- Email: [email protected]
Report of the President’s Conference on the Examination, Diagnosis, and Management of Temporomandibular Disorders
A s s o c ia t io n R e p o r t s
iJ S
Report of the President’s Conference on the Examination, Diagnosis, and Management of Temporomandibular Disorders Introduction by Dr. Robert H. Griffiths, DDS
r
Convening a conference on the etiology, diagnosis, and management of temporo mandibular disorders was one of my major goals as president of the American Dental As sociation. Although temporomandibular (TM) disorders may not be new, they do consti tute a relatively new area of research and study. As a result, few, if any, organized or stan dardized approaches to the examination, diag nosis, or treatment of TM disorders exist. It has been my belief that all of dentistry would bene fit from the establishment of a rational, un biased approach to these disorders. It was my hope that this conference would review some of the areas of confusion surrounding TM dis orders and arrive at an initial set of guidelines. Obviously, it was unrealistic to believe that we would be able to resolve all of our questions with one conference. Many areas and disci plines outside dentistry are currently involved in the field of TM disorder management. I have felt very strongly that the time has come for organized dentistry to take the initia tive to provide the leadership for the necessary study and discussions required to clarify this area. I have believed it imperative that we es tablish, from the outset, that the dentist is the primary therapist in managing TM disorder patients. It is up to us to take the lead in devel oping guidelines, based on sound scientific and clinical knowledge, that will allow us to help our patients. I asked that the conference participants focus their attention on those areas that would be both useful to the practitioner and therapeu tic to the patient. I identified three areas most in need of attention. First, there was the need to make some specific recommendations regard ing the protocol for examination of patients with symptoms indicative of TM disorders. This was the first step, and a very critical one, in the management of the disease. Secondly, there was the need to begin to develop the dif ferential diagnoses that could be used to iden tify the various kinds of these disorders. This information needed to be organized, pub lished, and distributed to the profession for the benefit of dentists and patients alike. Finally, I
believed it crucial to identify and recommend the most effective modes of therapy for the management of TM disorders. The conference examined a comprehensive and exhaustive set of issues. Although agree ment was frequently difficult to achieve, the conference participants did establish the guidelines presented here. It also recognized the need for the development of dental history questionnaires to assist in screening for TM disorders and for an improved classification for TM disorders. Although the task is far from being completed, I think that this conference achieved the goal that I had in mind for devel oping initial guidelines. It will remain for fu ture conferences to refine these guidelines. I would like to thank the people who assisted me in putting this program together. An advi sory committee of leading practitioners, edu cators, and researchers in the field of TM helped recommend and select the speakers who addressed the conference. In addition, a select group of practitioners, currently work ing in the field of occlusion and TM disorders, provided additional input during the work shop sessions of this conference. I would again add that the following guidelines represent an initial step and, as a re sult, suffer from imperfections inherent in such an effort. I would also invite your com ments and views about them.
Guidelines for clinical examination for TM disorders The conference participants indicated that, in addition to obtaining a comprehensive medi cal and dental history and performing a thorough dental examination of every patient, a brief screening history and examination per tinent to the temporomandibular disorders should be done to enable the practitioner to de termine the need for a more detailed evalua tion. Should the screening history and exami nation result in positive findings, the partici pants recommended a second more compre hensive assessment specifically related to the evaluation of temporomandibular disorders.
