[The following guidelines, authored by Drs. David Mock, Howard Tenenbaum, and Gerald Baker, of the Craniofacial Pain Unit, Mt. Sinai Hospital, Toronto, are reprinted here with the permission of RCDSO, Royal College of Dental Surgeons of Ontario, 6 Crescent Road, 5th Floor, Toronto, Ontario, M4W 1T1, Canada. They may be contacted at (416) 961-6555 or at (800) 565-4591, for further information.]

Guidelines Respecting the
Diagnosis and Management of
Temporomandibular Disorders
1995

College Guidelines contain practice parameters and standards which should be considered by all Ontario dentists in the care of their patients. It is important to note that these Guidelines may be used by the College or other bodies in determining whether appropriate standards of practice and professional responsibilities have been maintained.

The guiding principle of any treatment must be "primum non nocere" or, freely translated, "above all, do no harm." Irreversible procedures should only be considered after attempts at treatment with more conservative measures have failed and only if the severity and/or persistence of the patientÆs symptoms warrant it. The relative risks and benefits of the treatment versus the untreated symptoms must always be weighed. Before any procedure that may permanently alter the patientÆs dentition or jaw relationships is initiated, the patient must be well informed of the risks and therefore be a party to any decision to proceed.

Re-evaluation during the course of treatment is equally important to ensure that the course is appropriate.

• promote the concept of diagnosis-based treatment with conservative, reversible treatment modalities;
• emphasize the multifactorial, biological and functional basis of temporomandibular disorders;
• foster an understanding of the anatomy, physiology and pathology of the temporomandibular joints, associated musculature and related structures, as well as the behavioral and psychosocial aspects of these and related chronic pain disorders;
• expose the student or practitioner to the various options in conservative patient management;
• include a discussion of the potential adverse effects of the various treatment modalities;
• instill in students and practitioners the importance of co-operating and collaborating, where appropriate, with other health practitioners who have been trained to diagnose and render rational treatment of temporomandibular disorders. These include other dentists, dental specialties, physiotherapists, physicians and various specialists;
• allow the student or practitioner to determine when treatment is warranted and discourage therapy that is unnecessary, impractical or potentially detrimental to the patient;
• teach the student or practitioner to critically evaluate the literature and research on new concepts, treatment methods and diagnostic aids, equipping him or her to reject concepts, treatment modalities or devices that lack scientific validation; and
• result in the student or practitioner having an understanding of the other painful disorders and diseases that afflict the craniofacial complex and equip him or her with the knowledge and capability to differentiate these from temporomandibular disorders.

An Oral and Maxillofacial Surgeon who has successfully completed a residency in any accredited program in North America may have had adequate opportunity to assess and operate on patients with temporomandibular disorders. Additional training might be necessary in arthroscopic techniques as this relatively new treatment modality might not have been available in all residency programs.

Continuing education in the surgical management of TMD is widely available throughout North American and should represent a part of the surgeon's continuing dental education activities if he or she is to remain competent in the management of patients with this complex of disorders.

Short courses that promote one method of treatment or that are focused on specific diagnostic tools are often inadequate and may be potentially hazardous.

Practitioners who have taken any number of short courses should also recognize that these do not impart specialty status in this or any other field.

PROFESSIONAL RESPONSIBILITIES

• Current Medications, if any:
• Pain
  • 1. Localized Facial/Jaw Pain
    • - nature of pain, constant or episodic
    • - site, radiation pattern
    • - precipitating or aggravating factors
    • - relieving factors, conditions, treatment
  • 2. Earaches
    • - bilateral or unilateral (which side?)
    • - association with other symptoms
  • 3. Headaches
    • - site
    • - constant or episodic
    • - relationship to other symptoms
    • - duration and frequency
    • - precipitating factor(s)
    • - other related symptoms (ie. photophobia, phonophobia, nausea etc.)
    • - relieving factors, conditions, treatment
  • 4. Neck, Shoulder, Back, etc...
• Limitation of Mandibular Movement
  • - constant or episodic
  • - precipitating and aggravating factors
  • - relieving factors, conditions, treatment
• Joint Noises
  • - nature (ie. clicking, popping, grinding, etc.)
  • - side (left, right, both)
  • - constant, episodic
• Altered Sensation
  • - site
  • - nature (ie. tingling, numbness, hyperasthesia)
  • - constant or episodic
  • - precipitating factors
  • - relationship to other symptoms
• Tinnitus
  • - bilateral or unilateral (which side?)
  • - association with other symptoms
• Perceived Hearing Loss
  • - bilateral or unilateral (which side?)
  • - association with other symptoms
• Related Cognitive Losses or Affective Disorders
  • - ie. sleep disturbance, loss of energy, appetite, memory, concentration
• Related Emotional or Mood Changes
• Duration of Each of the Symptoms
• Relationship of Onset to Specific Events (ie. trauma, other injuries, stress, treatment, etc.)
• Parafunctional Habits
  • - bruxism, chenching, nail-biting, chewing gum
  • - daytime, nocturnal, frequency
  • - onset
• Previous Treatment for the Patient's Complaints and its Effectiveness

