Screening orthodontic patients for temporomandibular disorders

Transcription

1 Clin Dent Rev (2017) 1:8 DIAGNOSIS Screening orthodontic patients for temporomandibular disorders Gary Klasser 1 Charles Greene 2 Received: 5 April 2017 / Accepted: 19 July 2017 / Published online: 11 August 2017 Ó Springer International Publishing AG 2017 Abstract At a minimum, a screening evaluation for TMDs should be included as a component of the initial orthodontic evaluation process. It is also important for orthodontists to discriminate between major (significant) and minor (insignificant) signs and symptoms of TMD if they are discovered during the screening. If the patient has significant TMD issues, the orthodontist must decide whether to take on the responsibility for managing them prior to initiating orthodontic treatment. If not, an appropriate referral must be made. Furthermore, orthodontists must respond appropriately when a patient is referred specifically for the treatment of TMD issues. In this circumstance, it is important that communication with both the patient and the referring dentist follow current scientific concepts about TMD orthodontic relationships. If TMD signs and symptoms arise during orthodontic treatment, orthodontists must be cognizant of proper procedures. Because there is some potential for the development of TMD issues after orthodontic treatment in a segment of their population, it is important for orthodontists to react appropriately in these circumstances. Keywords Orthodontist Temporomandibular disorders (TMDs) Screening TMD orthodontic relationships & Gary Klasser gklass@lsuhsc.edu 1 2 Louisiana State University, New Orleans, USA University of Illinois at Chicago, Chicago, USA

2 8 Page 2 of 7 Clin Dent Rev (2017) 1:8 Quick reference/description The American Academy of Orofacial Pain (AAOP) defines temporomandibular disorders (TMDs) as a group of musculoskeletal and neuromuscular conditions that involve the TMJs, the masticatory muscles, and all associated tissues. Routine screening of all prospective orthodontic patients for the presence of temporomandibular disorders (TMDs) is needed because the following clinical situations can occur in orthodontic practice: The orthodontist may have a patient referred specifically for TMD issues. TMD signs and symptoms may arise during orthodontic treatment. A completed patient may develop TMD after orthodontic treatment. Oro-dental screening includes (1) caries history and current dental situation, (2) periodontal history and current findings of concern, (3) oral cancer screening and soft tissue examination, and (4) an evaluation of the orofacial region with emphasis regarding the temporomandibular joints (TMJs) and associated musculoskeletal structures. Screening protocols and forms are used to record various major and minor findings obtained during the screening exam. Symptoms Table 1 lists the symptoms of TMDs. Dental history The dental history should include information regarding previous dental disease, treatment, and habit history (awake and asleep). Medical history Medical history should include information regarding any previous surgery, hospitalizations, trauma, illness, developmental and acquired anomalies, sleep disorders and sleep-related breathing disorders, allergies, and medication usage (including prescribed, over the counter, herbal and vitamin supplements, and illicit drug use). Psychosocial history Psychosocial history includes a discussion of social, behavioral, and psychological issues; occupational, recreational, and family status; litigation, disability, or secondary gain issues. Comorbid conditions are frequently found in TMD patients, such as certain headaches, affective disorders (anxiety and depression), and nonorganic (functional)

3 Clin Dent Rev (2017) 1:8 Page 3 of 7 8 Table 1 History of chief complaints Symptoms Pain TMJ clicking or popping Functional difficulty Questions to be asked The location of the pain(s) Date of onset Event onset (spontaneous or stimulus induced) Quality Frequency Duration Intensity (based upon a numeric rating scale of 0 = no pain to 10 = the most extreme pain, or a visual analog scale using a 10-cm line labeled at one end with no pain and at the other end with most extreme pain ) Factors that alleviate, aggravate, or precipitate the pain; changes over time; previous treatment results; and any associated issues Patient should be asked for any history of nondental facial pain When did the clicking start? Has it become more frequent or louder? Is it associated with any pain? Does the jaw ever get stuck in trying to open or close? Did the patient ever report it to a physician or dentist? Patients should be asked if they have noticed a limitation in their ability to open their mouth widely? Was it always there or it has been developing over time? Ask if normal functions like chewing hard food, singing in a choir, yawning widely, chewing gum, or sitting through a long dental appointment produce fatigue and pain; if so, does this symptom linger afterward or go away fairly quickly? disorders such as fibromyalgia, irritable bowel syndrome, interstitial cystitis/bladder pain syndrome, chronic pelvic pain, and vulvodynia. Clinical examination A thorough physical examination consisting of inspection and palpation of the oral cavity, TMJ and adjacent structures with adjunctive use of auscultation should be performed (Table 2). Different joint sounds can be observed during the clinical examination of the TMJ. There may be a single click, which is often louder on opening and softer on closing (reciprocal click), or there may be multiple clicks in some cases. If the sound is a grating (crepitus) noise, the patient should be asked about a history of arthritides in other joints; if the TMJ is the only affected joint, questions can be raised about previous painful episodes in that area.

