohibitive. A
panoramic radiograph is appropriate for
identifying fractures, lesions in the maxilla and mandible, and gross degenerative
TMJ changes; however, this type of imaging is totally inaccurate when evaluating
condylar position because it artificially
displaces the mandible into an anterior
position to keep it in focus.
Computerized tomography (CT) is
the most accurate radiographic technique but it is rather complicated and the
equipment is cost-prohibitive unless the
dentist treats many TMD patients. The
transcranial lateral oblique technique is
the simplest and most reasonable way for
dentists to image the TMJ in the office.43
This technique is valuable but limited because of the image distortion and superimposition of bony structures; however,
these limitations are more a function of
interpretation than of the technique itself.44,45 Although transcranial radiography requires training in radiographic
technique and interpretation, it is accurate and fulfills the standard of care for
imaging the joint.21,22,37 In addition, the
equipment is inexpensive and additional
office space is not required.
Manipulating the mandible is the
most reliable method for diagnosing a
discal dislocation. A click that occurs
upon opening the mouth is the point at
which the articular disc actually goes
back into place; from an orthopedic
standpoint, this is the point when the discal dislocation is reduced. If a click is
heard frequently when the patient closes,
it means that the disc is being displaced
and the discal dislocation has developed
once again.
To confirm a distal dislocation, instruct the patient to open his or her
mouth until a click is heard or felt; at that
point, the patient should close, bringing
the mandible slightly forward until the
incisors are almost at an end-to-end position. The discal dislocation has been reduced successfully when the patient can
open and close at this mandibular position without hearing or feeling joint
clicking. Holding the mandible in this
anterior position with an anterior repositioning appliance can eliminate clicking
and locking and provide partial or total
pain relief within a few days.
Summer and Westesson reported such
relief in a 1997 study, noting that of 75
patients, 92% found relief by using an anterior repositioning appliance.46 Such an
orthopedic device must either cover all
the teeth of one arch or incorporate the
anterior determinants of occlusion (such
as anterior guidance and canine disclusion) to avoid intrusion or overeruption
of teeth.47,48 Patients must wear this appliance at all times, even while eating.49
While some authors have questioned
the efficacy of anterior repositioning appliances, it appears that if one does not
use joint sounds as the criterion for successful treatment, patients report a success rate of up to 75% in the reduction of
joint locking/pain, headaches, and ear
pain.27,50-52
Since many patients treated with anterior repositioning therapy are comfortable only in the anterior mandibular position, some ultimately will require Phase
II (definitive, irreversible) therapy, such
as orthodontic treatment, restorative
treatment, orthognathic surgery, or a
combination. The doctor must inform
each patient who uses the anterior repositioning appliance that such definitive
treatment may be necessary and document such disclosure in the patient’s
record.
Some authors maintain (and clinical
experience confirms) that not all chronically dislocated joints need treatment, especially those that do not lock or cause
pain.52,53 The ones that manifest pain
symptoms and joint clicking and/or
locking do not appear to improve spontaneously without treatment; the disappearance of joint clicking does not necessarily
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351
indicate that joint healing has occurred.54
In such cases, palliative therapy may be
appropriate. If unresolvable symptoms
persist, the patient may require splint
therapy.55
The pivot appliance is another type of
repositioning appliance; it is used to unlock articular discs. It usually is fabricated over the mandibular posterior teeth so
that only the maxillary first or second
molars contact the splint.56,57 In theory,
the anterior teeth tend to move closer together when the maxillary first molars
contact the pivot or the appliance’s raised
acrylic stop, creating a fulcrum around
the acrylic contact. This contact causes
the condyles to pivot down and away
from the mandibular or glenoid fossa,
which ultimately unlocks the joint. After
discal reduction, the pivot appliance is
converted into an anterior repositioning
appliance. This appliance should only be
used under strict supervision and for
only a few weeks to prevent orthodontic
movement of maxillary teeth.
SUPERIOR REPOSITIONING APPLIANCE
Known by numerous names, including
gnathologic appliance, centric relation
splint, stabilization splint, flat-plane splint,
anti-bruxism appliance, and occlusal appliance, the superior repositioning appliance is used to treat bruxism, muscle
hyperactivity, and muscle pain.58-60 Regardless of the name, the appliance’s major purpose is to provide neuromuscular
relaxation via the trigeminal afferent
neurons, first through the mesencephalic
nucleus and then through the motor nucleus. Through this complex reflex, the
motor innervation to the elevator muscles (that is, the temporalis, masseter, superior head of the lateral pterygoid and
the zygomandibularis) is adjusted, producing a neuromuscular relaxated position of the mandible that is independent
from the occluding surfaces of the opposing teeth.61
The superior repositioning appliance
covers all of the teeth in either the maxilla or mandible. Mechanically, there is no
difference which arch is used as long as all
of the teeth in the arch are covered, the
determinants of occlusion (anterior
guidance, posterior disclusion of the
teeth in lateral mandibular movements,
and canine disclusion) are in the splint’s
construction, and the vertical thickness is
kept to a minimum (1.0–2.0 mm).