Screening history fo r TM disorders The preliminary or screening history should be part of the routine health history and should include such questions as: —Do you have difficulty opening your mouth? —Do you hear noises from the jaw joints? —Does your jaw get “stuck,” “locked,” or “go out”? —Do you have pain in or about the ears or cheeks? —Do you have pain on chewing or yawning or wide opening? —Does your bite feel uncomfortable or un usual? —Have you ever had an injury to your jaw, head, or neck? —Have you ever had arthritis? —Have you previously been treated for a temporomandibular disorder? If so, when, what, how, and by whom? Screening examination A brief clinical examination for TM disorders should include: —Inspection for facial symmetry. —Evaluation of jaw movements. —Palpation, (masticatory muscle tenderness and joint tenderness, incoordinations, click ing, and crepitus). Should positive findings emerge from the screening history and examination, a more comprehensive evaluation should be done. This should include: —Health history. The medical and dental history pertinent to the temporomandibular symptoms. —A detailed examination related to the symptoms. —Radiographic examination for dental and TM pathology:* panoramic and complete full-mouth radiographs; transcranial ra diographs as indicated; other radiographs as indicated (tomograms, arthrograms). — Psychosocial factors related to TM symptoms. JADA, Vol. 106, January 1983 ■ 75
A SSO CIATIO N
REPO RTS
—Musculoskeletal problems. —Psychophysiologic disorders (ulcer, ten sion headache, asthma, colitis). —Medication usage. —Oral habits. —Occupational factors. —Emotional factors. —Other factors (tumors, developmental and acquired anomalies). •S P E C IA L C O N S ID E R A T IO N S A B O U T E V A L U A T IO N
—The use of radiographs for the purpose of assessing joint spaces has not been shown to be a reliable diagnostic procedure. —TM arthrography is not recommended as a routine diagnostic procedure to assess internal joint derangements. — Study casts for the analysis of occlusion should be made when necessary. —Additional clinical or laboratory tests should be conducted when specifically indi cated to rule out or confirm specific diagnoses.
Guidelines for differential diagnosis
event scales, by or under the supervision of a psychologist trained in their use.) —When there is reason to believe that or ganic pathologic conditions exist, radiographs of the temporomandibular joints should be taken. A transcranial, transpharyngeal, or panoramic radiograph can be used as a screen ing view, with tomography reserved for those patients in whom the screening radiograph shows a possible abnormality. —Transcranial radiography for the evalua tion of condylar position is not as reliable as tomographic assessment of joint spaces, but in either case there is insufficient evidence that eccentricity of the condyle in the fossa is a diagnostic sign of a temporomandibular disor der. —Study models may be used routinely. Al though the scientific literature has not shown th at occlu sa l problem s cause tem poro mandibular disorders, clinical data do confirm the two conditions frequently coexist, but the nature of the relationship between them is un clear at this time. —At this time, temporomandibular joint ar thrography should be considered a special diagnostic method with limited indications. It should be reserved for those patients with sus pected internal joint derangements in whom nonsurgical therapy of adequate duration has not resolved the symptoms and surgery is con templated, and in those patients with painful limitation of opening where dislocation of the disk is suspected. —No scientific studies have provided sup port for the concept that body muscle testing (applied kinesiology) is a reliable indicator of jaw dysfunction; that it can be used as a means for establishing proper jaw position or vertical dimension; or that it can provide useful infor mation on the local or systemic health status of the patient.
There is a need for an improved classification of TM disorders. Such disorders should be separated into those that occur primarily in the muscles of mastication; those that involve the TMJ; and those that occur in related areas that mimic temporomandibular disorders. The use of broad, nonspecific categories such as “ tem porom andibular jo in t dysfunction” should be discouraged. Until a more definitive classification is developed, the following is suggested (This classification is similar to one proposed by Weldon Bell.): —Masticatory muscle disorders: protective muscle splinting; masticatory muscle spasm (MPD syndrome); masticatory muscle inflam mation (myositis). —Problems involving derangement of the temporomandibular joint: incoordination; an terior disk displacement with reduction (click ing); anterior disk displacement without re duction (mechanical restriction; closed lock). — Problem s that resu lt from extrin sic trauma: traumatic arthritis; dislocation; frac ture; internal disk derangement; myositis, myospasm; tendonitis. —Degenerative joint disease: noninflam matory phase (“arthrosis”); inflammatory phase (osteoarthritis). —Inflammatory joint disorders: rheumatoid arthritis; infectious arthritis; metabolic ar thritis. —Chronic mandibular hypomobility: an kylosis (fibrous, osseous); fibrosis of articular capsule; contracture of elevator muscles (myostatic contracture, myofibrotic contrac ture); internal disk derangement (closed lock). —Growth disorders of the joint: devel opmental disorders; acquired disorders; neo plastic disorders.
On the basis of the literature reviews presented at this conference, it was concluded that at pre sent there is insufficient data to permit com parison of different forms of therapy to estab lish a priority for their use. However, the basic principle of using conservative reversible forms of therapy, whenever possible, was ad vocated. Moreover, it was emphasized that a warm, positive, and reassuring attitude on the part of the dentist is crucial in the treatment of these disorders. In addition, it was stressed that there should be a scientific basis for estab lishing a treatment modality and testing its ef ficacy. On the basis of these concepts, the fol lowing recommendations were made regard ing the various forms of treatment used for pa tients with temporomandibular disorders. However, it must be kept in mind that the order of the recommendations does not imply a priority sequence.
