Conservative Temporomandibular Disorder Management: What DO I do? Frequently Asked Questions

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1 TMDMngement Roin JM Gry Zid Al-Ani Conservtive Temporomndiulr Disorder Mngement: Wht DO I do? Frequently Asked Questions Astrct: There re mny myths nd fllcies surrounding the conservtive or non-surgicl mngement of ptients with temporomndiulr disorders (TMD). This pper is not tretise on splint design nd does not chmpion ny one prticulr tretment philosophy. It is, however, produced s the outcome of mny yers of lecturing nd tlking to fellow prctitioners nd represents the most frequently sked questions nd common misconceptions encountered y the uthors, who hve ddressed the topics rised with the intention of helping to void pitflls. The common symptoms encountered in generl dentl prctice re pin, either from muscles or the temporomndiulr joint (TMJ) itself, limittion or devition of mndiulr movement, nd joint sounds, nd the uthors hve ttempted to seprte fllcy nd fct. When pproprite exmples re given. There re generl tretment guidelines ut, while some methods pply to n individul, there is no pnce individul ptient tretment needs vry. Clinicl Relevnce: It is importnt tht ll tretments delivered to TMD ptient should e evidenced-sed nd should lwys e in the ptient s est interests. Mny tretment modlities re proposed tht do not fulfil these prmeters nd cn led to confusion in mngement. A reference nd reding list will e given which will direct the reder to n evidence-sed pproch to tretment. Some tretment suggestions re founded on the extensive clinicl experience of the uthors. There will not lwys e evidence from rndomized, controlled clinicl tril to sustntite support for specific tretment, ut the reder should e directed y wht the mjority of clinicins would undertke s responsile pproch. Dent Updte 2013; 40: The ojective of this Question nd Answer pper is to ddress questions on temporomndiulr disorder (TMD) mngement nd suggest simple exmintion nd tretment guidelines for TMD ptients tht, while not eing overly Roin JM Gry, BDS, MDS, PhD, MFGDP, FHEA, FDS RCS(Ed), Former Senior Lecturer in Dentl Medicine nd Surgery, University of Mnchester Dentl School, Specilist in Orl Surgery nd Zid Al-Ani, BDS, MSc, PhD, MFDS RCS(Ed), FHEA, University Techer, Glsgow Dentl Hospitl nd School, Glsgow, UK. complicted, should enle the dentist to elicit ll relevnt informtion. It is importnt to rememer tht, with TMD ptients, the one pproch for ll ide is not pproprite. It is, however, preferle to work to set exmintion protocol, so tht ny findings re meningful not only to you s prctitioner, for future reference, ut lso to nother clinicin who might ecome involved in the ptient s mngement. Idelly, ll findings should e recorded in mnner tht cn e dded to susequently. It is not pproprite to give pro-form for clinicl exmintion in the form of document in this pper s such informtion cn redily e ccessed elsewhere. As mny prctices re now computerized, simple menu cn redily e dpted from other sources for everydy use. Q. My ptient s min complint is pin. Wht do I do? A. First sort out the source of the pin. Pin mimicking TMD cn come from mny ntomicl sources nd differentil dignosis is of the utmost importnce. Pin from TMD will usully hve its source either from the joint itself or the ssocited mndiulr muscles. Pin from the joint cn e ssocited with n internl disc Novemer 2013 DentlUpdte 745

