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Temporomandibular Disorders: Diagnosis, Management, Education, and Research
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refinem ent and further d evelop m en t of d iagn ostic categories o f TM D; efficacy of various procedures and instrum ents in estab lish in g those d iagn o stic categories; a m ore com p lete understanding of the etio lo g y and m echanism s o f the disorder; and a series of random ized evalu ation s of com m on treatments. T h e ch allen ge to the research c o m m u n ity is clear.
CONTRIBUTIONS
So, h o w m any dentists does it take to treat TM Ds? It takes us all: it takes us in d iv id u a lly and it takes us collectively, k eep in g the p atien t’s needs forem ost. T h a t’s w h at dentistry does best. It’s an excitin g tim e in a m aturing en viron m en t in w h ich objectivity m ust replace rancor.
William F. Wathen, DMD
Charles McNeill, DDS; Norman D. Mohl, DDS, MA, PhD; John D. Rugh, PhD; Terry T. Tanaka, DDS
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g r o u p o f d e n ta l e d u c a to r s / researchers/practitioners m et for . an in fo r m a l w o r k s h o p at the A m erica n D en ta l A s s o c ia tio n D ec 1819, 1989. T h e objective o f the w orkshop w as to discuss an d m ake reco m m en d a tio n s r e g a r d in g te m p o r o m a n d ib u la r disorders (TM D ) w ith o u t tak in g any firm p o s it io n a r r iv in g at a c o n s e n s u s o n a p p r o p r ia te sta n d a rd s o f ca re. T h e d is c u s s io n s w ere b ased o n k n o w le d g e gained from research in the basic sciences and clin ical sciences, as w ell as clin ica l p r a c tic e e x p e r ie n c e . T h e d is c u s s io n included: —defin ition of TM D; —diagn ostic classification; — o u t lin e for an id e a l d ia g n o s t ic evaluation; —screening questionnaire; —screening exam ination; and —directions for the future. T h is report h ig h lig h ts the w ork sh op discussion. It sh ould be noted that this rep o rt d o es n o t c o n s t itu t e a p o s it io n or p olicy o f the A m erican D en tal A sso ciation.
Definition of TMD T em porom and ibular disorders represent a collective term em bracing a num ber
o f c lin ic a l p r o b le m s th a t in v o lv e the m a stic a to r y m u s c u la tu r e a n d /o r the tem porom andibular join t. T em p o rom a n d ib u la r disord ers are c o n sid ered to be a s u b c la ssific a tio n o f m u s c u lo sk e le ta l and rh eu m atologic disorders.1-3 A lth ou gh tr a d itio n a lly they have b een view ed as o n e syndrom e, current research supports the view that T M D s are a cluster of related disorders in the m asticatory system w ith m a n y c o m m o n fe a tu r e s .4 T h e m o st com m on in itia l sym ptom is pain, usually localized in the m uscles o f m astication, the p reau ricu lar area, or the tem p o r o m a n d ib u la r j o in t , or b o th . T h e p a in is u su ally aggravated by c h ew in g or other ja w fu n c t io n . C o m m o n sy m p to m s in c lu d e ja w a ch e, ea r a c h e , h e a d a c h e , and facial pain. In addition to com p lain ts of p a in , p a tie n ts w ith th ese d iso rd ers freq u en tly have lim ite d jaw m ovem en t and jo in t so u n d s, u su a lly described as c lick in g , p o p p in g , grating, or crepitus. P ain or dysfunction caused by n on m u scu lo sk eleta l causes such as n e u r o lo g ic , vascular, n eoplastic, or in fectiou s disease in the orofacial region is not considered a primary T M D even th ou gh m yofascial p ain m ay be present. U n fo r tu n a te ly , k n o w le d g e reg a rd in g the n atu ral h isto ry o r co u rse o f T M D is lim ited .5'7 T h e signs and sym ptom s
o f T M D m a y be tr a n s ie n t a n d selflim itin g , resolvin g w ith o u t serious lo n g term effects. In ad d ition , little is k n ow n a b o u t w h ic h sig n s a n d sy m p to m s w ill progress to more serious con d itio n s. M ost T M D s a p p e a r to be m ild a n d s e lflim itin g; how ever, a num ber o f patients w ith T M D d e v e lo p a c h r o n ic p a in syndrom e.810 A lth ou gh a large percentage o f th e p o p u la t io n h a v e s ig n s a n d /o r sym ptom s, it is estim ated that o n ly about 5% are in need o f treatm ent.11'15 C urrently, p r e d is p o sin g factors have not been sufficiently d efin ed to accurately identify patients at risk to develop T M D , n or ca n w e id e n tify p a tie n ts p r o n e to m ore severe T M D . In ad d itio n , current research has n ot clarified w h ich factors are e tio lo g ic or con trib u tory in nature. S om e factors w ill be risk factors o n ly , others causal in nature, w hereas others m ay result from or be p u rely coin cid en tal to the problem . Factors m ay be classified as p red isp o sin g , in itia tin g , and perp et u a tin g to e m p h a siz e th e ir r o le in the progression o f T M D s.1617
Diagnostic classification T h e A m erican D ental A ssociation (ADA) held a C onference o n the E xam in ation , D ia g n o s is , a n d M a n a g e m e n t o f T e m JADA, Vol. 120, M arch 1990 ■ 253
TWi D I S O R D E R S
Temporomandibular disorders: diagnosis, management, education, and research
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p o r o m a n d ib u la r D iso rd e r s in 1982. G u id e lin e s on the d ia g n o sis an d treat m e n t of te m p o ro m a n d ib u la r disorders were p u b lish ed in 1983.4 T h e need for a n im p roved c la s sific a tio n system w as stressed to com pare ep id em io lo g ic, d ia g n o s t ic , a n d tre a tm e n t d a ta . C u rren t research has m ade im p o rta n t advances in d ia g n o stic cla ssifica tio n s, d ia g n o stic criteria, and m u ltid im en sio n a l measures of severity. A m ajor effort has been under w a y by th e I n te r n a tio n a l H e a d a c h e S o ciety to d ev elo p a m ore lo g ic a l and c o m p le te d ia g n o s tic c la s s if ic a tio n for h ead ache disorders, cran ial n eu ra lg ia s, and facial p a in .18 T em p o ro m a n d ib u la r d isord ers are in c lu d e d in th eir c la s s i fic a t io n for h e a d a c h e or fa c ia l p a in associated w ith disorders of the cranium , eyes, ears, n ose, sin u ses, teeth, m o u th , or other facial or cranial structures (T ab le 1). T h e A m erica n A ca d em y o f C r a n io m an d ib u lar D isorders has collab orated w ith the International H eadache Society to expand the inform ation o n masticatory m u sc le an d te m p o r o m a n d ib u la r j o in t disorders in the c la s sific a tio n 5 (T a b les 1-3). T h ere was essen tial agreem ent by the authors w ith this classification and, in particular, w ith a m edical form at for an im p ro v ed d ia g n o s tic c la s s if ic a tio n sy stem an d to stress a m e d ic a l m o d el fo r th e b io p s y c h o s o c ia l an d p h y s ic a l m anagem ent o f T M D . T h ese g u id elin es propose a classification system for T M D that is integrated w ith an ex istin g m edical d ia g n o s tic system , and thu s, fa cilita tes com m u n ication and shared responsibility a m o n g den tists, p h y sicia n s, and a llie d h e a lth care p r o v id e r s in m a n a g in g p a tien ts w ith T M D . T h e o rig in a l c la s sification schem e appears in its entirety in C ephalgia (vol 8, suppl 7, 1988).18
Evaluation T h e c o lle c tio n o f b a selin e records and o th e r d ia g n o s tic d a ta is fu n d a m e n ta l to the proper m anagem ent o f T M D . In fact, m an agem en t g o a ls are predicated o n an accurate and com plete evaluation. T h e exten t to w h ich any or a ll of the e le m e n ts o f e v a lu a t io n are p u r su e d d ep ends on the m a g n itu d e o f the p re sen tin g sym ptom s and the p otential for the p rob lem p ro g ressin g p h y sic a lly or p sychosocially. O n the basis of clin ica l experience and expert o p in io n , screening for T M D is recom m ended as an essential part of the rou tin e dental e x a m in a tio n for all patients.4 T h e screening, com prised
o f a q u e s t io n n a ir e a n d e x a m in a tio n , d e te r m in e s th e p o s s ib le p r e se n c e or a b sen ce o f T M D s ig n s a n d sy m p to m s (T a b le s 4, 5). A ll fin d in g s fro m the sc r e e n in g q u e s t io n s a n d e x a m in a tio n sh o u ld be recorded in the p atien t’s chart. If s ig n if ic a n t f in d in g s are id e n tifie d , a com prehensive history and exam in ation sh o u ld be conducted.313'19 O n the basis of current literature and
Table 1 ■ Recommended diagnostic classification. 11. H eadache or facial p a in associated w ith disorders of cranium, eyes, ears, nose, sinuses, teeth, m o u th , or o th er facial or cran ial structures 11.1 11.2 11.3 11.4 11.5 11.6 11.7 11.8
Cranial bones including mandible Neck Eyes Ears Nose and sinuses Teeth and related oral structures TM J disorders Masticatory muscle disorders
Table 2 ■ Recommended diagnostic classification. 11.7 TMD 11.7.1 Deviation in form 11.7.2 Disk displacement 11.7.2.1 Disk displacement with reduction 11.7.2.2 Disk displacement without reduction 11.7.3 Hypermobility 11.7.4 Dislocation 11.7.5 Inflammatory conditions 11.7.5.1 Synovitis 11.7.5.2 Capsulitis 11.7.6 Arthritides 11.7.6.1 Osteoarthrosis 11.7.6.2 Osteoarthritis 11.7.6.3 Polyarthritides 11.7.7 Ankylosis 11.7.7.1 Fibrous 11.7.7.2 Bony
Table 3 ■ Recommended diagnostic classification. 11.8 Craniofacial muscle disorders 11.8.1 Myofascial pain 11.8.2 Myositis 11.8.3 Spasm 11.8.4 Reflex splinting 11.8.5 Contracture 11.8.6 Hypertrophy 11.8.7 Neoplasm
CONTRIBUTIONS
the g u id elin es p roposed by the 1982 ADA conference, it is suggested that the “gold standard” for d ia g n o sis is based on the evaluation of the history, clin ica l exam in a tio n , an d , w h e n a p p r o p r ia te , T M J im agin g.