4 8 Page 4 of 7 Clin Dent Rev (2017) 1:8 Table 2 Physical examination Inspection Palpation Auscultation Inspection of the head and neck Orthopedic evaluation of the TMJ including intracapsular sounds Assessment of the cervical spine Masticatory and cervical muscle evaluation Evaluation of the cranial nerves for neurovascular, neurosensory, and motor problems Observation of mouth opening, lateral excursions, and mandibular protrusion An intraoral assessment (hard and soft tissues) Palpate to assess clicking, popping, or other TMJ noises Palpation of the masticatory muscles and both TMJs for tenderness/pain Palpate adjacent structures Measurement of mouth opening, lateral excursions, and mandibular protrusion Check for clicking, popping, or other TMJ noises Diagnostic tests To develop a definitive diagnosis and/or provide appropriate management, adjunctive tests may be required. These tests include: Dental imaging (bitewing, periapical, and panoramic radiographs) to rule out dentoalveolar pathology. Medical imaging (computerized tomography, cone-beam computed tomography, magnetic resonance imaging, radionucleotide, and ultrasonography) to evaluate the TMJs. TMJ imaging is usually done when the history or examination, or both, is indicative of a recent or progressive pathological joint condition; significant dysfunction or alteration in range of mandibular movements; or significant and often sudden changes in occlusion (anterior open bite, posterior open bite, and mandibular shift). Other adjunctive tests to be considered are diagnostic anesthesia and serologic testing. Procedure The orthodontist must be prepared to deal with patients who present with orofacial pain symptoms. TMD signs and symptoms can be managed at three stages: at the time of presentation, during treatment, and after treatment (Table 3). Previous and current TMD screening forms or recommended protocols Screening forms are useful screening instruments for detecting TMD problems in the general dental patient population. The excellent levels of reliability, sensitivity,

5 Clin Dent Rev (2017) 1:8 Page 5 of 7 8 Table 3 Protocol for the management of TMD signs and symptoms within an orthodontic practice At time of presentation During treatment After treatment 1. If patient has signs and symptoms of TMD, then the patient should be informed that orthodontic treatment will not resolve those problems 2. Current TMD signs and symptoms should be noted, and a full TMD history and clinical examination should be undertaken and recorded 3. If the existing TMD is acute and severe, the commencement of orthodontic treatment should be postponed until the condition is either resolved or stabilized 1. Acknowledge and recognize the signs and symptoms of TMD 2. Reassure and educate the patient that TMD is not necessarily a progressive problem and in most cases symptoms will improve over time with conservative treatment 3. Active orthodontic treatment should be discontinued, and TMD signs and symptoms should be managed by either the orthodontist or an expert TMD colleague 4. Once signs and symptoms have been alleviated or controlled, active orthodontic treatment may be resumed with consideration to modification of treatment (reduction of forces on headgear, remove or lighten elastics, use of oral TMD treatment appliance) The patient should be monitored for signs and symptoms throughout the retention period. If symptoms arise, appropriate management should be provided and specificity demonstrate the validity and usefulness of this instrument in any clinical office setting. A structured questionnaire for screening all dental patients for the presence of TMD was first presented in In 2011, the following short (three-item) and long (six-item) versions of a newly developed TMD screening form were developed and validated (Table 4). Differential diagnoses to be considered during TMD screening Other orofacial pain disorders. Various types of headache disorders. Remember: Signs and symptoms associated with non-musculoskeletal sources in the orofacial region (neurologic, neurovascular, neoplastic, and glandular) are often similar to those arising from TMDs. Pitfalls and complications In some cases, even with expert care, the patient may continue to have low-level or recurrent TMD symptoms. TMDs are complex musculoskeletal pain disorders that share many characteristics with other somatic pain disorders, making diagnosis complicated.

6 8 Page 6 of 7 Clin Dent Rev (2017) 1:8 Table 4 TMD screening instrument Temporomandibular pain disorder screening instrument 1. In the last 30 days, on an average, how long did any pain in your jaw or temple area on other side last? pain b. From very brief to more than a week, but it does stop c. Continuous 2. In the last 30 days, have you had pain or stiffness in your jaw on awakening? 3. In the last 30 days, did the following activities change any pain (that is, make it better or make it worse) in your jaw or temple area on either side? A. Chewing hard or tough food B. Opening your mouth or moving your jaw or temple area on either side C. Jaw habits such as holding teeth together, cleaning,grinding or chewing gum D. Other jaw activities such as talking, kissing or yawning Items 1 through 3A constitute short version of the screening instrument, and items 1 through 3D constitute the long version. An a response receives 0 points, a b response 1 point and a c response 2 points. Scoring Thresholds: Short Screener (Threshold Value: 2) Long Screener (Threshold Value: 3) TMD screening instrument (Gonzalez et al.). Copyright 2011 American Dental Association. Pain and/or dysfunction of TMJ can be coincidental or might be a response to the orthodontic treatment forces, which creates difficulty in identifying whether the ongoing treatment is the cause. Chances of developing TMDs are greater in adolescent orthodontic patients than in adult patients. There is some potential for the development of TMD issues after orthodontic treatment, but they generally are not caused by that treatment.

7 Clin Dent Rev (2017) 1:8 Page 7 of 7 8 Further Reading 1. Greene CS, Klasser GD (2015) Screening orthodontic patients for temporomandibular disorders. In: Kandasamy S, Greene C, Rinchuse D, Stockstill J (eds). TMD and orthodontics: a clinical guide for the orthodontist. Springer, Cham, p doi: / _3 2. American Academy of Orofacial Pain (2013) Diagnosis and management of TMDs. In: De Leeuw R, Klasser GD (eds) Orofacial pain: guidelines for assessment, diagnosis, and management, 5th edn. Quintessence, Chicago, p Okeson JP (2013) History of and examination for temporomandibular disorders. In: Management of temporomandibular disorders and occlusion, 7th edn. St. Mosby, Louis, p Leite RA, Rodrigues JF, Sakima MT, Sakima T (2013) Relationship between temporomandibular disorders and orthodontic treatment: a literature review. Dental Press J Orthod 18: