One of the most controversial topics in dentistry is the subject of temporomandibular disorders (TMD). A TMD is a “collective term embracing a number of clinical problems that involve the masticatory muscles, the temporomandibular joint, or both.”1 The controversy concerns the etiology and subsequent treatment of TMD patients. Numerous approaches exist with dentists grouped into different philosophical camps. There is no consensus of opinion on the role of occlusion, the influence of anxiety and depression, and the natural history of TMD. It becomes apparent after reviewing the literature that there is ample evidence to support the role of different etiologies for TMD. The dental literature suffers from a paucity of randomized controlled studies; rigorous scientific evaluation is lacking. The etiology and pathophysiology of TMD is still poorly understood.2,3 Only recently have randomized clinical trials been reported; as these studies are disseminated, evidence-based treatment will evolve. Despite the current lack of scientific data and the resultant controversy, patients with TMD often require treatment. The objective of this article is to provide the clinician with a responsible approach to the initial management of patients with TMD.
BACKGROUND
In 1996 the National Institutes of Health (NIH) recognized the enormous diversity of treatments being offered to TMD patients. It would not be uncommon for a patient with TMD symptoms to have one doctor suggest full-mouth rehabilitation, another recommend a bite plate, another suggest occlusal equilibration, and another give the patient a jaw exercise program. It is not unusual for one dentist to prescribe medication and another to recommend surgery. In April of 1996, The National Institute of Dental Research and the NIH Office of Medical Applications of Research convened a Technology Assessment Conference on Management of Temporomandibular Disorders to provide the dental community and the general public with a “responsible assessment of management approaches to TMD.”3 More than 1,000 people attended this landmark conference. It brought together specialists in dentistry, medicine, surgery, cellular and molecular biology, biostatistics, epidemiology, immunology, behavioral and social sciences, pain management, tissue engineering, as well as representatives of the public, including TMD patients and advocacy groups. An independent, unbiased panel of accomplished scientists and doctors evaluated all of the information that was presented, and issued a conference statement summarizing the data and offering several conclusions.3
Some of the important conclusions included the following: “Because most individuals will experience improvement or relief of symptoms with conservative treatment the vast majority of TMD patients should receive initial treatment using noninvasive and reversible therapies.” “The efficacy of most treatment approaches for TMD is unknown, because most have not been adequately evaluated in long-term studies and virtually none in randomized controlled group trials.” “Therapies that permanently alter the patient’s occlusion cannot be recommended on the basis of current data.”3 These conclusions were not greeted with enthusiastic support by the profession, but remain valid.
Following are the conservative, noninvasive modalities, adhering to the recommendations set forth by the NIH that will serve dentists and their patients well.
PRINCIPLES OF TREATMENT
Although the popularity of specific treatments comes and goes, the basic principles of treatment do not change. Before discussing specific treatments, several guiding principles require explanation.
Noninvasive and Reversible Modalities
The first rule of treatment is “Do no harm.” Simple modalities, which are both noninvasive and reversible, should always initiate TMD treatment.2,4 These modalities carry very little risk, and the overwhelming majority of patients respond very well.3-6
The second rule of treatment is “Do know harm.” It is important to recognize when treatment is either not indicated because the diagnosis is not TMD related or the treatment itself is not reversible and may lead to unnecessary dental procedures. Many bite-plate appliances are used inappropriately and cause an inadvertent or unintentional change in the occlusion. Bite plates used properly should not permanently alter the dentition. Altering the occlusion by equilibration is not considered reversible, yet it is one of the most common procedures performed by dentists when confronted with a TMD patient.2 One objective of this article is to provide the clinician with alternatives to occlusal equilibration that carry little or no risk and are reversible.
Understanding Success
The treatment of TMD is often successful, and seemingly contradictory treatments can work equally well. There are many factors, other than treatment, which lead to a successful outcome, such as the cyclical nature of TMD, reduction of anxiety, adaptive capacity of joints and muscles, the placebo effect, and the doctor-patient relationship. All of these factors influence outcome.
A patient who meets with the doctor needs to receive an explanation for their pain. They should receive reassurance that they do not have a life-threatening disease, and they are often relieved to find a doctor who is knowledgeable about their condition and is concerned about them. Patients are comforted to know that others with similar problems have successful outcomes, and that they are not alone. The patient’s anxiety prior to coming to the doctor’s office is reduced, and the patient develops a more hopeful attitude toward recovery. All of these factors influence patient care prior to the rendering of any treatment. It is humbling to think of factors, in addition to treatment, that help patients improve. Sometimes patients get better because of the treatment that is provided, and sometimes they get better for reasons that are unclear. Randomized clinical trials are being conducted to more precisely identify the determinants for a successful outcome.
Management Versus Cure
Acute pain following trauma can be treated and cured. Chronic pain, where tissue damage occurred long ago, can be managed. With chronic conditions “cure” is not a useful term—management is more appropriate. Chronic pain can be reduced and can go into remission, but over the long term it should be managed. Patients learn to avoid certain activities which exacerbate symptoms, and learn what to do to minimize symptoms when they occur.
Continuous Reevaluation of Diagnosis
Many serious medical problems mimic TMD symptoms. Salivary gland tumors, intracranial lesions, and nasopharyngeal carcinoma are three examples. If a patient fails to respond to treatment in a reasonable time period the clinician must be vigilant and reevaluate the diagnosis. There is a great responsibility placed on the clinician who treats TMD patients; continuous reevaluation of the diagnosis is mandatory to avoid mistreatment.
INITIAL, REVERSIBLE, NONINVASIVE TMD MANAGEMENT
Establish a Diagnosis and Provide an Explanation
Explanation of the diagnosis to the patient is a simple yet often overlooked aspect of treatment.7 Patient anxiety stems from a misunderstanding of what the symptoms indicate and what may exacerbate those symptoms. When the doctor can provide a concise explanation of the diagnosis that the patient can understand, it serves to alleviate the patient’s anxiety and helps them understand the rationale for their treatment. An explanation of the diagnosis and placing it in proper perspective is the first step toward helping the patient improve. A patient who is told that they have an internal derangement of the joint may indicate to the patient that the damage is permanent and the situation hopeless. Explaining the diagnosis in these terms is not sufficient. The diagnosis must be placed in the proper perspective by explaining that up to one third of the population has evidence of internal derangement,1 and even when the disc is fully displaced, healing without surgery is possible and even likely.
TMD is too broad a term to be useful as a diagnosis. TMD involves problems with the masticatory muscles, the joint(s), or both. A specific diagnosis should be established for each patient. Myalgia, arthralgia, myospasm, synovitis, and internal derangement are examples of specific diagnoses.
The Soft Diet
Mastication of hard food places loading forces on the TM joints and involves contraction of the masticatory muscles used for chewing. By changing to a soft diet the TM joint is relieved of its load and less muscle activity is required. The soft food diet encompasses a spectrum that ranges from a liquid diet in severe cases to minor changes in consistency. A practical recommendation is to avoid chewy food. Substitute softer foods for chewy foods, such as fish instead of steak. Cutting food into smaller pieces also helps to decrease masticatory load.
Reducing Parafunctional Habits
Habits are usually an unconscious behavior. Breaking a habit first requires the person to become aware of the habit, then take steps to eliminate the behavior. Tooth grinding and jaw clenching are common habits that aggravate TMD symptoms. When these habits occur during waking hours it is possible to reduce or eliminate them by taking the unconscious jaw activity and making the person aware of it. Increasing cognitive awareness of tooth grinding and jaw clenching can be done using reminders. “Lips together teeth apart” (LTTA) is a refrain taught to clenchers and bruxers. The neutral, relaxed position for the jaw is with the lips together and the teeth slightly apart. The patient is told to put reminders, such as placing notes with the letters “LTTA,” in obvious places. Some patients use small clocks with an alarm set to go off at frequent intervals to serve as a reminder not to clench. These habit-breaking strategies are useful for habits that occur when the patient is awake but will not carry over to habits that occur during sleep. Other habits such as chewing gum and biting nails can be similarly addressed.
Self-directed Home Physical Therapy
Orthopedic treatment used to rehabilitate musculoskeletal problems can easily be applied to TMD. Both muscle and joint problems respond well to physical therapy. The role of mobilization of joints to promote healing has been studied extensively.8 Older concepts of immobilization have been abandoned. Joints must move in order to produce synovial fluid.9 Production of synovial fluid provides the joint with nutrition and lubrication. Joint mobilization promotes joint healing. Physical therapy can readily be used to treat TMD.
| Table 1. Self-directed Home Physical Therapy for Masticatory Muscles |
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• Apply hot or cold compress to sore muscles. Use whichever feels more comfortable. |
Application of hot or cold compresses, exercise, and massage form the basis for self-directed home physical therapy (Table 1). Applying heat or cold to the affected area is a matter of personal preference. This can be accomplished with ice in a plastic bag, a hot washcloth, electric heating pads, microwavable packs, and/or chemical hot/cold packs. For acute injuries cold is recommended, yet most TMD problems are not acute. The hot or cold application is left in place for 2 to 3 minutes, and then massage and exercise can begin.
Massage of the painful muscles is the next step. The patient uses the fingers to massage the tender muscles, usually the masseter or temporalis, for 5 to 10 seconds. Massage stops and the patient stretches the mouth open to the point where it is comfortable and not painful, and it is held stretched open for 5 to 10 seconds. This helps to stretch the masticatory muscles to their full length. The patient then alternates between massage and stretching for 5 to 10 repetitions, and can then go back to hot/cold packs. This regimen should be repeated frequently throughout the day.
When muscle pain is widespread (involving the cervical and shoulder musculature) it may be appropriate to refer the patient to a physical therapist. However, if the problem is restricted to the masticatory muscles and TM joint, then self-directed home physical therapy should be initiated.
Muscle Relaxation and Stress Reduction
Gaining control over tight sore muscles and producing relaxation can be accomplished with a variety of methods. Motivated patients with mild anxiety-related muscle tension may do well on their own with proper guidance. Before seeking professional help, patients may try reading a book about relaxation,10 listen to a relaxation tape, or do exercises (eg, yoga). For patients with more advanced problems referral to a psychologist or psychiatrist may be appropriate. A psychologist can teach biofeedback and stress- reduction skills, tools which are very helpful in reducing muscle tension and destructive habits.
Pharmacologic Management
| Table 2. Common Medications for Initial TMD Treatment | ||||||||||||||||||||||||||||||||||||||||||||||||
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Muscle Relaxants
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Pharmacologic intervention serves an important role in the initial management of TMD. Numerous categories of medications are useful, including nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, antianxiety agents, antidepressants, antiepileptics, and opioids. Initial management generally requires only NSAIDs and muscle relaxants (Table 2).
The NSAIDs are a large group of drugs which have the ability to inhibit cyclooxygenase, thereby preventing the formation of prostaglandins. No single NSAID has been shown to be superior to all others. Because there is a wide range of individual responses to different NSAIDs, if one drug is not working it is wise to try another. Newer COX-2 inhibitors (ie, Celebrex, Vioxx, Bextra) are more selective in their action and may cause less gastric disturbance. For the majority of patients, over-the-counter preparations are successful, such as ibuprofen (Motrin or Advil), naproxen (Aleve), or ketoprofen (Orudis).
Muscle relaxants are another type of medication useful in initial TMD treatment. There are several to choose from, and they differ in their strengths and side effects. Strong muscle relaxants produce more sedation. Sedation may be a welcome side effect if taken at night and a patient has difficulty sleeping. This may be an adverse side effect if someone takes the drug during the day and then cannot function. The dosage may need to be titrated to the therapeutic level. Several common muscle relaxants are provided in Table 2.
This brief mention of medications is not meant to be a substitute for a more complete description of pharmacologic management for TMD. Understanding benefits and risks, adverse effects, patient education, compliance, and potential for abuse are concepts that need to be explored when prescribing medications. The interested reader should refer to more in-depth discussions.11,12
Occlusal Appliances: Bite Plates
Occlusal appliances are known by numerous names, including bite plates, mouth guards, splints, and night guards. There are dozens of different designs, each one with its own group of advocates. Collectively they all do the same thing, that is, provide an acrylic platform to bite against. The effectiveness of bite plates to relieve TMD symptoms is well documented although there is no agreement as to why they work. Even placebo bite plates, which do not cover the occlusal surface, are effective.
No one bite plate design has been shown to be consistently more effective than any other. Some bite plates are designed to move the mandible to a new position. Unintended problems associated with these appliances include inadvertent movement of teeth. Partial coverage appliances have the potential to depress teeth under the appliance and cause super-eruption of the teeth that are not covered. Soft (rubbery) appliances can be deformed by clenching and may unintentionally move teeth and open interproximal contacts. Given these concerns the simplest design is desirable.7,13
| Table 3. Bite-Plate Appliances | ||
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The design that provides the least chance of producing an unexpected change in the occlusion is a hard appliance covering all the teeth in the arch, utilizing a flat occlusal surface adjusted to provide even contact in habitual closure (Table 3). In general it should not be worn 24 hours a day. It can be made for the maxilla or mandible. Maxillary bite plates have an advantage over mandibular appliances because occlusal contact can be distributed over the entire surface of the appliance. Mandibular appliances cannot adequately include contact with the maxillary central incisors without the risk of pushing these teeth labially.