S P E C IA L C O N S ID E R A T IO N S A B O U T D IA G N O S IS
Pharmacologic agents
—Although psychologic factors may be in volved in some TM disorders, there is no scien tific evidence to support the routine use of psychologic testin g in the diagnosis of temporomandibular disorders. (Psychologic testing refers to the administration of such in struments as the Minnesota Multiphasic Per sonality Inventory, various anxiety scales, life
The appropriate use of pharmacologic agents in the treatment of muscle and/or joint distur bances on a short-term basis can be a useful mode of therapy. Therapy commonly includes the use of nonaddictive analgesics, anti inflammatory drugs, anti-anxiety agents, and muscle relaxants. Less frequently used, but sometime indicated, are the use of antidepres sants.
76 ■ JADA, Vol. 106, January 1983
Guidelines for treatment
Occlusal adjustment therapy —It should be considered an irreversible treatment. —It should not be used routinely and espe cially not during the acute stage of mos1 temporomandibular disorders.
Occlusal appliances —Those appliances that are not designed tc intentionally and permanently reposition the mandible or the dentition should be consid ered a reversible form of therapy. —These appliances are recommended for many dysfunctional conditions involving the muscles of mastication and the TMJ. Sufficient scientific evidence for their efficacy exists.
Mandibular repositioning therapy —Intentional permanent placement of the mandible in a new position by means of prosthodontic treatment, orthodontic treatment, surgery, or by functional occlusal appliances should be considered an irreversible form of treatment. —Ordinarily, jaw repositioning occlusal ap pliances should be considered a reversible form of treatment unless followed by occlusal adjustment, prosthetic restorations, or or thodontic or surgical treatment. However, their effects may occasionally be irreversible. —Sufficient supporting evidence for this treatment approach was not presented at this Conference.
Physical therapy —This should be considered reversible treatment. —Sufficient supporting evidence for the ef ficacy of this treatment modality was not re viewed at this conference.
Surgery For certain conditions, such as developmental and acquired abnormalities, ankylosis, or neoplasia, surgery may be indicated as the ini tial treatment of choice. For functional disor ders, such as MPD syndrome, surgery is not in dicated. At the present time, there is no evi dence to support the use of surgery for the ini tial treatment of disk displacement. Only after failure of currently acceptable nonsurgical treatments should surgery be considered. However, failure of such treatments alone should not be considered as the only criterion for surgery. Surgical intervention must be based on clearly defined criteria of intracapsular pathologic conditions or anatomic derangement. There is currently little support for meniscectomy except in situations where the disk is so deranged, damaged, or diseased that no other alternative exists.
Osteopathic and chiropractic therapies —Data regarding the reversible or irreversi ble nature of these treatment modalities were not presented at this conference. —Supporting evidence for the efficacy of these treatment modalities currently does not exist.
A S S O C I A T IO N
Behavior therapies —For some dysfunctional conditions in volving the muscles of mastication, this ap proach is recommended and has reasonable scientific support. Behavioral strategies are also indicated for many chronic nonrespond ing temporomandibular patients. (The specific behavior therapies include biofeedback and re laxation training.) M em b ers o f th e a d v iso ry c o m m itte e o f th e temporomandibular conference were: Drs. Charles
A iling, Elliott Gale, William Greenfield, Daniel M. Laskin, Peter Neff, and John Rugh. Address requests for reprints to Dr. W illiam Ayer, Bureau of Econom ic and Behavioral Research, Amer ican Dental Association. T he participants in the conference June 1 to 4 ,1 9 8 2 , were: W illiam A. Ayer, W eldon E. B ell, Donald Blaschke, Sanford Block, W illiam Booth, James G. Burch, Francis M. Bush, Charles D. Carter, Glenn T. Clark, Kenneth M. Clemens. Peter E. Dawson, Lon R. Doles, Herbert B. Dolinsky, M. Franklin Dolwick, Donald H. Enlow, Clifford Fox, Sanford C. Frumker, Elliott N. Gale, Aaron Ganz, Lee
REPORTS
Getter, George Goodheart, Gar S. Graham, Charles S. Greene, W illiam Greenfield, John M. Gregg, Robert H. Griffiths, W alter Guralnick. John H. Harakel, John L. Hicks, W illiam B. Irby, Richard W. Janson, Mark P. Jarrett, Justin L. Jones, David A. Keith, Hans Kraus, D aniel M. Laskin, Charles G. Lewis, M ichael Lewis. R ob ert M aje w sk i, W . D. M cC all, Jr ., C h arles M cN eill, Benjam in Moffett, Norman D. Mohl, Daniel Myers, Peter Neff, Jeffrey P. Okeson, George R. Olfson, Ronald E. Olson. Benjam in Pereira, Harold T. Perry, Calvin Pierce, John D. Rugh, Frank Schm id, Gordon Schrotenboer, Robert Siegel, W illiam Solberg, Delmar Stauffer, Ar thur T. Storey, Stuart Super, Charles Widmer, Ber nard T. W illiam s, George Zarb.