Comprehensive history and examination T h e h isto r y s h o u ld p a r a lle l th e trad i tion al m edical history. T h e seq u en cin g o f a co m p reh en siv e h istory is (1) ch ief “ c o m p la in t( s )” ; (2) h isto r y o f p resen t illn e s s; (3) m e d ic a l h isto ry ; (4) d en ta l h isto ry ; a n d (5) p e r so n a l h is to r y .3’18'19 T h e purpose of the p atien t’s visit should be stated succinctly. T h e history o f the p resen t illn e s s sh o u ld in clu d e: date o f onset; o n set event; character; in ten sity; duration; frequency; location; rem issions; ch an ge over time; factors that alleviate, aggravate, or p recipitate the sym ptom s; and previous treatm ent results.3 T h e m e d ic a l h is to r y m a y in c lu d e p r e v io u s su r g e r y , h o s p it a liz a t io n s , tra u m a , illn e s s e s , d e v e lo p m e n ta l an d a c q u ir e d a n o m a lie s , a n d m e d ic a tio n usage. T h e p a tien t’s dental history should in c lu d e p r e v io u s d e n ta l d isea se, treat m ent, habit history, and attitude.20 T h e personal history o f T M D patients often identifies p ossib le con trib u tin g factors.13 A com prehensive p h ysical exam in ation for T M D patients consists o f observation and d ocu m en tation of a general in sp ec tio n o f the head a n d neck, o r th o p ed ic evaluation of the T M J and cervical spine, m a stic a to r y a n d c er v ic a l m u s c le e v a l uation, neurovascular, neurosensory, and m otor ev a lu a tio n o f the cranial nerves, and an in traoral e v a lu a tio n , in c lu d in g an occlu sal an alysis.3
Imaging
Im agin g is warranted w hen the clin ical exa m in a tio n or history, or both, indicate that a recent or progressive p a th o lo g ic jo in t co n d itio n exists, such as: trauma; sig n ific a n t d y sfu n ctio n or a lteration in r a n g e o f m o tio n ; se n s o r y or m o to r a lte r a tio n s; o r s ig n if ic a n t c h a n g e s in o cclu sio n (anterior o p en bite, posterior o p en bite, m andibular shift). J o in t im a g in g is n o t indicated for jo in t s o u n d s in th e a b se n c e o f o th e r T M D s ig n s a n d s y m p to m s . R o u t in e r a d io graphic exam in ation m ay in clu d e tom o graphic or transcranial T M J film s in clu d in g la te r a l p h a r y n g e a l, tr a n s o r b ita l, m od ified T ow n es, and panoram ic view s of the jaw s. T ranscranial radiography
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Table 4 ■ Recommended screening questionnaire for TMD. 1. Do you have difficulty or pain, or both, when opening your mouth, as for instance, when yawning? 2. Does your jaw get “stuck,” “locked,” or “go o ut”? 3. Do you have difficulty or pain, or both, when chewing, talking, or using your jaws? 4. 5. 6. 7. 8.
Are you aware of noises in the jaw joints? Do you have pain in or about the ears, temples, or cheeks? Does your bite feel uncomfortable or unusual? Do you have frequent headaches? Have you had a recent injury to your head, neck, or jaw?
9. Have you previously been treated for a jaw joint problem? If so, when? Note: If any one of the first three questions is answered affirmatively, the clinician should complete a comprehensive history and exam ination; for questions 4 th ro u g h 8, tw o sh o u ld be answ ered affirm atively, an d fo r q u estio n 9, a positive answer to two other questions (4-8) is required to w arrant further evaluation.
CONTRIBUTIONS
T M D p atien ts w ith u se of p ain diaries a n d se lf-a sse ssm e n t in s tr u m e n ts, su c h as the H o lm e s and R a h e Scale for life c h a n g e s .40 T w o tests, IM P A T H 41 an d the T M J Scale,42'43 are design ed for use by dentists treating T M D . If warranted, this in itia l assessm ent m ay be follow ed o r p rec ed ed by an e v a lu a t io n by a p sych o lo g ist or psychiatrist. In fact, there are a n u m b e r o f p s y c h o lo g ic a l an d b e h a v io r a l factors th a t s h o u ld b e rec o g n iz ed d u r in g scre e n in g an d c o m p re h en sive e v a lu a tio n s that co u ld in d icate the n ecessity for fu rth er e v a lu a tio n by a m ental health professional (T able 6).
Additional clinical tests Table 5 ■ Recommended screening examination procedures for TMD. 1. Measure range of motion of the m andible on opening and right and left laterotrusion. 2. Palpate for preauricular TM J tenderness. 3. Palpate for TM J crepitus. 4. Palpate for TM J clicking. 5. Palpate for tenderness in the masseter and temporalis muscles. 6. Note excessive occlusal wear, excessive tooth mobility, fremitus, or m igration in the absence of periodontal disease, and soft tissue alterations, for example, buccal mucosal ridging, lateral tongue scalloping. 7. Inspect symmetry and alignm ent of the face, jaws, and dental arches. Note: Any positive fin d in g for procedures 1 th ro u g h 3 w arrants consideration for a com prehensive history and exam ination, whereas any two positive findings for procedures 4 through 6 suggest the same consideration; procedure 7 requires two other positive findings (4-6) to suggest the same consideration.
o f the T M J has o n ly lim ite d p u r p o se as a screening radiographic study. C orrected cep h alom etric tom o g ra p h y is a m ore accu rate m e th o d fo r r a d io g r a p h ic a lly e x a m in in g p a tie n ts w ith suspected T M J degenerative disease and is preferred over transcranial projections w h en an osseou s p a th o lo g ic c o n d itio n is suspected. T em p orom an d ib u lar jo in t radiographs to assess condylar p o sitio n by m eans of jo in t space m easurem ents are con traind icated for d ia g n o stic p u r poses.20-23 A lso, condylar p o sitio n in the fossa is not a d iagnostic aid for articular disk displacem ent.24 A rth rograp h y p ro v id es a fu n c tio n a l dynam ic study of the disk and condyle. H o w ev er, b eca u se o f the in v a s iv e n e ss o f the procedure, radiation, and d isco m fort that can occur, it sh ou ld be lim ited to selected T M D cases of disk d isp la ce m ent w hen the dynam ic im a g in g results w ill alter the co u rse o f trea tm e n t.25'29 C om puted axial tom ography is valuable as a n a d ju n c t im a g in g te c h n iq u e in assessm ent o f bony ab norm alities, such as, d e v e lo p m e n ta l a n o m a lie s, trau m a, and neoplastic conditions of the T M J.30-
32 M agnetic resonance im a g in g has diverse capabilities for exam in ation o f m ost cases o f suspected TM J soft tissue disorders— disk d isp lacem en t—and elim in a tes c o n cern over safety o f io n izin g radiation.3337
Behavioral and psychosocial assessment A sse ss m e n t o f c h r o n ic T M D p a tie n ts sh o u ld in clu d e beh avioral and p sy c h o social ev a lu a tio n .38 T h u s, it is strongly a d v is e d th a t th e o r a l h is to r y in c lu d e q u estion s to evaluate behavioral, social,
A d d itio n a l d ia g n o stic stu d ies a v ailab le fo r a s s is t in g th e c o n f ir m a t io n o f th e p h ysical d iagn osis in clu d e b iop sy, p u lp testin g , tr a n s illu m in a tio n , casts, in je c tio n s, and lab oratory tests. T h e se tests s h o u ld n o t b e c o n s id e r e d as r o u tin e procedures, b u t rather be u sed to s u p p le m e n t k n o w le d g e g a in e d d u r in g the history, exam in ation , an d im agin g. D e n ta l c a sts ca n f a c ilit a t e d e ta ile d e x a m in a t io n o f b o th th e s ta tic a n d f u n c t io n a l r e la t io n s h ip s o f the teeth . H ow ever, m uscle tenderness, jo in t pain, a n d ed em a c a n n e g a t iv e ly a ffe c t th e accuracy of the m o u n tin g s. D ia g n o stic in je c tio n s in c lu d e n erve b lo ck , trigger p o in t, an d jo in t in je c tio n s . T h e se can be an im portant adjunct to the d iagnostic p rocess. F in a lly , la b o ra to ry d ia g n o s tic te s tin g m ay in c lu d e b lo o d ch e m istries and u rinalysis to identify sp ecific hem a t o lo g ic , r h e u m a t o lo g ic , m e ta b o lic , or o th e r m ark ers s u g g e s tiv e o f s y s te m ic disease.