The following checklist is presented as an aid in the clinical examination process:

• 1. General Extra-Oral
  • Facial swelling or significant asymmetry
• 2. Temporomandibular Apparatus
  • Palpation of
    • - the temporomandibular joints both facially and via the external auditory meatus
    • - the muscles of mastication and facial musculature both extra- and intra-orally
  • Limitation of Mandibular Movement
    • - inter-incisal opening (measured)
    • - path of mandibular movement during opening or closing (ie. deviation)
    • - condylar movements
    • - lateral movement of the mandible, adequate, inadequate, symmetrical
    • - presence or absence of pain on opening or lateral movement of the mandible
  • Joint Noises
    • - audible or palpable
    • - nature (ie. click, crepitus)
    • - bilateral or unilateral (side)
    • - on opening, closing or both
    • - early or late
• 3. Intra-Oral
  • Dentition
    • - missing teeth
    • - state of repair of dentition
    • - dentures, (full partial, adequate or inadequate)
    • - presence or absence of dental or periodontal disease
    • - wear facets
    • - oral mucosal lesions or disorders
    • - vertical dimension
  • Occlusion
    • - note status of patient's occlusion and any changes such as open bite (e.g. might indicate loss of condylar integrity)
    • - whether occlusal relationships are functional or not
• 4. Other
  • - trigger points for pain
  • - dental sensitivity
  • - altered sensitivity (e.g. pin-prick, light touch)

• Radiographic Investigation
  Radiographic investigation may be indicated if clinical evaluation and/or the medical or dental history suggest:
  
  
  • 1. An abnormality of the osseous components of the jaws or joints.

    Investigations may include panoramic radiography (to rule out significant osseous or dental disease in the mandible or maxilla or severe condylar changes) or more detailed investigation using plain films, tomography, computerized tomography and/or nuclear bone scans (99m technetium).

  • 2. An internal derangement/disc displacement of the joints.

    The imaging modalities that assess positional, functional and morphologic abnormality of the articular disc are arthrography and magnetic resonance imaging (MRI). Arthrography is an invasive procedure that carries with it some morbidity and a risk of misdiagnosis, particularly of medical and lateral displacements,while MRI, although non-invasive, is both expensive and difficult to obtain, requires considerable experience and skill in interpretation. Such studies should only be considered when the results will affect the course of treatment. Since disc displacements have been documented in asymptomatic individuals, imaging of the disc is only justified when the derangement is likely to be clinically significant and the patient has failed to respond to conservative treatment.

  • 3. An extra-articular disorder.

    Radiographs of the dentition (for suspected dental disease) or other structures anatomically related to the temporomandibular joints, such as the salivary glands, sinuses, cranium or neck, may be indicated to rule out other craniofacial disease.

    Consultation with a radiologist is often advisable when radiographic investigation not normally performed in a dental office is indicated. The radiologist can recommend the procedures with optimal safety and economy, that would yield the most useful information.

• Laboratory Investigation
  • - laboratory investigation is only necessary if previous investigation has suggested a metabolic or auto-immune disorder.
• Other Consultations
  • - in selected cases, a consultation with other health care professionals (ie. family physician, neurologist, otolaryngologist, physiatrist, rheumatologist, psychologist, psychiatrist) may be indicated.
  • The clinical value of a number of diagnostic aids currently in use has not been demonstrated in well-controlled and scientifically based studies; these include jaw tracking devices, EMG recording, and sonography. These aids may have some use for research purposes but may not necessarily facilitate diagnosis or patient treatment.

• Masticatory Muscle Disorders* - myospasm, myofascial pain (possibly related to other disorders such as fibromyalgia)
• Internal Derangement/Disc Displacement*
• Arthridites* - (ie. osteoarthritis, rheumatoid arthritis, psoriatic arthritis, septic arthritis, gout, pseudogout, lupus erythematosis)

The possible diagnoses (*) listed above represent a currently accepted classification of temporomandibular disorders. The differential diagnosis, however, must also include the following:

• Direct Traumatic Injuries, including:
  • - fractures of the condyle, condylar neck, coronoid process or temporal bone
  • - joint dislocation, subluxation or ligamentous/capsular disorders
• Post-traumatic Disorders and Pain syndromes (multifactorial and often refractory to treatment)
• Developmental Disorders
• Neoplasms (of the components of the temporomandibular joints or related structures)
• Idiopathic Arthralgias, Dysfunctions

The final diagnosis may, in some cases, be a combination of more than one of the above. Other causes of facial pain not originating from the temporomandibular apparatus may need to be considered, including, but limited to, the neuralgias (e.g. trigeminal neuralgia, atypical facial pain), demyelinating diseases, CNS tumours, vascular headaches, muscle contraction-type) headaches, dentoalveolar disease, sinus disease, ear disease, salivary gland disease and psychogenic disorders.