Denture cleansers Council on Dental M aterials, Instruments, and Equipment
he importance of cleanliness in dentures cannot be overemphasized. The relationship between the inflammation associated with denture stomatitis and denture cleanliness in cludes different degrees of severity.1'3 Improp erly cleaned dentures are sources of both bac teria and fungus that may cause localized or systemic infections, which, on very rare occa sions, may be fatal.4 Hence there is an impetus for educating patients to clean their dentures and to make proper use of denture cleansers. Knowledge of the constituents of denture cleansers, their efficacy, adverse effects, and safety would aid in dispensing appropriate in formation to the patients. Denture wearers attempt to clean their den tures in a variety of ways: rinsing in water, using self-cleaning denture cleansers, and brushing with powder or paste dentifrice.5'8 All these methods may have undesirable ef fects. For example, pastes and powders may be abrasive to acrylic teeth and denture bases.9 Immersion-type cleansers may have harmful effects on the plastic or metal components of the dentures.
stains by brushing without physically damag ing the acrylic components of dentures. Other ingredients, such as surfactants, are included to increase the effectiveness of the abrasive. Oxidizing-type cleansers h y p o c h l o r i t e s . Alkaline hypochlorites dis solve or solubilize organic matter or matrixes on which tartar forms. They solubilize the mucin and other albuminoids. The calcium phosphate can then be washed or brushed off. These agents also disinfect the denture.
Table ■ Major active ingredients of some denture cleansers.__________________________________________________ Product
A ctive ingredients_______________
Complete (paste) Denalan Dentu-Creme (paste) D.O.C.
Calcium carbonate Sodium peroxide Calcium carbonate Sodium perborate Trisodium phosphate Potassium m onopersulfate Sodium borate perhydrate Sodium acid pyrophosphate Sodium perborate Trisodium phosphate Sodium phosphate Sodium polymetaphosphate Sodium perborate Trisodium phosphate Sodium perborate Trisodium phosphate Sodium perborate Trisodium phosphate Troclosene potassium Potassium monopersulfate Sodium perborate monohydrate Sodium tripolyphosphate Potassium monopersulfate Sodium perborate monohydrate Proteolytic enzyme Mineral acid
Efferdent tablets
Composition of denture cleansers Denture cleansers that are currently on the market contain a variety of ingredients. The paste-type cleansers contain mild abrasive powders. The soak-type cleansers contain oxidizing agents or mineral acids.10'12 More re cently, denture cleansers based on enzymes have become available.13'16 Other agents added to the cleansers include coloring, flavoring, and surface-active agents. Some commonly used denture cleansers and their ingredients are listed in the Table.
Effervescent denture tablets Extar denture cleansers K.I.K. Kleenite Mersene denture cleanser Polident denture cleanser powder Polident tablets
Paste-type cleansers These cleansers are formulated with mild abra sives such as calcium carbonate powder to as sist the mechanical removal of plaque and
H y p o ch lo rites are co rro siv e to m etal. Hexametaphosphate, excessive alkali, or sodium silicate are sometimes added to de crease the degree of corrosiveness of the al kaline hypochlorites. This type of denture cleanser has been shown to be better for “stains.” These stains, often thought to be caused by tea and tobacco, are probably caused by blood or food residues. Brown stains that remain in the crevices can be a result of iron phosphate present in the tartar on the den ture.10 Resistant tartar and heavy deposits are said to be removed with a few overnight soaks.
