Craniomandibular (TMJ) disorders — The state of the art. Part II: Accepted diagnostic and treatment modalities

TEMPOROMANDIBULAR SECTIOV

GEORGE

JOINT

l

OCCLUSION

I:I~ITOR

A. ZARB

Craniomandibular (TM J) disorders - The state of the art. Part II: Accepted diagnostic and treatment modalities Charles

McNeill,

Walnut

Creek, Calif.

D.D.S.*

T

he philosophy of the American Academy of Craniomandibular Disorders has beento minimize “a single concept, single treatment” methodology that is prevalent in current craniomandibular (TMJ) therapy. An emphasison the team concept, using the specialtiesof dentistry and medicineto attain proper patient evaluation and treatment, is essential.Effective management of TMJ disordersmust be directed toward the whole patient, including all emotional and physical problems. Knowledge of functional anatomy, growth and development, and physiopathology of the head and neck regions is a necessaryrequirement. It is the clinician’s responsibility to differentiate between pain of dental origin and pain due to other causes.Knowledge within the various medical specialties increasesthe diagnostician’s acumen and permits early and proper referral when TMJ disorder is a doubtful cause of the symptoms. Frequently, both diagnosisand treatment are multidisciplinary in scope. Input from psychiatrists, psychologists, neurologists, neurosurgeons, orthopedic surgeons, physiatrists, internists, and others outside dentistry is often necessary. Similarly, treatment frequently requires multidisciplinary cooperation. Thus, it is paramount that the clinician be aware of diseaseentities that have signs and symptoms similar to those of craniofacial pain. Disease categories that may demonstrate signs and symptomsof craniofacial pain are the following: I. Neurologic disorders A. Neuralgias (typical and atypical)

Presented at [he meeting of the American Academy of Craniomandibular Dtsordera, Chicago, 111. “Chairman, ,Zd Hoc Committee, 1982 Position Paper; Director, Postgraduate Continuing Education, Occlusion Study Groups, School of Dentistry, San Francisco, University of California, (Xif.

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II.

III.

IV. V. VI.

VII.

VIII.

IX. X.

B. Neuropathies C. Central nervous systemlesions Vascular disorders A. Migraine and migrainous variants B. Temporal arteritis C. Aneurysm D. Angina Orthopedic disorders A. Musculoskeletal (Cervical disk disease) B. Myofascial syndromes C. Flexion-extension injuries (whiplash) D. Osteogenicpain Ophthalmic diseases Otoiaryngeal diseases Oral pain A. Dental pain B. Salivary gland disease C. Soft tissuelesions D. Tongue disorders Neoplasia A. Intracranial B. Extracranial Metabolic (systemic) disorders A. Endocrine B. Collagen Allergies Psychogenicdisorders

A classificationof TMJ disorderswas published by the Regional Workshop Committees of the American Academy of Craniomandibular Disorders in the JOLRK.\L OF PROSTHFXIC DENTISTRY.’ The specific classifications are indexed in the book Internat&nal Clam& c&on of DiseuAes(ICD), ninth revision, Clinical Modification, volume 2, by corresponding ICD numbers. The book izspublished by the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. The classification is as follows:

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I. Craniomandibular disorders of organic A, Articular disturbances 1. Disk derangements a. Disk dysfunction b. Disk displacement c. Disk dyscrasias 2. Condylar displacement 3. Inflammatory conditions a. Synovitis b. Diskitis c. Capsulitis d. Osteochondritis e. Contusion 4. Arthritides a. Osteoarthritis (localized) b. Traumatic c. Rheumatoid arthritis d. Polyarthritis (gout, lupus) e. Rheumatoid variants f p;;;: .MZ”,’. . 5. Ankylosis a. Fibrous b. Osseous 6. Fractures a. Mandible b. Maxilla 7. Neoplasia a. Chondroma b. Osteoma d. Primary malignancy d. Metastatic malignancy 8. Developmental abnormalities a. Hyperplasia b. Hypoplasia c. Agenesis d. Osteochondromatosis B. Nonarticular disturbances 1. Neuromuscular conditions a. Myofascitis b. Contracture c. Trismus/spasm d. Dyskinesia 2. Disturbances involving referral of secondary symptoms a. Latent myofascial tenderness b. Active myofascial trigger points 3. Dental occlusal conditions (dentofacial movement abnormality) a. Unstable occlusion (structural imbalance) 394

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b. Premature posterior tooth contacts c. Lack of posterior occlusal support d. Distal thrust to mandible II. Craniomandibular disorders of nonorganic (functional) origin A. Myofascial pain dysfunction syndrome B. Bruxism C. Inordinate occlusal awareness (neurosis) D. Atypical facial pain E. Conversion hysteria III. Craniomandibular disorders of nonorganic origin combined with secondary organic tissue changes A. Articular (degenerative joint disease) B. Nonarticular 1. Neuromuscular (disorders of fascia, ligaments, and muscles) 2. Oral a. Teeth (occlusal wear) b. Soft tissues (periodontium) c. Hard tissues (excessive resorption of alveolar ridge)

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The purpose of this second position paper is to expand on the accepted diagnostic and treatment modalities used by most Academy members. These modalities have been divided into four groups: (1) baseline records, (2) behavior modification, (3) repair and regeneration, and (4) orthopedic stabilization. It is mandatory that the proper baseline records be obtained first in an effort to establish the correct diagnosis. Following this, the clinician may use either behavior modification modalities or modalities that allow for the repair and regeneration of the masticatory tissues. It is common practice to use a combination of these two groups before orthopedic stabilization is provided. Thus, the following equation: /

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524.5

Baseline records \

Behavior modification \

-Orthopedic

stabilization

Repair and regeneration/

Each modality in all four diagnostic and treatment groups has been rated for scientific validity as follows: (1) clinically practiced and reported, (2) clinically documented, and (3) scientifically documented. The rating of each modality allows the dentist, the physician, and other interested parties (such as third MARCH

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party carriers) to have an evaluation based on sound scientific principles. These ratings are the opinions of the Ad Hoc Committee for the 1982 position paper Certain invasive clinical procedures for the treatment of TMJ disorders such as surgical or restorative treatment are valid but because of the nature of their treatment, cannot necessarily be tested with a doubleblind study. Pharmacotherapeutic and certain physical modalities can be scientifically evaluated on that basis. However, acupuncture is just receiving scientific support with recent studies in the West. For example, even though clinically reported as successful, “dental kinesiology” has not yet withstood the test of scientific investigation. The committee realizes that developing a rating system may introduce constraints that delay acceptance of newer concepts and theories that may prove to be scientifically true.

BASELINE RECORDS A well-organized, disciplined approach to fact finding should be used to develop the necessary baseline records to provide a viable diagnosis and plan of treatment. The necessary baseline records should include a comprehensive history, a thorough clinical examination, radiographic surveys, diagnostic casts and other indicated diagnostic tests or consultations. The baseline records are listed and all are clinically and/or scientifically documented. I. History ii. Chief complaint B. Present illness history C. General health and total patient assessment D. Past medical and dental histories II. Clinical examination A. Observation (gait, posture, etc.) B. Palpation C. Auscultation D. Occlusal analysis (morphological) E. Mandibular movement evaluation 1. Functional 2. Parafunctional F. Neuromuscular evaluation III. Radiographic survey ,4. Full mouth survey/periapical radiographs B. Panoramic survey C. Transcranial films D. Cephalometric films E. Tomography/xerography F. Polytomography/corrected cephalometric tomography THE JOURNAL

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G. Computerized axial tomography scanning H. Arthrography I. Ultrasonic scanning J. Nuclear scanning IV. Diagnostic casts A. Related B. Unrelated V. Other diagnostic aids or tests A. Photographs B. Diagnostic anesthesia C. Electronic mandibular movement instrumentation D. Neuromuscular recordings and evaluation E. TMJ loading tests F. Synovial fluid evaluation G. Stress tests H. Personality profile tests VI. Referral ,and/or consultation to other medical specialties,

BEHAVIOR MODIFICATION Modalities that come under the classification of behavior modification are considered when the clinical impression is that the psychophysiological or nonorganic aspects of the patient’s symptoms outweigh the clearly physical or organic aspects. Usually the symptoms are nonarticular or periarticular as to location rather than articular. The following are the behavior modification modalities: I. Counseling (clinically documented) A. Education regarding present illness B. Anxiety control C. Muscle relaxation techniques II. Pharmacotherapy (scientifically documented) A. Pain control (analgesics) B. Tranquilizers C. Sedatives-hypnotics D. Antidepressants III. Biofeedback (clinically documented) A. Electromyography B. ElectroNencephalography C. Galvanic skin response D. Heart rate/blood pressure IV. Bruxism prostheses (clinically documented) A. Soft mouth guard B. Anterior occlusion prostheses C. Mandibular posterior coverage D. Complete maxillary or mandibular coverage V. Hypnothera.py (clinically practiced and reported) VI. Psychotherapy (clinically documented) 395

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REPAIR AND REGENERATION

ORTHOPEDIC

Treatment modalities that assist in repair and regeneration of the tissues of the masticatory system are considered when the physical or organic aspects of the patient’s symptoms dominate the psychologic or nonorganic aspects. These treatment modalities are the following:

Definitive treatment of the masticatory system should be deferred until after the acute symptoms have been controlled and a subsequent evaluation made. Muscle splinting or edema within the joint, for example, can cause a transitory malposition of the condyle within the fossa, resulting in a gross malrelation of opposing teeth. It is not always necessary to alter the occlusion after the acute condition has been controlled, providing the occlusal relationships return to an acceptable state. Orthopedic stabilization can be achieved by the following:

I. Physical medicine A. Hot packs/ice (clinically documented) B. Massage/manipulation (clinically documented) C. Diathermy (clinically documented) D. Ultrasound (clinically documented) E. Electrical stimulation (TENS) (clinically documented) F. Exercises including myofunctional therapy (clinically documented) G. Applied kinesiology (clinically practiced and reported) H. Cranial osteopathy (clinically practiced and reported) II. Pharmacotherapy (scientifically documented) A. “Muscle relaxants” B. Anti-inflammatory agents C. Corticosteroids (intra-articular) D. Antibiotics III. Anesthesia (clinically documented) A. Muscle/fascia (trigger points) B. TM J (intracapsular/extracapsular) C. Refrigerant sprays repositioning prostheses (clinIV. Orthopedic ically documented) (not orthodontic appliances) A. Maxillary occlusion prostheses (Sved appliance) B. Mandibular pivot or fulcrum prostheses C. Provisional fixed restorations D. Other prostheses V. Acupuncture (clinically practiced and reported) A. Pressure B. Needle/electrical C. TENS VI. Surgery (clinically documented) A. Disk derangements B. Ankylosis C. Fractures D. Tumors E. Arthritides F. Developmental abnormalities

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I. Orthopedic stabilization prostheses (clinically documented) A. Maxillary B. Mandibular II. Equilibration (clinically documented) A. Limited B. Extensive C. Complete III. Restoration (clinically documented) A. Limited B. Complete mouth rehabilitation IV. Prosthodontic therapy (clinically documented) A. Fixed B. Removable V. Orthodontic therapy (clinically documented) A. Fixed appliances B. Removable appliances C. Functional appliances VI. Orthognathic surgery (clinically documented)

CONCLUSION All dentists are licensed to treat TMJ disorders. Each practitioner should assesshis or her own knowledge, skill, and ability and work within the parameters of those limitations. It should be the responsibility of the practitioners to evaluate those patients who have conditions requiring greater expertise than they possess and refer them to those facilities or individuals that have the capability to provide effective care. Physicians, including orthopedic surgeons and otolaryngologists, usually prefer not to treat the temporomandibular joint or associated structures. It is sometimes difficult to determine if a specific treatment modality is either medical or dental in nature. However, most therapy is directed to the temporomandibular joint and surrounding muscles and not to the teeth. When treatment is provided only to the teeth, it

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becomes dental in nature; otherwise, it must be considered medical treatment like the treatment of any other joint-muscle complex in the body. Although TMJ disorders are a medical problem, dentists by virtue of their training are ideally suited to treat the problem with the help of allied medical specialties. REFERENCE I. hfcNeill, (: , Danzig, W. Id., Farrar, W. B., &lb, H., Lerman, X!

I).. k1olTe11. B. C!., Pertes. R., Solberg, W. K., and

ARTICLES TO APPEAR IN FUTURE ISSUES A conversion alternative to ceramics in a crown-and-sleeve prosthesis

coping

Walter H. Kunisch, D.D.S., and James Dodd

An evaluation of the retentive properties of various permanent crown posts H. G. Kurer, L.D.S., M.Sc.(Manc),

M.G.D.S., R.C.S.(Eng)

Flexible temporary obturators for patients with severely limited jaw opening Frank R. Lauciello, D.D.S., David M. Casey, D.D.S., and Duane S. Crowther, D.M.D.

Relieving intraoral pressures generated during orthopedic treatment M. F. Levenson, D.D.S.

Jaw separation and maximum incising force Beverly R. Mackenna, M.B., Ch.B., Ph.D., and Kemal S. Turker, B.D.S., Ph.D.

“Phantom bite”: Classification

and treatment

Joseph J. Marbach, D.D.S., John R. Varoscak, D.D.S., and R. Terry 13lank, D.D.S.

Long-term results of treatment for temporomandibular pain-dysfunction

joint

Christina Mejersjo, L.D.S., and Gunnar E. Carlsson, L.D.S., Odont.Dr.

Effect of eugenol and eugenol cements on cured composite resin Philip L. Millstein,

D.M.D.,

and Dan Nathanson, D.M.D.

Rapid boxing of impressions Assad F. Mora, B.D.S., M.S.D., and Malcolm E. Boone, D.D.S., M.S.1~

Stress-relaxation testing. Part IV: Clasp pattern dimensions and their influence on clasp behavior H. F. Morris, D.D.S., M.S., K. Asgar, Ph.D., J. S. Brudvik, D.D.S., S. Winkler, D.D.S., and E. P. Roberts

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