Management D e n tists w h o c h o o se to m a n a g e T M D m ust use a d iagn ostic classification based o n esta b lish ed c o n c e p ts o f p h y s io lo g y
Lentists who choose to manage TMD must use a diagnostic classification based on concepts of physiology and pathology.
e m o t io n a l, a n d c o g n it iv e facto rs th a t m ay initiate, sustain, or result from the p atien t’s co n d itio n .59 Som e p sych ological asp ects o f illn e s s can be id e n tifie d in
a n d p a th o lo g y . P r o p o s e d tr e a tm e n t sh o u ld have been subjected to laboratory testing for safety as w ell as random ized clin ica l testing for efficacy. T h e proposed
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Table 6
■ Recommended checklist of psychological and behavioral factors.
1. Clinically significant anxiety or depression 2. Evidence of drug abuse 3. 4. 5. 6.
Repeated failures with conventional therapies Evidence of secondary gain Major life events, for example, new job, marriage or divorce, death Pain duration greater than 6 months
7. History of possible stress-related disorders 8. Inconsistency in response to drugs 9. Inconsistent, inappropriate, and vague reports of pain, or both 10. Overdramatization of symptoms 11. Symptoms that vary with life events Note: The first two factors are the most significant and warrant further evaluation by a mental health professional; factors 3-6 need at least one more factor for consideration of referral, and factors 7-11 require three or more factors for consideration of referral to a mental health professional.
th e a b se n c e o f a c h ie f c o m p la in t, the o u tc o m e o f su c h tr e a tm e n t w ill be d ifficu lt to assess.
Future directions T h e fu tu re d ir e c tio n o f T M D a c tiv ity n eed s to be in th e areas o f im p r o v e d basic and clin ica l research; predoctoral, p o s td o c to r a l, a n d c o n t in u in g d e n ta l ed u cation curricula; and relation s w ith the h ealth in su ran ce in d u stry— m edical and dental. Research A t th is tim e , r esea rch s u g g e s ts th a t accurate d istin ction s between m ild T M D a n d h e a lth c a n n o t be m ade; h o w ev er, patients w ith m oderate to severe disease can be c lin ic a lly id e n tifie d th r o u g h a history and clin ica l exam in ation . Ideally, d ia g n o s t ic d ata s h o u ld d e te r m in e if disease is present and the exten t o f disease, estab lish a b aselin e o n w h ich to ju d ge treatment results, and d istin g u ish T M D from other sources o f head and neck pain.
#he future direction of TMD activity needs to be in the areas of improved basic and clinical research, dental education curricula, and relations with the health insurance industry. n ec e ssa rily be treated. S uch trea tm en t sh o u ld be on ly im plem ented after both th e d e n tist an d p a tie n t reco g n ize th a t th ere is n o c u rren t e v id e n c e th a t th e p o s itiv e s ig n s w ill e sc a la te to o v e r t sym ptom s in the future, and that, in
T h er e is a n eed for w e ll-c o n tr o lle d , ra n d o m ized c lin ic a l stu d ies. R e c en tly , there has been a generalized agreem ent that clin ica l studies m ust use w ell-defined p atien t d ia g n o stic su b grou p s and w ellm atch ed co n tr o ls in order to esta b lish
b ette r c o r r e la tio n s a m o n g th e m a n y variables associated w ith T M D .45 C lin ical success is n ot necessarily scien tific proof o f cause an d effect, so that w e n eed to a p p ro a ch T M D b o th as a sc ie n c e an d an art.46
Education
U n fo r tu n a te ly , m a n y c u r r e n t d e n ta l ed u cation al program s are n ot adequately t r a in in g s tu d e n ts to m a n a g e T M D p a tie n ts. P red o cto ra l e d u c a tio n a l p r o gram s sh o u ld p rovid e in creased fa m il iarity w ith d ia g n o s tic r e a so n in g , ra d i o lo g y , n e u r o lo g y , p h y s ic a l m e d ic in e , a n d p h a r m a c o lo g y — w ith in c r e a s e d e m p h a s is o n h is to r y -t a k in g , p h y s ic a l d iagn osis, and the ab ility to understand co m p lex diseases in a p sych osocial co n text.3’12 A num ber of dental sch o o ls have esta b lish ed p o std o cto ra l resid en cy p ro g ra m s fo r a d v a n c e d t r a in in g in th e eva lu a tio n and m an agem en t o f ch ro n ic p ain and T M D . W hen this in form ation is n o t o b ta in e d in d e n ta l s c h o o l, th e d en tist needs to ob ta in th is k n o w led g e in h ig h - q u a lity c o n t in u in g e d u c a tio n courses. It is critical for p racticin g dentists to be selective in th eir c h o ic e o f these c o u r se s . A n u m b e r o f m e e t in g s are p la n n ed in the near future to ex a m in e predoctoral, postdoctoral and c o n tin u in g e d u c a tio n c u r r ic u la a n d r e v ie w m a n a g e m e n t g u id e lin e s for T M D .47>48 T h e n ew ly form ed A ssociation o f U n iversity T M D O rofacial P ain Program s is m eetin g at the 1990 IA DR m eetin g in C in cin n ati to add direction to the sam e top ics.49 Health care benefits In th e p a st, th e b ro a d , n o n s p e c if ic
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tr e a tm e n t s h o u ld h a v e b een p r o v e d th ro u gh rig o ro u sly co n tro lle d research to be both appropriate and effective for the specific disorder(s) b ein g tested. T h e treatment sh ould have specific value for th e d iso r d e r as o p p o s e d to r e sp o n s e s m ain ly the result o f n on sp ecific factors such as placebo effects, p ositive aspects of the doctor-patient relation sh ip , sp o n taneous rem issions, and overtreatment.44 T h e g o a ls for m a n a g e m e n t o f a ll patients w ith T M D include: — reduce pain; — restore norm al jaw function; — red u ce th e n eed for fu tu re h e a lth care; and — restore norm al lifestyle fu n ction in g. T h ese goals are best achieved by a w elld efin ed program d esig n ed to treat th e p h y sic a l d isord er an d redu ce th e c o n tr ib u tin g fa cto rs. T h e m a n a g e m e n t o p t io n s an d s e q u e n c in g o f tr ea tm e n t for T M D are con sisten t w ith treatm ent o f m u s c u lo s k e le ta l d iso rd ers in o th e r p a rts o f th e b o d y . O p t io n s in c lu d e b e h a v io r a l th era p y , o r th o p e d ic s t a b i liz a tio n , p h a r m a c o th e r a p y , p h y s ic a l m edicine, occlusal therapy, and surgery.3 4 A key d e te r m in a n t o f su cc e ss in th e m anagem ent of m usculoskeletal disorders is the success in ed u ca tin g the p a tie n t about, and a ch ievin g com p lia n ce w ith , th e se lf-c a r e a sp e c ts o f m a n a g e m e n t, in c lu d in g habit m odification and proper u se o f th e jaw . G o a ls o f m a n a g e m e n t are best achieved by u sin g the o p tim a l com b in ation of treatment op tio n s in the proper sequence. In m ost cases, the m ost co n serv a tiv e a p p ro a ch sh o u ld be c o n sidered first; treatment op tion s are added as needed, u sin g non invasive procedures before irreversible, invasive ones. A sid e from s e r io u s or p o t e n t ia lly serious disease, p ositive sig n s fou n d in d en tal p a tien ts w h o have n ot had an y sym ptom s relative to T M D sh o u ld n ot
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d e s ig n a t io n o f T M J h as p e r h a p s led in su r a n c e carriers to c o n sid e r b e n e fit coverage for treatment as if T M D were due to a sin gle cause w ith o n e treatment a p p r o p r ia te in a ll cases. T o d a y , w ith the com bined efforts o f m any researchers in d en tistry and m e d ic in e , b io p s y c h o p h y s ic a l d ia g n o s tic c la s s if ic a t io n s o f T M D h ave b een e sta b lis h e d b a sed o n m edical m od els.5052 T h ese classification sy stem s w ill fa c ilita te c o m m u n ic a tio n an d shared responsibility a m o n g dentists, p h y sicia n s, an d a llied h ea lth care p ro v id e r s in th e m a n a g e m e n t o f T M D p a tie n ts. T o d a y , m a n a g e m e n t o p tio n s an d seq u en cin g of the treatm ent for T M D is c o n s is te n t w ith tre a tm e n t o f o th e r orth op edic and rheum atologic disorders. R eversible, n o n in v a siv e treatm ent su ch as b e h a v io r a l m o d if ic a t io n , p h y s ic a l therapy, m ed ica tio n , and in tero cc lu sa l a p p lia n c e s are endorsed for the in itia l care of nearly all T M D s. T h e em phasis is o n conservative therapy that prom otes th e m u s c u lo s k e le ta l s y s te m ’s n a tu r a l h e a lin g capacity, in v o lv in g the patients in the physical an d behavioral m anage m ent of their o w n problem . W ith T M D patients w h o have more com p lex ch ron ic p a in , in terd iscip lin a ry an d m u ltid is c i plinary m anagem ent has becom e the m ore successful overall m anagem ent program . As T M D s are sim ilar to m usculoskeletal an d r h e u m a t o lo g ic d iso r d e r s, a n d d o n ot directly involve disorders o f dentition; they need to be inclu ded m ore fu lly in h e a lth care b e n e fits, regard le ss o f the clin icia n p rovid in g the service.53 In 1987, M in n e s o ta b eca m e th e fir st sta te to m andate T M D coverage and, currently, a num ber o f states are consid erin g T M D legislation for this coverage.64
Conclusion T h e w orkshop sum m arized current in for m ation on T M D in regard to d iagn ostic c la s s if ic a t io n , e v a lu a t io n , s c r e e n in g e x a m in a tio n s , an d d ir e c tio n fo r th e future.
-------------------- JliO A -------------------Dr. McNeill is clinical professor, departm ent of restorative dentistry, an d director of C raniofacial Pain-T M J Clinic, School of Dentistry, University of California, San Francisco. Dr. Mohl is professor, d e p a rtm e n t o f o ra l m ed icin e, S chool of D ental Medicine, SUNY, Buffalo. Dr. R u gh is professor, d e p a rtm e n t of o ral an d m a x illo fa c ia l surgery, chairm an of the D ivision of Research, U niversity of Texas Health Science Center, San Antonio. Dr. T an ak a is associate clin ical professor, School of Dentistry, University of Southern C alifornia, and
director, Facial Pain-TM J Clinic, San Diego. 1. Bell WE. O rofacial p a in s . C lassificatio n , diag n o sis, m an ag em en t. 4 th ed. C hicago:Y ear Book; 1989. 2. Bell WE. Tem porom andibular disorders. Clas sification, diagnosis, management. 3rd ed. Chicago: Year Book; 1990. 3. McNeill C. Craniom andibular disorders: guide lines for the evaluation, diagnosis, and management. J Craniom andib Disord Facial O ral Pain 1990 (In press). 4. G riffiths RH. R eport of the president’s con ference on exam ination, diagnosis and management of tem poromandibular disorders. JADA 1983;106:757. 5. Rasmussen CO. Clinical findings during the course of tem porom andibular arthropathy. Scand J Dent Res 1981;89:283-8. 6. Nickerson JW , Boering G. N atural course of osteoarthrosis as it relates to internal derangement of the tem porom andibular joint. O ral M axillofac Surg Clin North Am 1989;1:1-19. 7. Stegenga B, deBont LGM, Boering G. Osteoar throsis as the cause of craniom andibular pain and dysfunction: a u nifying concept. J O ral M axillo Surg 1989;47:249-56. 8. D w orkin SF, Burgess JA. O rofacial p ain of psychogenic orig in : cu rre n t concepts an d classi fication. JADA 1987;115:565-71. 9. N ational institutes of health consensus devel opm ent conference. T h e in teg rated ap p ro ach to the management of pain. N IH consensus development conference statement. Vol. 6 no 3. W ashington DC: US Government Printing Office; 1986. 10. Sternbach RA. Survey of pain in the United States: the N uprin pain report. Clin J Pain 1986;2:4953. 11. Solberg WK. E pidem iology, incidence, and prevalence of tem poromandibular disorders: a review. T h e p resid en t’s conference on the ex am in atio n , diagnosis, and management of tem poromandibular disorders. Am erican D ental A ssociation; 1983:309. 12. R ugh JD , Solberg WK. O ral health status in the United States: Tem porom andibular disorders. J Dent Educ 1985;49:398-404. 13. Schiffm an E, F ricton JR . E pidem iology of TM J and craniofacial pain. In: Fricton JR , Kroening RJ, Hathaway KM, eds. TM J and craniofacial pain: diagnosis and m anagem ent. St. L ouis: IEA P u b lishers; 1988:1-10. 14. Schiffman E, Fricton JR , Haley D, Shapiro BL. T he prevalence and treatment needs of subjects w ith te m p o ro m a n d ib u la r disorders. JADA 1990;120:295-303. 15. Dworkin SF, Hanson-H uggins KH, LeResche LR, et al. Epidem iology of signs an d sym ptom s in tem porom andibular disorders: I. C linical signs in cases and controls. JADA 1990;120:273-81. 16. M cNeill C. D anzig WM, F arrar WB, et al. C ran io m an d ib u lar (TM J) disorders—the state of the art (Position paper of the Am erican academy of c ra n io m a n d ib u la r disorders) J P ro sth et Dent 1980;44:434-7. 17. M cN eill C. C ra n io m a n d ib u la r (T M J) d is orders—the state of the art. Part II: accepted diagnosis an d tre a tm e n t an d m o d alities. J P ro sth e t D ent 1983;49:393-7. 18. C lassificatio n an d d ia g n o stic c rite ria for headache disorders, cranial neuralgias and facial p a in . C e p h alg ia , a n in te rn a tio n a l jo u rn a l of headache. Oslo: Norwegian University Press; 1988. (Vol 8, suppl 7). 19. Clark G T , Seligman DA, Solberg WK, Pul-
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lin g er AG. G u id elin es for the e x a m in a tio n and diagnosis of tem porom andibular disorders. J Cra niom andib Disord Facial Oral Pain 1989;3:6-14. 20. A m erican D ental A ssociation. R ecom m en d atio n s in ra d io g ra p h ic p ractices, 1984 C o u n cil on Dental Materials, Instrum ents, and Equipm ent. JADA 1984; 109. 21. A q u ilin o SA, M atteso n SR, H o lla n d GA, P hillips C. E valuation of condylar position from tem porom andibular jo in t radiographs. J Prosthet Dent 1985;53:88-97. 22. P u llin g e r AG, S olberg WK, H o lle n d e r L, G uichet D. T om ographic analysis of m and ib u lar condyle position in diagnostic subgroups of tem p o ro m a n d ib u la r d isorders. J P ro sth e t D ent 1986;55:723-9. 23. P u llin g e r AG, H o lle n d e r L , S o lb erg WK, Petersson A. A tom ographic study of m andibular condyle position in an asym ptom atic population. J Prosthet Dent 1985;53:706. 24. Dixon DC, Graham GS, Mayhew RB, Oesterle L J, Simms D, Pierson WP. T h e validity of transcran ial radiography in d iag n o sin g T M J an terio r disk displacement. JADA 1984;108:615-8. 25. Katzberg RW, Dolwick MF, Helms CA, Hopens T , Bales DJ, Coggs GC. Arthrotom ography of the tem porom andibular joint. Amer J Roentgenology 1980;134:995-1003. 26. Westesson PL. Double-contrast arthrography of the T M J: intro d u ctio n of a technique. J O ral Maxillofac Surg 1983;41:163-72. 27. Westesson PL, Bronstein DI. TM J: Comparison of single and double-contrast arthrography. R adi ology 1985:164-5. 28. R oberts CA, K atzberg RW , T a lle n ts RA, Espeland MA, Handelm an SL. Correlation of clinical parameters to the arthrographic depiction of TM J internal derangem ents. O ral S urg O ral Med O ral Pathol 1988;66:32. 29. R onquillo HI, Guay J, T allents R H , Katzberg RW , M urphy W. T o m o g rap h ic analysis of m an dibular condyle position compared to arthrographic findings of the TM J. J Craniom andib Disord Facial Oral Pain 1988;2:59-64. 30. Helms CA, Morrish RB, Kircos L T, Katzberg RW, Dolwick WF. C om puted tom ography of the m eniscus te m p o ro m a n d ib u la r jo in t: p relim in ary observations. Radiology 1982;145:719-22. 31. M anzione JV , K atzberg RW , Brodsky G L, Seltzer SE, M ellins HZ. Internal derangem ents of the tem porom andibular jo in t: diagnosis by direct s a g itta l co m p u ted to m o g ra p h y . R ad io lo g y 1984;150:111-5. 