SUMMARY
The existing dental literature does not support the superiority of any one type of treatment to manage TMD. Few studies meet rigorous scientific standards of the randomized clinical trial. This has led to enormous controversy.
| Table 4. Elements of Patient Education |
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1. Explanation of diagnosis |
The initial management of TMD does not have to be controversial. Noninvasive, reversible modalities can be employed that carry very little risk and a high degree of success (Table 4). The success rate of this approach has been studied and determined to be 75% to 90%.4-6
Of course, not every patient will get better with this approach. For those who do not improve more advanced techniques must be used, and referral to specialists in TMD, neurology, and rehabilitation medicine may be required. A few patients will need surgery.
Initial treatment of TMD requires relatively simple modalities, such as patient education, adherence to a soft diet, reducing oral habits, self-directed home physical therapy, muscle relaxation, the use of medication, and the proper use of bite plates. The majority of TMD patients will respond successfully to these basic treatments.
Author’s Note
For dentists and other professionals who would like to learn more about TMD and orofacial pain, the book Orofacial Pain by Lund et al13 is recommended.
References
1. American Academy of Orofacial Pain. JP Okeson, ed. Orofacial Pain: Guidelines for Assessment, Diagnosis, and Management. Chicago, Ill: Quintessence Publishing Co, Inc; 1996.
2. Stohler CS, Zarb GA. On the management of temporomandibular disorders: a plea for a low tech, high-prudence therapeutic approach. J Orofacial Pain. 1999;13:255-261.
3. Management of Temporomandibular Disorders. NIH Technology Assessment Statement. 1966;Apr 29-May1:1-31.
4. Greene CS. The etiology of temporomandibular disorders: implications for treatment. J Orofacial Pain. 2001;15:93-105.
5. Greene CS, Laskin DM. Long-term evaluation for myofascial pain dysfuction syndrome: a comparative analysis. J Am Dent Assoc. 1983;107:235-238.
6. Okeson JP, Hayes DK. Long-term results of treatment for temporomandibular disorders: an evaluation by patients. J Am Dent Assoc. 1986;112:473-478.
7. Syrop SB. In: Peterson LJ, ed. Principles of Oral and Maxillofacial Surgery. Philadelphia, Pa: JB Lippincott Co; 1992:1905-1931, Chapter 67.
8. Israel HA, Syrop SB. The important role of motion in the rehabilitation of patients with mandibular hypomobility: a review of the literature. J Craniomandibular Pract. 1997;15:1-10.
9. Israel HA. Current concepts in the surgical management of temporomandibular joint disorders. J Oral Maxillofac Surg. 1994;52:289-294.
10. Benson H. The Relaxation Response. New York, NY: Avon Books; 1976.
11. Ganzberg S, Quek SYD. Pharmacotherapy. In: Pertes RA, Gross SG, eds. Clinical Management of Temporomandibular Disorders and Orofacial Pain. Chicago, Ill: Quintessence Publishing Co, Inc; 1995: Chapter 13.
12. Syrop SB. Pharmacologic therapy. In: Kaplan AS, Assael LA, eds. Temporomandibular Disorders. Philadelphia, Pa: WB Saunders Co; 1991: Chapter 25.
13. Lund JP, Lavigne GJ, Dubner R, et al. Orofacial Pain: From Basic Science To Clinical Management. Chicago, Ill: Quintessence Publishing Co, Inc: 2001.
Dr. Syrop is an associate professor of clinical dentistry in the Division of Oral and Maxillofacial Surgery at Columbia University and Weil Medical College. Currently he is the section chief of Temporomandibular Disorders Service, Division of Dentistry, New York Presbyterian Hospital. He is the former director for 15 years of the Temporomandibular Joint Facial Pain Clinic at Columbia University. He is active in teaching and has been a member of the part-time faculty at Columbia University School of Dental and Oral Surgery for the past 20 years. Dr. Syrop is a member of the American Academy of Orofacial Pain, a diplomate of the Board of Orofacial Pain, and has written numerous chapters and articles on the nonsurgical management of TMD. Dr. Syrop has extensive experience in the clinical management of patients with TMD and has been in private practice for 21 years in New York, NY.