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General Dentistry
Some dentists prefer to cover the
mandibular teeth so as not to impinge or
reduce the rhythmic motion of the cranial bones.62,63 Regardless of which arch is
used, the goals are the same; namely, neuromuscular relaxation and the reduction
of muscle hyperactivity, pain, and the effects of chronic bruxism.
NOCICEPTIVE TRIGEMINAL INHIBITION
APPLIANCE
Although the superior repositioning appliance has been shown to be safe and effective in reducing muscle pain and the
effects of bruxism, some patients still
clench intensely, often producing all
types of pain (such as migraine
headaches) while literally destroying even
the most rigidly constructed appliance.
The development of the nociceptive
trigeminal inhibition appliance (NTITSS, Inc., Mishawaka, IN; 877.468.4877)
appears to overcome this problem. This
appliance has received FDA approval for
bruxing, as well as for migraine and tension-type headaches.64,65 Regardless of
the specific etiology of headache pain,
pericranial muscle tenderness and the development of myofascial trigger points in
the mandibular elevator muscles appear
to be two common characteristics. The
nociceptive trigeminal inhibition appliance is designed to reduce or eliminate
these probable causes of headache pain,
demonstrating how treating TMDs can
help improve the quality of life for numerous patients.
The nociceptive trigeminal inhibition
appliance reduces or eliminates the tendency to clench and permits lateral and
protrusive movements of the mandible
without engaging the canines. It provides
an anterior midline stop; like the superior repositioning appliance, it eliminates
the occluding surface that is required to
generate intense clenching for the posterior or canine teeth in any mandibular
position.66 Anatomically, this midline anterior stop activates the jaw opening reflex and activates the mandibular depressors while inhibiting the elevator muscles, prohibiting intense clenching as a result. If the muscle spindles are unable to
clench, the elevator muscles are prevented from becoming hypersensitive.67
Chronic sympathetic irritation (such as
clenching) makes these elevator muscles
very susceptible to pain and, in the presence of various triggers (for example,
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stress, overactivity, alcohol, hormonal
changes, food additives, and so forth), to
the subsequent development of migraine
and tension-type headaches.68 In the
FDA study of the efficacy of this appliance, there was statistically significant reduction in migraine episodes (61.9%),
tension-related headache episodes (37.3%),
reduced use of rescue medication (46.8%),
phonophobia (68.4%), photophobia
(65.6%), and nausea (78.0%).64,65
Obviously, not all headaches can be
reduced or eliminated with the use of any
type of device but the superior repositioning appliance and the nociceptive
trigeminal inhibition appliance can affect
the lives of patients and their families.
Adjunctive therapy
Adjunctive therapy consists of treatment
modalities that augment and assist definitive or causative types of treatment for
TMD. This category is vast and varied,
consisting of both traditional and nontraditional modes of therapy. As with the
discussion of causative therapy earlier in
this article, only the more popular and
widely used types of therapy are listed.
PHYSIOTHERAPY
In the United States, physiotherapy is a
combination of physical therapy, massage
therapy, and electromodalities (for example, ultrasound, low-intensity laser, and
so forth). In Canada and Australia, physiotherapy is synonymous with physical
therapy.
Successful adjunctive (and palliative)
treatment often is achieved by utilizing a
chiropractor, craniosacral therapist, osteopathic physician, massage therapist, or
physical therapist. Each of these disciplines has its own technique(s) for reducing dysfunction and musculoskeletal
pain. These techniques are very effective
at providing palliative relief of pain when
used in a combination with intraoral appliance therapy and medications.
ELECTROTHERAPY
Electrotherapy is another category of adjunctive therapy that can be administered
in the dental office.69 Modalities include
electrogalvanic stimulation, ultrasound,
low-level laser, and infrared, all of which
are useful for decreasing swelling and
pain by opening the capillaries in the area
and increasing circulation. Each of these
types of electrotherapy accomplishes
these biological effects differently.
Electrogalvanic stimulation utilizes
negative polarity over the painful,
swollen area. This negative charge produces an alkaline effect within the tissues,
denaturing proteins and producing vasodilatation of the capillaries; this in turn
permits the outward flow of metabolites
and tissue fluids.
Ultrasound is a mechanical vibration that produces heat and vasodilatation by increasing the tissue temperature, thus increasing metabolic activity.