32. R a u stia AM, P h y tin e n J , V irtan en KK. E xam ination of the tem p o ro m an d ib u lar jo in t by direct sagittal com puted tom ography. Clin Radiol 1985;36:291-6. 33. Westesson PL, Katzberg RW , T alle n ts RR, et al. C T and MR of the T M J: com parison w ith au to p sy specim ens. Am J R a d io l 1987; 148:116571. 34. Carr AB, Gibilisco JA, Berquist T H . Magnetic resonance im aging of the tem porom andibular join t— p relim in ary work. J C ra n io m a n d ib D isord O ral Facial Pain 1987;1:89-96. 35. Sanchez-Woodworth RE, T allents RH, Katz berg RW, Guay JA. Bilateral internal derangements of the TM J: evaluation by MRI imaging. Oral Surg Oral Med Oral Pathol 1988;65:281. 36. Helm s CA, Kaban LB, M cN eill C, D odson T . T e m p o ro m a n d ib u la r jo in t: m o rp h o lo g y and signal intensity characteristics of the disc a t MR imaging. Radiology 1989;172:817-20. 37. H elm s CA, Doyle GW , O rw ig D, M cN eill C, K aban LB. S taging of in te rn a l derangem ents
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P ro g ram s P la n n in g Session, ad hoc S teerin g C om m ittee. San F rancisco: Am er Assoc D ent Research; 1989. 50. Stegenga B, deB ont L G M , B oerin g G. A p ro p o se d c la s sific a tio n of te m p o ro m a n d ib u la r d iso rd ers based o n synovial jo in t p a th o lo g y . J Craniom andib Pract 1989;7:107-18. 51. L u n n R. P rinciples, concepts and practices of c ra n io m a n d ib u la r diseases. A m erican E q u ili bration Society Com pendium 1987;20:181-227. 52. T alley R L , M urphy G J, S m ith SD, Baylin MA, H aden JL . S tandards for the history, exam ination, diagnosis, and treatm ent of tem porom an d ib u la r d iso rd ers (TM D ): a p o sitio n p a p e r. J Craniomandib Pract 1990;8:60-77. 53. Fricton JR , Schulte J. T hird party reimburse m ent for T M J injuries: a position paper. Departments of o ra l a n d m a x illo fa c ia l surgery an d p h y sic al medicine and rehabilitation. Minneapolis: University of Minnesota, 1987. 54. M innesota A ccident an d H ealth In su ran ce S tatutes. D ental procedures. C hap 62A.043. 1987 (Suppl).
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J Craniom andib Pract 1988;6:18-25. 43. L u n d een T F , L e v itt SR, M cK inney MW. C linical ap p licatio n s of the T M J scale. J C rani om andib Pract 1988;6:339. 44. Green CS, Marbach JJ. Epidemiologic studies of m a n d ib u la r d y sfu n ctio n : a critic a l review. J Prosthet Dent 1982;48:184-90. 45. International Association of Dental Research. Proceedings of the Neuroscience G roup Meeting. Montreal: 1988. 46. Zarb GA, M ohl ND. O cclusion and tem po rom andibular disorders: A prologue. In: Mohl ND, Zarb GA, Carlsson GE, Rugh JD, eds. A textbook of occlusion. Chicago: Quintessence; 1988:377-83. 47. H ead an d Neck P ain Satellite Sym posium : Review of tem porom andibular jo in t m anagem ent guidelines. Cincinnati: IADR Neuroscience Group; 1990. 48. First E ducational Conference to develop the cu rricu lu m in T M disorders and orofacial pain. Newark, NJ: University of Medicine and Dentistry of New Jersey; A pril 1990. 49. Association of University TMD Orofacial Pain
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of the T M J w ith m ag n etic reso n an ce im ag in g : prelim inary observations. J C raniom andib Disord Facial Oral Pain 1989;3:93-9. 38. Rugh JD. Psychological factors in the etiology of m asticatory pain and dysfunction. In: L askin D, et al, eds. T h e p re sid e n t’s conference on the exam ination, diagnosis and m anagem ent of tem porom andibular disorders. Chicago: American Dental Association; 1982:85-94. 39. Olson RE. Behavioral exam inations in MPD. In: Laskin DM, et al, eds. T he president’s conference on the exam in atio n , diagnosis, and m anagem ent of tem poromandibular disorders. Chicago: American Dental Association 1983; 104-5. 40. Moody PM, Kemper JT , Okeson JP, Calhoun TC, Packer MV. Recent life changes and myofascial pain syndrome. J Prosthet Dent 1982;48:328-30. 41. Fricton JR , Nelson A, M onsein M. Im path: m icrocom puter assessment of behavioral and psy chological factors in cran io m an d ibular disorders. J Craniomandib Pract 1987;5:372. 42. Levitt SR, McKinney MW, Lundeen TF. T he T M J scale: cross-variation and reliability studies.
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refinem ent and further d evelop m en t of d iagn ostic categories o f TM D; efficacy of various procedures and instrum ents in estab lish in g those d iagn o stic categories; a m ore com p lete understanding of the etio lo g y and m echanism s o f the disorder; and a series of random ized evalu ation s of com m on treatments. T h e ch allen ge to the research c o m m u n ity is clear.
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So, h o w m any dentists does it take to treat TM Ds? It takes us all: it takes us in d iv id u a lly and it takes us collectively, k eep in g the p atien t’s needs forem ost. T h a t’s w h at dentistry does best. It’s an excitin g tim e in a m aturing en viron m en t in w h ich objectivity m ust replace rancor.
William F. Wathen, DMD
Charles McNeill, DDS; Norman D. Mohl, DDS, MA, PhD; John D. Rugh, PhD; Terry T. Tanaka, DDS
A
g r o u p o f d e n ta l e d u c a to r s / researchers/practitioners m et for . an in fo r m a l w o r k s h o p at the A m erica n D en ta l A s s o c ia tio n D ec 1819, 1989. T h e objective o f the w orkshop w as to discuss an d m ake reco m m en d a tio n s r e g a r d in g te m p o r o m a n d ib u la r disorders (TM D ) w ith o u t tak in g any firm p o s it io n a r r iv in g at a c o n s e n s u s o n a p p r o p r ia te sta n d a rd s o f ca re. T h e d is c u s s io n s w ere b ased o n k n o w le d g e gained from research in the basic sciences and clin ical sciences, as w ell as clin ica l p r a c tic e e x p e r ie n c e . T h e d is c u s s io n included: —defin ition of TM D; —diagn ostic classification; — o u t lin e for an id e a l d ia g n o s t ic evaluation; —screening questionnaire; —screening exam ination; and —directions for the future. T h is report h ig h lig h ts the w ork sh op discussion. It sh ould be noted that this rep o rt d o es n o t c o n s t itu t e a p o s it io n or p olicy o f the A m erican D en tal A sso ciation.
