A Plea for the TMD Patient

“I am a 34-year-old woman who has been diagnosed with TMJ. I have been to many physicians and dentists, and everyone has a different idea about what the problem is and what to do about it. The pain is always present and I am becoming increasingly frustrated. I tell myself to relax, I eat soft foods, I play mind-over-matter games, but the pain is getting worse and it's driving me crazy.”

Unfortunately, this woman's story is neither rare nor unique, and many are even more tragic. Nonsurgical treatments may improve the condition of some of these patients, and surgical procedures are justified in other cases, but we are far from understanding the etiology and pathogenesis of the various tempromandibular disorders (TMDs). As a result, the empirical therapies used in many of these patients only make their condition worse. A recent report by the Agency for Healthcare Research and Quality confirmed the findings of the 1996 National Institutes of Health Technology Assessment Conference and of certain other reviews of this subject. The conclusions of the Agency's report was, “In the current era of evidence-based health care, the body of evidence on TMD treatment generated since 1996 is generally limited and lacking in rigor. Particularly lacking are studies with sufficient power and patient follow-up to detect any true differences in effectiveness among alternative treatments.”

The report also stated that health care services and costs are significantly greater in the TMD population than in patients without TMD. Interestingly, much of the care received by patients with TMD is related to conditions not generally recognized to be associated with TMD itself. The fact is that in many of these patients, TMD may be only 1 component of a complex set of possibly related comorbid problems, such as irritable bowel syndrome, mitral valve prolapse, hypermobile joints, musculoskeletal pain, and chemical sensitivity.

As we learn more about the tempromanibular joint (TMJ) and its associated structures, many in the dental community are reassessing their practice patterns. It is clear that the various TMDs are far more complex than was previously believed. To find solutions to these problems, collaboration with the medical scientific community is essential, moving TMJ research to a new level of multidisciplinary studies involving experts in arthritis; TMJ pathology; bone, joint, and muscles physiology; neuroscience; pain management; genetics; endocrinology; immunology; and tissue repair/engineering.

In the meantime, patients with TMD and those treating them are faced with a serious dilemma. Until we know the causes of the various TMDs, and safe and effective treatments evolve that are based on scientific evidence, what can we do to help patients without adding to their problems?

First and foremost is the need to make an accurate diagnosis. The terms TMD and TMJ encompass a variety of problems and a 1-diagnosis - 1-treatment philosophy is no longer acceptable. Practitioners must understand that there can be a relationship between the masticatory muscle-related disorders and TMJ pathology, and that both often need to be considered in total patient management. Second, treatment of patients with TMD should always start with the simplest approaches and not progress until each has been given an adequate trial. However, irreversible forms of therapy should be avoided whenever possible. Finally, although surgery can be beneficial in properly selected cases, repeated surgery is not the answer to chronic TMJ pain and dysfunction.

It is important also to realize that patients with TMD have special needs other than the care of their joint or muscle problems. Because of their disability, they are likely to be extremely sensitive to dental procedures and frequently have limited mouth opening. Even a routine procedure such as a prophylaxis can cause weeks of pain and dysfunction. As a result, patients may choose to neglect necessary dental care. This is a terrible choice, with long term consequences that only add to their problems. With appropriate accommodations, the dental practitioner can provide proper oral care for patients with TMD, even when not involved in the primary treatment of their problem.

Finally, the dentists' concern with TMD patients involves an obligation to keep abreast of current advances in the field. Certainly, it is imperative to seek sound supportive data for any of the treatments proposed. Many of the problems that exist are related to the continued use of empirical treatments rather than evidence-based therapy. Rational management of patients with TMD will only come from a better understanding of the etiology and pathogenesis of their particular condition, and that will only come form continued research. Your support of these efforts will ultimately help provide the solutions to the enigma of TMD that now confronts both patients and practitioners.

Tempromandibular Disorders

Background - Debate continues over the causes and effective treatments for tempromandibular disorders (TMDs). In patients with TMD, restoration of posterior teeth may alleviate symptoms, but the relationship between TMD symptoms and loss of molar support remains unclear. Rates of missing mandibular posterior teeth were compared with patients with TMD versus asymptomatic controls.

Methods - The study included 263 symptomatic patients seeking treatment at the authors’ TMD clinic and 82 asymptomatic volunteers. All TMD patients had localized jaw pain with joint motion or while eating. Examination was performed to document the number of mandibular bicuspid and molar teeth, except for third molars. The presence of disk displacement was assessed by magnetic resonance imaging scan.

Results - Patients with TMD symptoms who had evidence of disk displacement were somewhat more likely to be missing mandibular posterior teeth. The prevalence of missing mandibular right teeth was16% in controls with normal joints, 26% in controls with evidence of disk displacement, 33% in TMD patients with normal joints, and 39% in TMD patients with disk displacement. A similar pattern was noted on the left side.

Discussion - Patients with TMD and disk displacement appear to have an increased prevalence of missing mandibular posterior teeth. These missing teeth may be associated with an increased rate of degenerative joint disease.

No association between anterior tooth wear and TMD

Background - The relationship between bruxism and the development of tempromandibular disorders (TMDs) remains unclear. On common sign of bruxism is incisal tooth wear. The relationship between anterior tooth wear and TMDs was examined in a case-control study.

Methods - The cases were 208 consecutive patients seeking treatment for symptomatic TMD. One hundred seventy-two prosthodontic patients without evidence of TMD served as controls. Patients with more than 1 missing premolar or molar zone in opposing arches and those with missing or heavily restored anterior teeth were excluded. This left 154 TMD cases and 120 controls (mean age, 31 years). Casts of the anterior were made and graded for wear on a scale of 0 to 5. The association between tooth wear and TMD was examined by multivariate analysis, adjusting for age and sex.

Results - In both groups, tooth wear was significantly related to age. The TMD and control groups were similar in the percentage of patients with tooth wear scores of 0 to 1. Controls were more likely than TMD patients to have tooth wear scores of 2.5 of higher. However, in the multivariate model, the difference between groups was not significant.

Discussion - Anterior tooth wear does not appear to be associated with TMD risk. This study finds higher rates of incisal tooth wear in controls than in TMD cases, but the difference disappears after adjustment for age and sex.