The concept of routine irreversible alteration of the patient's temporomandibular joints, jaws, occlusion or dentition is not supported by sound scientific studies. Such modalities of treatment can only be justified in selected cases where a nonfunctional occlusion (e.g. loss of posterior support, severe lack of adequate inter-arch dental contact) has been clearly and irrefutably demonstrated to be related to the etiology, when conservative methods of treatment have failed and if the patient's signs and symptoms justify such an approach. It is important to recognize that failure to manage a patient's symptoms with a conservative method does not necessarily imply nor guarantee the success of another more invasive technique.

Where permanent alterations are an expected outcome, the patient must be fully informed and consent to the treatment. In general, most TMD's are actually managed rather than definitively treated and available modalities include:

• Reassurance and Patient Education
• Medication:
  • - analgesics,
  • - muscle relaxants,
  • - anti-inflammatory drugs

  Note that some drugs may be contraindicated in some cases (eg. NSAIDS in patients with gastro-intestinal disorders). The practitioner must be familiar with the potential drug interactions and side effects of any medication prescribed and be prepared to deal with adverse reactions.

• Physical therapy, either simple patient directed therapy such as rest, moist heat and exercises or directed therapy by a qualified physiotherapist
• Psychological or psychiatric treatment by appropriately qualified practitioners
• Stabilization type of occlusal appliances (ie. intraoral appliances designed to provide even and balanced occlusal contact without either forcefully altering the mandibular rest position or permanently altering the dental occlusion)
• Rarely, anterior repositioning appliances with subsequent "stepping back" (gradually returning the mandible to its previous anatomical position) or weaning the patient off their use. Permanent anterior repositioning of the mandible with orthodontics or fixed/removable prosthodontics is not validated by well controlled, well designed scientific research.
• Trigger point injections, where indicated, for the muscles of mastication. If conservative treatment such as that previously described successfully reduces the patient's symptoms, restoration to function of a non-functional occlusion may be warranted. There is inadequate research demonstrating any value to occlusal adjustment or alteration, except where the patient's occlusion is non-functional.
• Dental treatment may be indicated to correct previous restorative or prosthetic treatment that has resulted in an iatrogenic malocclusion. If conservative treatment is unsuccessful, invasive procedures to correct the malocclusion can be considered, but only if the patients symptom's and dysfunction warrant it and only with the patient's consent, after the possible effects have be explained.

Treatment modalities that have not been scientifically validated should not be routinely employed. If such techniques are to be considered, the patient must be informed that there is not scientific support for their use and/or that they are experimental. Again, the patient must be advised of any possible adverse effects, including delay in appropriate treatment. In any case, these interventions should be non-invasive and not result in any irreversible changes.

Where there is no obvious causal relationship between the patient's complaints and the anatomical or pathological abnormality, surgery cannot, with reasonable certainty, be expected to be curative. Similarly, if the patient presents with chronic pain, assessment and management of the psycho-social effects of the temporomandibular disorder is appropriate prior to considering a surgical procedure. This may require the assistance of other health care professionals.

It is understood that pain or other dysfunctions of the temporomandibular joint and surrounding regions may be the result of disorders unrelated to joint disease. The surgeon must be satisfied that adequate consideration has been given to investigation sufficient to reasonably rule out other causes or factors.

Other health care providers may be consulted when symptoms and diagnosis warrant. These may include the patient's physician, a neurologist, an otolaryngologist, a rheumatologist, or psychiatrist.

The patient is entitled to a full explanation of the apparent disease in "lay terms" as well as the proposed surgical intervention. In this regard, the explanation ought to include a discussion of treatment options, including no treatment, and the likely effects of each decision. The proposed intervention should be described including the benefits and risks of the particular procedure. The patient must be informed that surgical intervention of any type, in an of itself, may created irreversible and negative changes. Furthermore, there needs to be a clear understanding that the long term success of such surgery is unpredictable and that additional surgical intervention may be required.

The patient must understand that signs and symptoms of a temporomandibular disorder might be the result of a combination of multiple factors. Accordingly, surgical management directed to one region, which might effectively control signs and symptoms, may not necessarily or predictably affect the remaining complaints.

Finally, the patient must understand that the post-operative management is an integral and important part of the overall treatment strategy. This may include physiotherapy, medical, psychological, dental, and pharmacologic support. Post-operative management may progress for several years.

There is no scientifically validated evidence in support of surgery to treat "simple" clicking as the only presenting symptom, without associated locking or pain. This is not recommended as a treatment atrategy.

There is little evidence in support of the suggestion that surgical or orthodontic correction of malocclusion will predictably alter the course of an intra-articular disorder. Correction of a malocclusion should be considered on it own merits.