Definition of TMD T em porom and ibular disorders represent a collective term em bracing a num ber
o f c lin ic a l p r o b le m s th a t in v o lv e the m a stic a to r y m u s c u la tu r e a n d /o r the tem porom andibular join t. T em p o rom a n d ib u la r disord ers are c o n sid ered to be a s u b c la ssific a tio n o f m u s c u lo sk e le ta l and rh eu m atologic disorders.1-3 A lth ou gh tr a d itio n a lly they have b een view ed as o n e syndrom e, current research supports the view that T M D s are a cluster of related disorders in the m asticatory system w ith m a n y c o m m o n fe a tu r e s .4 T h e m o st com m on in itia l sym ptom is pain, usually localized in the m uscles o f m astication, the p reau ricu lar area, or the tem p o r o m a n d ib u la r j o in t , or b o th . T h e p a in is u su ally aggravated by c h ew in g or other ja w fu n c t io n . C o m m o n sy m p to m s in c lu d e ja w a ch e, ea r a c h e , h e a d a c h e , and facial pain. In addition to com p lain ts of p a in , p a tie n ts w ith th ese d iso rd ers freq u en tly have lim ite d jaw m ovem en t and jo in t so u n d s, u su a lly described as c lick in g , p o p p in g , grating, or crepitus. P ain or dysfunction caused by n on m u scu lo sk eleta l causes such as n e u r o lo g ic , vascular, n eoplastic, or in fectiou s disease in the orofacial region is not considered a primary T M D even th ou gh m yofascial p ain m ay be present. U n fo r tu n a te ly , k n o w le d g e reg a rd in g the n atu ral h isto ry o r co u rse o f T M D is lim ited .5'7 T h e signs and sym ptom s
o f T M D m a y be tr a n s ie n t a n d selflim itin g , resolvin g w ith o u t serious lo n g term effects. In ad d ition , little is k n ow n a b o u t w h ic h sig n s a n d sy m p to m s w ill progress to more serious con d itio n s. M ost T M D s a p p e a r to be m ild a n d s e lflim itin g; how ever, a num ber o f patients w ith T M D d e v e lo p a c h r o n ic p a in syndrom e.810 A lth ou gh a large percentage o f th e p o p u la t io n h a v e s ig n s a n d /o r sym ptom s, it is estim ated that o n ly about 5% are in need o f treatm ent.11'15 C urrently, p r e d is p o sin g factors have not been sufficiently d efin ed to accurately identify patients at risk to develop T M D , n or ca n w e id e n tify p a tie n ts p r o n e to m ore severe T M D . In ad d itio n , current research has n ot clarified w h ich factors are e tio lo g ic or con trib u tory in nature. S om e factors w ill be risk factors o n ly , others causal in nature, w hereas others m ay result from or be p u rely coin cid en tal to the problem . Factors m ay be classified as p red isp o sin g , in itia tin g , and perp et u a tin g to e m p h a siz e th e ir r o le in the progression o f T M D s.1617
Diagnostic classification T h e A m erican D ental A ssociation (ADA) held a C onference o n the E xam in ation , D ia g n o s is , a n d M a n a g e m e n t o f T e m JADA, Vol. 120, M arch 1990 ■ 253
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p o r o m a n d ib u la r D iso rd e r s in 1982. G u id e lin e s on the d ia g n o sis an d treat m e n t of te m p o ro m a n d ib u la r disorders were p u b lish ed in 1983.4 T h e need for a n im p roved c la s sific a tio n system w as stressed to com pare ep id em io lo g ic, d ia g n o s t ic , a n d tre a tm e n t d a ta . C u rren t research has m ade im p o rta n t advances in d ia g n o stic cla ssifica tio n s, d ia g n o stic criteria, and m u ltid im en sio n a l measures of severity. A m ajor effort has been under w a y by th e I n te r n a tio n a l H e a d a c h e S o ciety to d ev elo p a m ore lo g ic a l and c o m p le te d ia g n o s tic c la s s if ic a tio n for h ead ache disorders, cran ial n eu ra lg ia s, and facial p a in .18 T em p o ro m a n d ib u la r d isord ers are in c lu d e d in th eir c la s s i fic a t io n for h e a d a c h e or fa c ia l p a in associated w ith disorders of the cranium , eyes, ears, n ose, sin u ses, teeth, m o u th , or other facial or cranial structures (T ab le 1). T h e A m erica n A ca d em y o f C r a n io m an d ib u lar D isorders has collab orated w ith the International H eadache Society to expand the inform ation o n masticatory m u sc le an d te m p o r o m a n d ib u la r j o in t disorders in the c la s sific a tio n 5 (T a b les 1-3). T h ere was essen tial agreem ent by the authors w ith this classification and, in particular, w ith a m edical form at for an im p ro v ed d ia g n o s tic c la s s if ic a tio n sy stem an d to stress a m e d ic a l m o d el fo r th e b io p s y c h o s o c ia l an d p h y s ic a l m anagem ent o f T M D . T h ese g u id elin es propose a classification system for T M D that is integrated w ith an ex istin g m edical d ia g n o s tic system , and thu s, fa cilita tes com m u n ication and shared responsibility a m o n g den tists, p h y sicia n s, and a llie d h e a lth care p r o v id e r s in m a n a g in g p a tien ts w ith T M D . T h e o rig in a l c la s sification schem e appears in its entirety in C ephalgia (vol 8, suppl 7, 1988).18
Evaluation T h e c o lle c tio n o f b a selin e records and o th e r d ia g n o s tic d a ta is fu n d a m e n ta l to the proper m anagem ent o f T M D . In fact, m an agem en t g o a ls are predicated o n an accurate and com plete evaluation. T h e exten t to w h ich any or a ll of the e le m e n ts o f e v a lu a t io n are p u r su e d d ep ends on the m a g n itu d e o f the p re sen tin g sym ptom s and the p otential for the p rob lem p ro g ressin g p h y sic a lly or p sychosocially. O n the basis of clin ica l experience and expert o p in io n , screening for T M D is recom m ended as an essential part of the rou tin e dental e x a m in a tio n for all patients.4 T h e screening, com prised
o f a q u e s t io n n a ir e a n d e x a m in a tio n , d e te r m in e s th e p o s s ib le p r e se n c e or a b sen ce o f T M D s ig n s a n d sy m p to m s (T a b le s 4, 5). A ll fin d in g s fro m the sc r e e n in g q u e s t io n s a n d e x a m in a tio n sh o u ld be recorded in the p atien t’s chart. If s ig n if ic a n t f in d in g s are id e n tifie d , a com prehensive history and exam in ation sh o u ld be conducted.313'19 O n the basis of current literature and
Table 1 ■ Recommended diagnostic classification. 11. H eadache or facial p a in associated w ith disorders of cranium, eyes, ears, nose, sinuses, teeth, m o u th , or o th er facial or cran ial structures 11.1 11.2 11.3 11.4 11.5 11.6 11.7 11.8
Cranial bones including mandible Neck Eyes Ears Nose and sinuses Teeth and related oral structures TM J disorders Masticatory muscle disorders
Table 2 ■ Recommended diagnostic classification. 11.7 TMD 11.7.1 Deviation in form 11.7.2 Disk displacement 11.7.2.1 Disk displacement with reduction 11.7.2.2 Disk displacement without reduction 11.7.3 Hypermobility 11.7.4 Dislocation 11.7.5 Inflammatory conditions 11.7.5.1 Synovitis 11.7.5.2 Capsulitis 11.7.6 Arthritides 11.7.6.1 Osteoarthrosis 11.7.6.2 Osteoarthritis 11.7.6.3 Polyarthritides 11.7.7 Ankylosis 11.7.7.1 Fibrous 11.7.7.2 Bony
Table 3 ■ Recommended diagnostic classification. 11.8 Craniofacial muscle disorders 11.8.1 Myofascial pain 11.8.2 Myositis 11.8.3 Spasm 11.8.4 Reflex splinting 11.8.5 Contracture 11.8.6 Hypertrophy 11.8.7 Neoplasm
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the g u id elin es p roposed by the 1982 ADA conference, it is suggested that the “gold standard” for d ia g n o sis is based on the evaluation of the history, clin ica l exam in a tio n , an d , w h e n a p p r o p r ia te , T M J im agin g.