Sonac
JADA, Vol. 106, January 1983 ■ 77
iJ S
Report of the President’s Conference on the Examination, Diagnosis, and Management of Temporomandibular Disorders Introduction by Dr. Robert H. Griffiths, DDS
r
Convening a conference on the etiology, diagnosis, and management of temporo mandibular disorders was one of my major goals as president of the American Dental As sociation. Although temporomandibular (TM) disorders may not be new, they do consti tute a relatively new area of research and study. As a result, few, if any, organized or stan dardized approaches to the examination, diag nosis, or treatment of TM disorders exist. It has been my belief that all of dentistry would bene fit from the establishment of a rational, un biased approach to these disorders. It was my hope that this conference would review some of the areas of confusion surrounding TM dis orders and arrive at an initial set of guidelines. Obviously, it was unrealistic to believe that we would be able to resolve all of our questions with one conference. Many areas and disci plines outside dentistry are currently involved in the field of TM disorder management. I have felt very strongly that the time has come for organized dentistry to take the initia tive to provide the leadership for the necessary study and discussions required to clarify this area. I have believed it imperative that we es tablish, from the outset, that the dentist is the primary therapist in managing TM disorder patients. It is up to us to take the lead in devel oping guidelines, based on sound scientific and clinical knowledge, that will allow us to help our patients. I asked that the conference participants focus their attention on those areas that would be both useful to the practitioner and therapeu tic to the patient. I identified three areas most in need of attention. First, there was the need to make some specific recommendations regard ing the protocol for examination of patients with symptoms indicative of TM disorders. This was the first step, and a very critical one, in the management of the disease. Secondly, there was the need to begin to develop the dif ferential diagnoses that could be used to iden tify the various kinds of these disorders. This information needed to be organized, pub lished, and distributed to the profession for the benefit of dentists and patients alike. Finally, I
believed it crucial to identify and recommend the most effective modes of therapy for the management of TM disorders. The conference examined a comprehensive and exhaustive set of issues. Although agree ment was frequently difficult to achieve, the conference participants did establish the guidelines presented here. It also recognized the need for the development of dental history questionnaires to assist in screening for TM disorders and for an improved classification for TM disorders. Although the task is far from being completed, I think that this conference achieved the goal that I had in mind for devel oping initial guidelines. It will remain for fu ture conferences to refine these guidelines. I would like to thank the people who assisted me in putting this program together. An advi sory committee of leading practitioners, edu cators, and researchers in the field of TM helped recommend and select the speakers who addressed the conference. In addition, a select group of practitioners, currently work ing in the field of occlusion and TM disorders, provided additional input during the work shop sessions of this conference. I would again add that the following guidelines represent an initial step and, as a re sult, suffer from imperfections inherent in such an effort. I would also invite your com ments and views about them.
Guidelines for clinical examination for TM disorders The conference participants indicated that, in addition to obtaining a comprehensive medi cal and dental history and performing a thorough dental examination of every patient, a brief screening history and examination per tinent to the temporomandibular disorders should be done to enable the practitioner to de termine the need for a more detailed evalua tion. Should the screening history and exami nation result in positive findings, the partici pants recommended a second more compre hensive assessment specifically related to the evaluation of temporomandibular disorders.
Screening history fo r TM disorders The preliminary or screening history should be part of the routine health history and should include such questions as: —Do you have difficulty opening your mouth? —Do you hear noises from the jaw joints? —Does your jaw get “stuck,” “locked,” or “go out”? —Do you have pain in or about the ears or cheeks? —Do you have pain on chewing or yawning or wide opening? —Does your bite feel uncomfortable or un usual? —Have you ever had an injury to your jaw, head, or neck? —Have you ever had arthritis? —Have you previously been treated for a temporomandibular disorder? If so, when, what, how, and by whom? Screening examination A brief clinical examination for TM disorders should include: —Inspection for facial symmetry. —Evaluation of jaw movements. —Palpation, (masticatory muscle tenderness and joint tenderness, incoordinations, click ing, and crepitus). Should positive findings emerge from the screening history and examination, a more comprehensive evaluation should be done. This should include: —Health history. The medical and dental history pertinent to the temporomandibular symptoms. —A detailed examination related to the symptoms. —Radiographic examination for dental and TM pathology:* panoramic and complete full-mouth radiographs; transcranial ra diographs as indicated; other radiographs as indicated (tomograms, arthrograms). — Psychosocial factors related to TM symptoms. JADA, Vol. 106, January 1983 ■ 75
A SSO CIATIO N
REPO RTS
—Musculoskeletal problems. —Psychophysiologic disorders (ulcer, ten sion headache, asthma, colitis). —Medication usage. —Oral habits. —Occupational factors. —Emotional factors. —Other factors (tumors, developmental and acquired anomalies). •S P E C IA L C O N S ID E R A T IO N S A B O U T E V A L U A T IO N
—The use of radiographs for the purpose of assessing joint spaces has not been shown to be a reliable diagnostic procedure. —TM arthrography is not recommended as a routine diagnostic procedure to assess internal joint derangements. — Study casts for the analysis of occlusion should be made when necessary. —Additional clinical or laboratory tests should be conducted when specifically indi cated to rule out or confirm specific diagnoses.