This mechanical vibration also decreases pain by activating large myelinated
peripheral neurons that attenuate pain
or nociception stimulation at the spinal
cord and trigeminal (pons) levels. The
effects of ultrasound may be enhanced
when used in conjunction with massage
and exercise.70,71
IONTOPHORESIS
Iontophoresis is the process in which ions
in solution are driven through intact skin
by using a direct current between two
electrodes. It is a safe and effective
method of electrotherapy that uses ultrasonic energy to drive a medication deep
into the tissues.72,73 This is especially useful for directing anti-inflammatory medications into the TMJ. The current is so
low that the patient perceives little or no
sensation.
LOW-LEVEL LASER
Dentists have utilized laser therapy in
various applications for years.74,75 Lowlevel laser treatment is beneficial for reducing the pain of TMD by causing endorphin release.76 Laser therapy induces
nitric oxide synthesis, which causes the
endothelial linings of capillaries to dilate,
improving circulation in the area.77,78
Laser therapy also may return injured tissues to a more optimum energy level, improving circulation and decreasing pain
and swelling as a result.
INFRARED
Like most forms of electrotherapy, infrared produces vasodilatation of the
capillary beds by initiating the synthesis
of nitric oxide, improving circulation
and decreasing swelling as a result.79 This
small neurotransmitter improves circulation by opening the endothelial linings of
capillaries.
CAPSAICIN
Capsaicin is a topical analgesic that has
been approved for pain relief by the
FDA.80,81 It releases substance P and painrelated neuropeptides to reduce pain perception and inflammation and must be
applied multiple times every day for at
least 14 days before analgesic effects are
noted. Side effects include local burning
and warming and reddening of the skin;
these side effects diminish with time and
eventually disappear.82
BOTULINUM TOXIN
Botulinum toxin has been advocated for
treating chronic myofascial trigger points
and headache pain.83 This type of therapy presents three problems. First, treatments last only 9–12 months at most and
require multiple toxin injections. Second, this type of therapy is aimed at
symptoms in most cases, rather than at
the cause of the trigger points’ perpetuation. Third, a session of these injections
can be costly and uncomfortable for the
patient.
PSYCHOLOGICAL COUNSELING
It might be appropriate to administer
some type of psychological survey to
TMD patients; the literature is replete
with studies reporting the effects of one’s
psychological outlook and health on
TMDs and orofacial pain in general. Two
such ADA-approved psychological batteries have been devised specifically for
dentists. The TMJ Scale and Chronic
Pain Battery (Pain Resource Center,
Durham, NC; 800.542.7246) both were
developed by a psychiatrist and a biostatistician, using the input of several dentists who treat TMD patients. These surveys can be administered and graded in
the office, providing accurate answers
and helping the doctor to predict psychological trends that might affect treatment
outcomes.84-88 These tests also help dentists to refer patients to the appropriate
psychologist or counselor.
Hypnosis, biofeedback, acupuncture,
nutritional counseling, supplements and
vitamin usage, and alternative types of
therapy all are reasonable and often-recommended types of adjunctive therapy.
Definitive therapy
Definitive therapy (also referred to as
Phase II treatment) generally is irre-
versible and should be considered only if
the patient is almost or completely symptom-free most of the time or when lingering symptoms can be eliminated by
using a splint or anesthetic blockade. It
often is not required when a patient responds favorably to a splint or other
types of treatment.
Quality of life issues must be addressed if a patient is without pain while
wearing a splint but finds that symptoms return as soon as the splint is removed. If it is reasonable to suggest that
the patient must wear a splint 24 hours a
day for the remainder of his or her life in
order to be symptom-free, definitive
treatment must be considered. Such
treatment may consist of occlusal adjustment, occlusal reconstruction, orthodontic therapy, orthognathic surgery, cast overlay removable partial
dentures, restoring the vertical dimension of existing dentures (at the therapeutic or splint position), or replacing
the dentures.
When all other treatment modalities
for continuous TMJ pain fail, dentists can
inject a local anesthetic without vasoconstrictor into the joint. If the local anesthetic reduces or elminates pain, the patient should be referred to an oral and
maxillofacial surgeon for consultation;
however, it should be remembered that if
the patient requires joint surgery of any
type, a superior repositioning appliance
should be fabricated and placed for immediate use after surgery and adjusted
within 24 hours of the surgery.
Summary
Dentists can make a tremendous impact
in the lives of people suffering from TMJ
pain; however, dentists must learn to recognize these disorders as contributors to
facial and head pain. Otherwise, many of
these patients will have to undergo unnecessary treatment that often is invasive
and irreversible. Money will be spent and
the patient will be no better and may
even be worse.