Comprehensive history and examination T h e h isto r y s h o u ld p a r a lle l th e trad i tion al m edical history. T h e seq u en cin g o f a co m p reh en siv e h istory is (1) ch ief “ c o m p la in t( s )” ; (2) h isto r y o f p resen t illn e s s; (3) m e d ic a l h isto ry ; (4) d en ta l h isto ry ; a n d (5) p e r so n a l h is to r y .3’18'19 T h e purpose of the p atien t’s visit should be stated succinctly. T h e history o f the p resen t illn e s s sh o u ld in clu d e: date o f onset; o n set event; character; in ten sity; duration; frequency; location; rem issions; ch an ge over time; factors that alleviate, aggravate, or p recipitate the sym ptom s; and previous treatm ent results.3 T h e m e d ic a l h is to r y m a y in c lu d e p r e v io u s su r g e r y , h o s p it a liz a t io n s , tra u m a , illn e s s e s , d e v e lo p m e n ta l an d a c q u ir e d a n o m a lie s , a n d m e d ic a tio n usage. T h e p a tien t’s dental history should in c lu d e p r e v io u s d e n ta l d isea se, treat m ent, habit history, and attitude.20 T h e personal history o f T M D patients often identifies p ossib le con trib u tin g factors.13 A com prehensive p h ysical exam in ation for T M D patients consists o f observation and d ocu m en tation of a general in sp ec tio n o f the head a n d neck, o r th o p ed ic evaluation of the T M J and cervical spine, m a stic a to r y a n d c er v ic a l m u s c le e v a l uation, neurovascular, neurosensory, and m otor ev a lu a tio n o f the cranial nerves, and an in traoral e v a lu a tio n , in c lu d in g an occlu sal an alysis.3
Imaging
Im agin g is warranted w hen the clin ical exa m in a tio n or history, or both, indicate that a recent or progressive p a th o lo g ic jo in t co n d itio n exists, such as: trauma; sig n ific a n t d y sfu n ctio n or a lteration in r a n g e o f m o tio n ; se n s o r y or m o to r a lte r a tio n s; o r s ig n if ic a n t c h a n g e s in o cclu sio n (anterior o p en bite, posterior o p en bite, m andibular shift). J o in t im a g in g is n o t indicated for jo in t s o u n d s in th e a b se n c e o f o th e r T M D s ig n s a n d s y m p to m s . R o u t in e r a d io graphic exam in ation m ay in clu d e tom o graphic or transcranial T M J film s in clu d in g la te r a l p h a r y n g e a l, tr a n s o r b ita l, m od ified T ow n es, and panoram ic view s of the jaw s. T ranscranial radiography
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Table 4 ■ Recommended screening questionnaire for TMD. 1. Do you have difficulty or pain, or both, when opening your mouth, as for instance, when yawning? 2. Does your jaw get “stuck,” “locked,” or “go o ut”? 3. Do you have difficulty or pain, or both, when chewing, talking, or using your jaws? 4. 5. 6. 7. 8.
Are you aware of noises in the jaw joints? Do you have pain in or about the ears, temples, or cheeks? Does your bite feel uncomfortable or unusual? Do you have frequent headaches? Have you had a recent injury to your head, neck, or jaw?
9. Have you previously been treated for a jaw joint problem? If so, when? Note: If any one of the first three questions is answered affirmatively, the clinician should complete a comprehensive history and exam ination; for questions 4 th ro u g h 8, tw o sh o u ld be answ ered affirm atively, an d fo r q u estio n 9, a positive answer to two other questions (4-8) is required to w arrant further evaluation.
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T M D p atien ts w ith u se of p ain diaries a n d se lf-a sse ssm e n t in s tr u m e n ts, su c h as the H o lm e s and R a h e Scale for life c h a n g e s .40 T w o tests, IM P A T H 41 an d the T M J Scale,42'43 are design ed for use by dentists treating T M D . If warranted, this in itia l assessm ent m ay be follow ed o r p rec ed ed by an e v a lu a t io n by a p sych o lo g ist or psychiatrist. In fact, there are a n u m b e r o f p s y c h o lo g ic a l an d b e h a v io r a l factors th a t s h o u ld b e rec o g n iz ed d u r in g scre e n in g an d c o m p re h en sive e v a lu a tio n s that co u ld in d icate the n ecessity for fu rth er e v a lu a tio n by a m ental health professional (T able 6).
Additional clinical tests Table 5 ■ Recommended screening examination procedures for TMD. 1. Measure range of motion of the m andible on opening and right and left laterotrusion. 2. Palpate for preauricular TM J tenderness. 3. Palpate for TM J crepitus. 4. Palpate for TM J clicking. 5. Palpate for tenderness in the masseter and temporalis muscles. 6. Note excessive occlusal wear, excessive tooth mobility, fremitus, or m igration in the absence of periodontal disease, and soft tissue alterations, for example, buccal mucosal ridging, lateral tongue scalloping. 7. Inspect symmetry and alignm ent of the face, jaws, and dental arches. Note: Any positive fin d in g for procedures 1 th ro u g h 3 w arrants consideration for a com prehensive history and exam ination, whereas any two positive findings for procedures 4 through 6 suggest the same consideration; procedure 7 requires two other positive findings (4-6) to suggest the same consideration.
o f the T M J has o n ly lim ite d p u r p o se as a screening radiographic study. C orrected cep h alom etric tom o g ra p h y is a m ore accu rate m e th o d fo r r a d io g r a p h ic a lly e x a m in in g p a tie n ts w ith suspected T M J degenerative disease and is preferred over transcranial projections w h en an osseou s p a th o lo g ic c o n d itio n is suspected. T em p orom an d ib u lar jo in t radiographs to assess condylar p o sitio n by m eans of jo in t space m easurem ents are con traind icated for d ia g n o stic p u r poses.20-23 A lso, condylar p o sitio n in the fossa is not a d iagnostic aid for articular disk displacem ent.24 A rth rograp h y p ro v id es a fu n c tio n a l dynam ic study of the disk and condyle. H o w ev er, b eca u se o f the in v a s iv e n e ss o f the procedure, radiation, and d isco m fort that can occur, it sh ou ld be lim ited to selected T M D cases of disk d isp la ce m ent w hen the dynam ic im a g in g results w ill alter the co u rse o f trea tm e n t.25'29 C om puted axial tom ography is valuable as a n a d ju n c t im a g in g te c h n iq u e in assessm ent o f bony ab norm alities, such as, d e v e lo p m e n ta l a n o m a lie s, trau m a, and neoplastic conditions of the T M J.30-
32 M agnetic resonance im a g in g has diverse capabilities for exam in ation o f m ost cases o f suspected TM J soft tissue disorders— disk d isp lacem en t—and elim in a tes c o n cern over safety o f io n izin g radiation.3337
Behavioral and psychosocial assessment A sse ss m e n t o f c h r o n ic T M D p a tie n ts sh o u ld in clu d e beh avioral and p sy c h o social ev a lu a tio n .38 T h u s, it is strongly a d v is e d th a t th e o r a l h is to r y in c lu d e q u estion s to evaluate behavioral, social,
A d d itio n a l d ia g n o stic stu d ies a v ailab le fo r a s s is t in g th e c o n f ir m a t io n o f th e p h ysical d iagn osis in clu d e b iop sy, p u lp testin g , tr a n s illu m in a tio n , casts, in je c tio n s, and lab oratory tests. T h e se tests s h o u ld n o t b e c o n s id e r e d as r o u tin e procedures, b u t rather be u sed to s u p p le m e n t k n o w le d g e g a in e d d u r in g the history, exam in ation , an d im agin g. D e n ta l c a sts ca n f a c ilit a t e d e ta ile d e x a m in a t io n o f b o th th e s ta tic a n d f u n c t io n a l r e la t io n s h ip s o f the teeth . H ow ever, m uscle tenderness, jo in t pain, a n d ed em a c a n n e g a t iv e ly a ffe c t th e accuracy of the m o u n tin g s. D ia g n o stic in je c tio n s in c lu d e n erve b lo ck , trigger p o in t, an d jo in t in je c tio n s . T h e se can be an im portant adjunct to the d iagnostic p rocess. F in a lly , la b o ra to ry d ia g n o s tic te s tin g m ay in c lu d e b lo o d ch e m istries and u rinalysis to identify sp ecific hem a t o lo g ic , r h e u m a t o lo g ic , m e ta b o lic , or o th e r m ark ers s u g g e s tiv e o f s y s te m ic disease.
Management D e n tists w h o c h o o se to m a n a g e T M D m ust use a d iagn ostic classification based o n esta b lish ed c o n c e p ts o f p h y s io lo g y
Lentists who choose to manage TMD must use a diagnostic classification based on concepts of physiology and pathology.
e m o t io n a l, a n d c o g n it iv e facto rs th a t m ay initiate, sustain, or result from the p atien t’s co n d itio n .59 Som e p sych ological asp ects o f illn e s s can be id e n tifie d in
a n d p a th o lo g y . P r o p o s e d tr e a tm e n t sh o u ld have been subjected to laboratory testing for safety as w ell as random ized clin ica l testing for efficacy. T h e proposed
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Table 6
■ Recommended checklist of psychological and behavioral factors.
1. Clinically significant anxiety or depression 2. Evidence of drug abuse 3. 4. 5. 6.
Repeated failures with conventional therapies Evidence of secondary gain Major life events, for example, new job, marriage or divorce, death Pain duration greater than 6 months
7. History of possible stress-related disorders 8. Inconsistency in response to drugs 9. Inconsistent, inappropriate, and vague reports of pain, or both 10. Overdramatization of symptoms 11. Symptoms that vary with life events Note: The first two factors are the most significant and warrant further evaluation by a mental health professional; factors 3-6 need at least one more factor for consideration of referral, and factors 7-11 require three or more factors for consideration of referral to a mental health professional.
th e a b se n c e o f a c h ie f c o m p la in t, the o u tc o m e o f su c h tr e a tm e n t w ill be d ifficu lt to assess.