Guidelines for differential diagnosis
event scales, by or under the supervision of a psychologist trained in their use.) —When there is reason to believe that or ganic pathologic conditions exist, radiographs of the temporomandibular joints should be taken. A transcranial, transpharyngeal, or panoramic radiograph can be used as a screen ing view, with tomography reserved for those patients in whom the screening radiograph shows a possible abnormality. —Transcranial radiography for the evalua tion of condylar position is not as reliable as tomographic assessment of joint spaces, but in either case there is insufficient evidence that eccentricity of the condyle in the fossa is a diagnostic sign of a temporomandibular disor der. —Study models may be used routinely. Al though the scientific literature has not shown th at occlu sa l problem s cause tem poro mandibular disorders, clinical data do confirm the two conditions frequently coexist, but the nature of the relationship between them is un clear at this time. —At this time, temporomandibular joint ar thrography should be considered a special diagnostic method with limited indications. It should be reserved for those patients with sus pected internal joint derangements in whom nonsurgical therapy of adequate duration has not resolved the symptoms and surgery is con templated, and in those patients with painful limitation of opening where dislocation of the disk is suspected. —No scientific studies have provided sup port for the concept that body muscle testing (applied kinesiology) is a reliable indicator of jaw dysfunction; that it can be used as a means for establishing proper jaw position or vertical dimension; or that it can provide useful infor mation on the local or systemic health status of the patient.
There is a need for an improved classification of TM disorders. Such disorders should be separated into those that occur primarily in the muscles of mastication; those that involve the TMJ; and those that occur in related areas that mimic temporomandibular disorders. The use of broad, nonspecific categories such as “ tem porom andibular jo in t dysfunction” should be discouraged. Until a more definitive classification is developed, the following is suggested (This classification is similar to one proposed by Weldon Bell.): —Masticatory muscle disorders: protective muscle splinting; masticatory muscle spasm (MPD syndrome); masticatory muscle inflam mation (myositis). —Problems involving derangement of the temporomandibular joint: incoordination; an terior disk displacement with reduction (click ing); anterior disk displacement without re duction (mechanical restriction; closed lock). — Problem s that resu lt from extrin sic trauma: traumatic arthritis; dislocation; frac ture; internal disk derangement; myositis, myospasm; tendonitis. —Degenerative joint disease: noninflam matory phase (“arthrosis”); inflammatory phase (osteoarthritis). —Inflammatory joint disorders: rheumatoid arthritis; infectious arthritis; metabolic ar thritis. —Chronic mandibular hypomobility: an kylosis (fibrous, osseous); fibrosis of articular capsule; contracture of elevator muscles (myostatic contracture, myofibrotic contrac ture); internal disk derangement (closed lock). —Growth disorders of the joint: devel opmental disorders; acquired disorders; neo plastic disorders.
On the basis of the literature reviews presented at this conference, it was concluded that at pre sent there is insufficient data to permit com parison of different forms of therapy to estab lish a priority for their use. However, the basic principle of using conservative reversible forms of therapy, whenever possible, was ad vocated. Moreover, it was emphasized that a warm, positive, and reassuring attitude on the part of the dentist is crucial in the treatment of these disorders. In addition, it was stressed that there should be a scientific basis for estab lishing a treatment modality and testing its ef ficacy. On the basis of these concepts, the fol lowing recommendations were made regard ing the various forms of treatment used for pa tients with temporomandibular disorders. However, it must be kept in mind that the order of the recommendations does not imply a priority sequence.