Dentists who choose not to treat these
disorders should make an appropriate
and timely referral to a colleague who is
trained in such diagnostic and treatment
modalities. Not all dentists need to treat
TMDs but all dentists must take an active
part in recognizing the causes of such
suffering.
July-August 2004
353
Author information
Dr. Shankland is Director of the TMJ and
Facial Pain Center in Columbus, OH,
where he also maintains a practice limited to the diagnosis and treatment of
craniofacial and TMJ disorders.
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To order reprints of this article,
contact Donna Bushore at 866.879.9144, ext. 156
or [email protected].
July-August 2004
355
Exercise No. 143
Subject Code: 180
Myofascial Pain/Occlusion
The 15 questions for this exercise are based
on the article, “Temporomandibular disorders: Standard treatment options,” on
pages 349–355. This exercise was developed by William U. Wax, DMD, FAGD, in
association with the General Dentistry
DART Committee.
DART
2. The American Academy of Orofacial Pain
recommends TMD screening that includes
history, examination, and ______________.
A. questionnaire
B. diagnosis
C. prognosis
D. use of devices
3. Which of the following is not included in
palliative therapy?
A. Temporary intraoral appliances
B. Heat
C. Anterior positioning appliances
D. Medication
4. Which of the following best describes Phase
I therapy?
A. Reversible
B. Irreversible
C. Diagnostic
D. Orthognathic
5. Applying moist heat immediately following
acute temporomandibular joint (TMJ) injury can benefit the patient. To be most effective, the heat must be applied within 72
hours of the injury.
A. Both statements are true.
B. The first is true; the second is false.
C. The first is false; the second is true.
D. Both statements are false.
General Dentistry
• determine the sources of temporomandibular disorders
(TMDs);
• categorize the treatment phases of TMD;
• choose the most appropriate type of therapy for an individual
patient; and
• determine if the dentist should treat or refer the patient.
Answers for this exercise must be received by July 31, 2005.
Answer form and instructions are on pages 365-366.
1. TMD pain may result from malfunction of
which of the following?
1. Muscles
2. Carious teeth
3. Bones
4. Ligaments
A. 1, 2, and 3 only
B. 1, 2, and 4 only
C. 1, 3, and 4 only
D. 2, 3, and 4 only
356
Reading the article and successfully
completing this exercise will enable you to:
6. Which of the following usually indicates
dislocation of the articular disc?
A. Clicking
B. Ear pain
C. Headache
D. Masticatory muscle pain
7. Discs usually are displaced in what
direction?
A. Posterior-lateral
B. Posterior-medial
C. Anterior-lateral
D. Anterior-medial
8. Which of the following is not useful in
diagnosing displaced articular discs?
A. History
B. Panoramic radiograph
C. Transcranial radiograph
D. CT scan
9. An opening click occurs when the disc is
displaced from the condyle. A closing click
occurs when the disc returns to the condyle
head.
A. Both statements are true.
B. The first is true; the second is false.
C. The first is false; the second is true.
D. Both statements are false.
10. Which of the following types of appliances
can be used to treat TMD?
1. Anterior positioning appliance
2. Nociceptive trigeminal inhibition
(NTI) appliance
3. Centric relation splint
4. Pivot appliance
A. 1, 2, and 3 only
B. 1, 2, and 4 only
C. 2, 3, and 4 only
D. 1, 2, 3, and 4
www.agd.org
11. The NTI appliance activates the mandibular
elevator muscles; it also eliminates canine
guidance.
A. Both statements are true.
B. The first is true; the second is false.
C. The first is false; the second is true.
D. Both statements are false.
12. Which of the following adjunctive therapies
is the most problematic?
A. Electrotherapy
B. Ultrasound
C. Laser therapy
D. Botulinum toxin injections
13. Which of the following are possible side
effects of anti-inflammatory medications?
1. Gastrointestinal irritation
2. Decreased platelet aggregation
3. Liver damage
4. Increased neutrophil count
A. 1, 2, and 3 only
B. 1, 2, and 4 only
C. 1, 3, and 4 only
D. 2, 3, and 4 only
14. Temporary appliances can be used to diagnose a cause of TMD. Medication is very
helpful for making such a determination.
A. Both statements are true.
B. The first is true; the second is false.
C. The first is false; the second is true.
D. Both statements are false.
15. A chronic clencher experiences masseter
pain while attempting to open his or her
mouth. Which of the following treatments
can be efficacious?
A. Glucosamine sulfate and chondroitin
sulfate
B. Anterior repositioning appliance
C. Ethyl chloride sweeps and moist heat
D. Superior repositioning appliance