Future directions T h e fu tu re d ir e c tio n o f T M D a c tiv ity n eed s to be in th e areas o f im p r o v e d basic and clin ica l research; predoctoral, p o s td o c to r a l, a n d c o n t in u in g d e n ta l ed u cation curricula; and relation s w ith the h ealth in su ran ce in d u stry— m edical and dental. Research A t th is tim e , r esea rch s u g g e s ts th a t accurate d istin ction s between m ild T M D a n d h e a lth c a n n o t be m ade; h o w ev er, patients w ith m oderate to severe disease can be c lin ic a lly id e n tifie d th r o u g h a history and clin ica l exam in ation . Ideally, d ia g n o s t ic d ata s h o u ld d e te r m in e if disease is present and the exten t o f disease, estab lish a b aselin e o n w h ich to ju d ge treatment results, and d istin g u ish T M D from other sources o f head and neck pain.
#he future direction of TMD activity needs to be in the areas of improved basic and clinical research, dental education curricula, and relations with the health insurance industry. n ec e ssa rily be treated. S uch trea tm en t sh o u ld be on ly im plem ented after both th e d e n tist an d p a tie n t reco g n ize th a t th ere is n o c u rren t e v id e n c e th a t th e p o s itiv e s ig n s w ill e sc a la te to o v e r t sym ptom s in the future, and that, in
T h er e is a n eed for w e ll-c o n tr o lle d , ra n d o m ized c lin ic a l stu d ies. R e c en tly , there has been a generalized agreem ent that clin ica l studies m ust use w ell-defined p atien t d ia g n o stic su b grou p s and w ellm atch ed co n tr o ls in order to esta b lish
b ette r c o r r e la tio n s a m o n g th e m a n y variables associated w ith T M D .45 C lin ical success is n ot necessarily scien tific proof o f cause an d effect, so that w e n eed to a p p ro a ch T M D b o th as a sc ie n c e an d an art.46
Education
U n fo r tu n a te ly , m a n y c u r r e n t d e n ta l ed u cation al program s are n ot adequately t r a in in g s tu d e n ts to m a n a g e T M D p a tie n ts. P red o cto ra l e d u c a tio n a l p r o gram s sh o u ld p rovid e in creased fa m il iarity w ith d ia g n o s tic r e a so n in g , ra d i o lo g y , n e u r o lo g y , p h y s ic a l m e d ic in e , a n d p h a r m a c o lo g y — w ith in c r e a s e d e m p h a s is o n h is to r y -t a k in g , p h y s ic a l d iagn osis, and the ab ility to understand co m p lex diseases in a p sych osocial co n text.3’12 A num ber of dental sch o o ls have esta b lish ed p o std o cto ra l resid en cy p ro g ra m s fo r a d v a n c e d t r a in in g in th e eva lu a tio n and m an agem en t o f ch ro n ic p ain and T M D . W hen this in form ation is n o t o b ta in e d in d e n ta l s c h o o l, th e d en tist needs to ob ta in th is k n o w led g e in h ig h - q u a lity c o n t in u in g e d u c a tio n courses. It is critical for p racticin g dentists to be selective in th eir c h o ic e o f these c o u r se s . A n u m b e r o f m e e t in g s are p la n n ed in the near future to ex a m in e predoctoral, postdoctoral and c o n tin u in g e d u c a tio n c u r r ic u la a n d r e v ie w m a n a g e m e n t g u id e lin e s for T M D .47>48 T h e n ew ly form ed A ssociation o f U n iversity T M D O rofacial P ain Program s is m eetin g at the 1990 IA DR m eetin g in C in cin n ati to add direction to the sam e top ics.49 Health care benefits In th e p a st, th e b ro a d , n o n s p e c if ic
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tr e a tm e n t s h o u ld h a v e b een p r o v e d th ro u gh rig o ro u sly co n tro lle d research to be both appropriate and effective for the specific disorder(s) b ein g tested. T h e treatment sh ould have specific value for th e d iso r d e r as o p p o s e d to r e sp o n s e s m ain ly the result o f n on sp ecific factors such as placebo effects, p ositive aspects of the doctor-patient relation sh ip , sp o n taneous rem issions, and overtreatment.44 T h e g o a ls for m a n a g e m e n t o f a ll patients w ith T M D include: — reduce pain; — restore norm al jaw function; — red u ce th e n eed for fu tu re h e a lth care; and — restore norm al lifestyle fu n ction in g. T h ese goals are best achieved by a w elld efin ed program d esig n ed to treat th e p h y sic a l d isord er an d redu ce th e c o n tr ib u tin g fa cto rs. T h e m a n a g e m e n t o p t io n s an d s e q u e n c in g o f tr ea tm e n t for T M D are con sisten t w ith treatm ent o f m u s c u lo s k e le ta l d iso rd ers in o th e r p a rts o f th e b o d y . O p t io n s in c lu d e b e h a v io r a l th era p y , o r th o p e d ic s t a b i liz a tio n , p h a r m a c o th e r a p y , p h y s ic a l m edicine, occlusal therapy, and surgery.3 4 A key d e te r m in a n t o f su cc e ss in th e m anagem ent of m usculoskeletal disorders is the success in ed u ca tin g the p a tie n t about, and a ch ievin g com p lia n ce w ith , th e se lf-c a r e a sp e c ts o f m a n a g e m e n t, in c lu d in g habit m odification and proper u se o f th e jaw . G o a ls o f m a n a g e m e n t are best achieved by u sin g the o p tim a l com b in ation of treatment op tio n s in the proper sequence. In m ost cases, the m ost co n serv a tiv e a p p ro a ch sh o u ld be c o n sidered first; treatment op tion s are added as needed, u sin g non invasive procedures before irreversible, invasive ones. A sid e from s e r io u s or p o t e n t ia lly serious disease, p ositive sig n s fou n d in d en tal p a tien ts w h o have n ot had an y sym ptom s relative to T M D sh o u ld n ot
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d e s ig n a t io n o f T M J h as p e r h a p s led in su r a n c e carriers to c o n sid e r b e n e fit coverage for treatment as if T M D were due to a sin gle cause w ith o n e treatment a p p r o p r ia te in a ll cases. T o d a y , w ith the com bined efforts o f m any researchers in d en tistry and m e d ic in e , b io p s y c h o p h y s ic a l d ia g n o s tic c la s s if ic a t io n s o f T M D h ave b een e sta b lis h e d b a sed o n m edical m od els.5052 T h ese classification sy stem s w ill fa c ilita te c o m m u n ic a tio n an d shared responsibility a m o n g dentists, p h y sicia n s, an d a llied h ea lth care p ro v id e r s in th e m a n a g e m e n t o f T M D p a tie n ts. T o d a y , m a n a g e m e n t o p tio n s an d seq u en cin g of the treatm ent for T M D is c o n s is te n t w ith tre a tm e n t o f o th e r orth op edic and rheum atologic disorders. R eversible, n o n in v a siv e treatm ent su ch as b e h a v io r a l m o d if ic a t io n , p h y s ic a l therapy, m ed ica tio n , and in tero cc lu sa l a p p lia n c e s are endorsed for the in itia l care of nearly all T M D s. T h e em phasis is o n conservative therapy that prom otes th e m u s c u lo s k e le ta l s y s te m ’s n a tu r a l h e a lin g capacity, in v o lv in g the patients in the physical an d behavioral m anage m ent of their o w n problem . W ith T M D patients w h o have more com p lex ch ron ic p a in , in terd iscip lin a ry an d m u ltid is c i plinary m anagem ent has becom e the m ore successful overall m anagem ent program . As T M D s are sim ilar to m usculoskeletal an d r h e u m a t o lo g ic d iso r d e r s, a n d d o n ot directly involve disorders o f dentition; they need to be inclu ded m ore fu lly in h e a lth care b e n e fits, regard le ss o f the clin icia n p rovid in g the service.53 In 1987, M in n e s o ta b eca m e th e fir st sta te to m andate T M D coverage and, currently, a num ber o f states are consid erin g T M D legislation for this coverage.64
Conclusion T h e w orkshop sum m arized current in for m ation on T M D in regard to d iagn ostic c la s s if ic a t io n , e v a lu a t io n , s c r e e n in g e x a m in a tio n s , an d d ir e c tio n fo r th e future.
-------------------- JliO A -------------------Dr. McNeill is clinical professor, departm ent of restorative dentistry, an d director of C raniofacial Pain-T M J Clinic, School of Dentistry, University of California, San Francisco. Dr. Mohl is professor, d e p a rtm e n t o f o ra l m ed icin e, S chool of D ental Medicine, SUNY, Buffalo. Dr. R u gh is professor, d e p a rtm e n t of o ral an d m a x illo fa c ia l surgery, chairm an of the D ivision of Research, U niversity of Texas Health Science Center, San Antonio. Dr. T an ak a is associate clin ical professor, School of Dentistry, University of Southern C alifornia, and
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