S P E C IA L C O N S ID E R A T IO N S A B O U T D IA G N O S IS
Pharmacologic agents
—Although psychologic factors may be in volved in some TM disorders, there is no scien tific evidence to support the routine use of psychologic testin g in the diagnosis of temporomandibular disorders. (Psychologic testing refers to the administration of such in struments as the Minnesota Multiphasic Per sonality Inventory, various anxiety scales, life
The appropriate use of pharmacologic agents in the treatment of muscle and/or joint distur bances on a short-term basis can be a useful mode of therapy. Therapy commonly includes the use of nonaddictive analgesics, anti inflammatory drugs, anti-anxiety agents, and muscle relaxants. Less frequently used, but sometime indicated, are the use of antidepres sants.
76 ■ JADA, Vol. 106, January 1983
Guidelines for treatment
Occlusal adjustment therapy —It should be considered an irreversible treatment. —It should not be used routinely and espe cially not during the acute stage of mos1 temporomandibular disorders.
Occlusal appliances —Those appliances that are not designed tc intentionally and permanently reposition the mandible or the dentition should be consid ered a reversible form of therapy. —These appliances are recommended for many dysfunctional conditions involving the muscles of mastication and the TMJ. Sufficient scientific evidence for their efficacy exists.
Mandibular repositioning therapy —Intentional permanent placement of the mandible in a new position by means of prosthodontic treatment, orthodontic treatment, surgery, or by functional occlusal appliances should be considered an irreversible form of treatment. —Ordinarily, jaw repositioning occlusal ap pliances should be considered a reversible form of treatment unless followed by occlusal adjustment, prosthetic restorations, or or thodontic or surgical treatment. However, their effects may occasionally be irreversible. —Sufficient supporting evidence for this treatment approach was not presented at this Conference.
Physical therapy —This should be considered reversible treatment. —Sufficient supporting evidence for the ef ficacy of this treatment modality was not re viewed at this conference.
Surgery For certain conditions, such as developmental and acquired abnormalities, ankylosis, or neoplasia, surgery may be indicated as the ini tial treatment of choice. For functional disor ders, such as MPD syndrome, surgery is not in dicated. At the present time, there is no evi dence to support the use of surgery for the ini tial treatment of disk displacement. Only after failure of currently acceptable nonsurgical treatments should surgery be considered. However, failure of such treatments alone should not be considered as the only criterion for surgery. Surgical intervention must be based on clearly defined criteria of intracapsular pathologic conditions or anatomic derangement. There is currently little support for meniscectomy except in situations where the disk is so deranged, damaged, or diseased that no other alternative exists.
Osteopathic and chiropractic therapies —Data regarding the reversible or irreversi ble nature of these treatment modalities were not presented at this conference. —Supporting evidence for the efficacy of these treatment modalities currently does not exist.
A S S O C I A T IO N
Behavior therapies —For some dysfunctional conditions in volving the muscles of mastication, this ap proach is recommended and has reasonable scientific support. Behavioral strategies are also indicated for many chronic nonrespond ing temporomandibular patients. (The specific behavior therapies include biofeedback and re laxation training.) M em b ers o f th e a d v iso ry c o m m itte e o f th e temporomandibular conference were: Drs. Charles
A iling, Elliott Gale, William Greenfield, Daniel M. Laskin, Peter Neff, and John Rugh. Address requests for reprints to Dr. W illiam Ayer, Bureau of Econom ic and Behavioral Research, Amer ican Dental Association. T he participants in the conference June 1 to 4 ,1 9 8 2 , were: W illiam A. Ayer, W eldon E. B ell, Donald Blaschke, Sanford Block, W illiam Booth, James G. Burch, Francis M. Bush, Charles D. Carter, Glenn T. Clark, Kenneth M. Clemens. Peter E. Dawson, Lon R. Doles, Herbert B. Dolinsky, M. Franklin Dolwick, Donald H. Enlow, Clifford Fox, Sanford C. Frumker, Elliott N. Gale, Aaron Ganz, Lee
REPORTS
Getter, George Goodheart, Gar S. Graham, Charles S. Greene, W illiam Greenfield, John M. Gregg, Robert H. Griffiths, W alter Guralnick. John H. Harakel, John L. Hicks, W illiam B. Irby, Richard W. Janson, Mark P. Jarrett, Justin L. Jones, David A. Keith, Hans Kraus, D aniel M. Laskin, Charles G. Lewis, M ichael Lewis. R ob ert M aje w sk i, W . D. M cC all, Jr ., C h arles M cN eill, Benjam in Moffett, Norman D. Mohl, Daniel Myers, Peter Neff, Jeffrey P. Okeson, George R. Olfson, Ronald E. Olson. Benjam in Pereira, Harold T. Perry, Calvin Pierce, John D. Rugh, Frank Schm id, Gordon Schrotenboer, Robert Siegel, W illiam Solberg, Delmar Stauffer, Ar thur T. Storey, Stuart Super, Charles Widmer, Ber nard T. W illiam s, George Zarb.
Denture cleansers Council on Dental M aterials, Instruments, and Equipment
he importance of cleanliness in dentures cannot be overemphasized. The relationship between the inflammation associated with denture stomatitis and denture cleanliness in cludes different degrees of severity.1'3 Improp erly cleaned dentures are sources of both bac teria and fungus that may cause localized or systemic infections, which, on very rare occa sions, may be fatal.4 Hence there is an impetus for educating patients to clean their dentures and to make proper use of denture cleansers. Knowledge of the constituents of denture cleansers, their efficacy, adverse effects, and safety would aid in dispensing appropriate in formation to the patients. Denture wearers attempt to clean their den tures in a variety of ways: rinsing in water, using self-cleaning denture cleansers, and brushing with powder or paste dentifrice.5'8 All these methods may have undesirable ef fects. For example, pastes and powders may be abrasive to acrylic teeth and denture bases.9 Immersion-type cleansers may have harmful effects on the plastic or metal components of the dentures.
stains by brushing without physically damag ing the acrylic components of dentures. Other ingredients, such as surfactants, are included to increase the effectiveness of the abrasive. Oxidizing-type cleansers h y p o c h l o r i t e s . Alkaline hypochlorites dis solve or solubilize organic matter or matrixes on which tartar forms. They solubilize the mucin and other albuminoids. The calcium phosphate can then be washed or brushed off. These agents also disinfect the denture.
Table ■ Major active ingredients of some denture cleansers.__________________________________________________ Product
A ctive ingredients_______________
Complete (paste) Denalan Dentu-Creme (paste) D.O.C.
Calcium carbonate Sodium peroxide Calcium carbonate Sodium perborate Trisodium phosphate Potassium m onopersulfate Sodium borate perhydrate Sodium acid pyrophosphate Sodium perborate Trisodium phosphate Sodium phosphate Sodium polymetaphosphate Sodium perborate Trisodium phosphate Sodium perborate Trisodium phosphate Sodium perborate Trisodium phosphate Troclosene potassium Potassium monopersulfate Sodium perborate monohydrate Sodium tripolyphosphate Potassium monopersulfate Sodium perborate monohydrate Proteolytic enzyme Mineral acid
Efferdent tablets
Composition of denture cleansers Denture cleansers that are currently on the market contain a variety of ingredients. The paste-type cleansers contain mild abrasive powders. The soak-type cleansers contain oxidizing agents or mineral acids.10'12 More re cently, denture cleansers based on enzymes have become available.13'16 Other agents added to the cleansers include coloring, flavoring, and surface-active agents. Some commonly used denture cleansers and their ingredients are listed in the Table.
Effervescent denture tablets Extar denture cleansers K.I.K. Kleenite Mersene denture cleanser Polident denture cleanser powder Polident tablets
Paste-type cleansers These cleansers are formulated with mild abra sives such as calcium carbonate powder to as sist the mechanical removal of plaque and
H y p o ch lo rites are co rro siv e to m etal. Hexametaphosphate, excessive alkali, or sodium silicate are sometimes added to de crease the degree of corrosiveness of the al kaline hypochlorites. This type of denture cleanser has been shown to be better for “stains.” These stains, often thought to be caused by tea and tobacco, are probably caused by blood or food residues. Brown stains that remain in the crevices can be a result of iron phosphate present in the tartar on the den ture.10 Resistant tartar and heavy deposits are said to be removed with a few overnight soaks.
Sonac
JADA, Vol. 106, January 1983 ■ 77