2 TMDMngement derngement, degenertive joint disese or n cute inflmmtory pin, s is seen with trumtic rthritis. Pin ssocited with the mstictory muscles is frequently ssocited with prfunction. 1 Pin my respond to nonsteroidl nti-inflmmtory drug (NSAID), such s Iuprofen. If you prescrie this, dvise the ptient tht he/she must tke the drug regulrly fter food for 2 3 dys efore the nti-inflmmtory effect is mximized. If it is tken only on n s needed sis, it is no more effective thn prcetmol. 2-4 If there re plple res of tenderness in the muscles, then physiotherpy hs gret enefit. Electrophysiotherpy is thought to hve its ction y incresing cpillry permeility nd enhncing the uptke of inflmmtory exudte from the tissues surrounding the muscle fires. Some modlities of physiotherpy lso enhnce lood flow. 5,6 Ptients my lso experience pin with function. It is dvisle to suggest the ptient keeps strictly to soft diet, such s pst, mince, fish, eggs, etc. Chewing met nd tering ctions such s iting into crusty French red nd gels increse the joint lod nd should e voided. Ptients should e counselled tht iting into something hrd with the mouth wide open, such s into n pple, gretly increses the lod cross the joint nd should lso e voided. Ptients should cut up pples nd rw vegetles. On infrequent occsions when ptients experience intrctle pin from, for instnce, dvnced degenertive joint disese, intr-rticulr injection of steroid nd locl nesthetic cn e given. This, however, flls into the remit of specilist tretment nd, while rrely undertken, longside rthrocentesis does ply prt in mngement. 7,8 Q. Wht does TMJ tenderness signify? A. There re two common presenttions. Tenderness cn e centred over the temporomndiulr joint, rditing up into the temple, down the mndile, sometimes to the occiput, nd to the neck nd lso long the zygom. This is the distriution of tenderness tht is ssocited with fcil rthromylgi/pin dysfunction syndrome/myofcil pin nd follows the res of muscle ttchments. Alterntively, pin cn e precisely loclized to the temporomndiulr joint in the preuriculr re nd this distriution is usully ssocited with degenertive joint disese, such s osteorthrosis. Plption of the TMJ in the immedite pre-uriculr region (Figure 1) only gives limited informtion owing to the reltively poor nerve supply to the cpsule nd disc. More relile informtion is gined y plption vi the externl uditory metus (er cnl). 9 The little finger is plced in the externl uditory metus nd gentle forwrds pressure is pplied (Figure 2). The ptient is sked to open nd close his/her mouth gently. The posterior ilminr zone of the disc nd cpsule is highly innervted. If this prt of the joint is inflmed, or if the disc is displced, this re will e tender to exmine, especilly if this tissue is interposed etween the hed of the condyle nd the foss. It cn lso e extremely pinful to pproximte the molr teeth on the ffected side owing to compression of the retrodiscl tissue. This is common complint when ptients ttend with n cute disc displcement of recent onset. 21 Q. Wht out muscle exmintion; wht should e done? A. This should e limited to wht is interpretle. The usully exmined muscles re the msseter, temporlis, lterl pterygoid nd digstric. 10 These re smll muscles nd re generlly tender where they re ttched to one. The medil pterygoid is not ccessile to digitl plption. The msseter cn e exmined i-mnully with one finger inside the mouth nd one finger outside the mouth (Figure 3, ). This muscle is usully tender in ptients who hve clenching hit. The temporlis muscle is usully tender in its origin. The re where tenderness is frequently found is in the temple ove nd slightly nterior to the TMJ nd these re the nterior verticl elevtor fires (Figure 4). This muscle is tender in ptients who re ruxists. The lterl pterygoid muscle is not Figure 1. Lterl plption of the TMJ. Figure 2. Intr-uriculr plption of the TMJ. Figure 3. () Plption of the origin nd () insertion of the msseter. Figure 4. Plption of the nterior verticl fires of the temporlis. 746 DentlUpdte Novemer 2013

3 TMDMngement ccessile for digitl plption. 11 This muscle is est tested ginst forced resistnce, wherey the ptient is sked to open his/ her mouth, with the opertor s hnd plced under the chin resisting further movement (Figure 5, ). If there is pterygoid muscle spsm, then discomfort will e felt in the pre-uriculr re on the ffected side. The digstric muscle is depressor of the mndile. The clinicl mnifesttion of tenderness in the digstric muscle is pin ehind the scending rmus of the mndile, over the posterior elly in the region under the erloe. This tends to e tender in ptients who rux on their nterior teeth. Q Wht do TMJ sounds signify? A. Wht do you men y sounds? Joint sounds vry. The common sounds re clicking nd crepittion. An erly or mid opening cycle click is commonly cused y disc displcement. If the intrrticulr disc is displced, then the ptient cn usully open to mm without cusing click. This is consistent rnge of mesurement due to the rottionl condylr movement. Once this rottory phse is exceeded, trnsltion occurs when the hed of the condyle moves forwrds cross the intr-rticulr disc. If the disc is displced then, s trnsltion commences, the hed of the condyle encounters the disc in n unexpected nd displced position. Friction is uilt up until the hed of the condyle jumps pst the disc with positive udile relese of energy, which is the click. The closing click tends to e softer thn the opening click, s it is more of pssive movement when the disc repositions. Another explntion for lte opening click could e suluxtion, when the disc is not displced t the commencement of mouth opening, ut the click occurs s result of the condylr hed moving considerly further thn the disc nd, therey, ttining displced position. The click ssocited with fcil rthromylgi or myofcil pin tends to e present on wking in the morning for the first hour or so. Therefter, s the muscles relx, the disc returns to its norml ntomicl nd functionl position, owing to the elstic pull of the posterior prt of the disc, nd the click disppers. It my return t times of incresed muscle tension, such s when eting. If, however, the click is consistently present throughout movement, this is more indictive of true internl derngement in which the disc is consistently displced. It is importnt to differentite etween the two types of clicks on the sis of the ptient s history s this will directly ffect the tretment pln. Ptients often confuse TMJ clicking with disloction. True disloction is extremely rre nd generlly occurs when trum is pplied to the mndile with the mouth open. In such circumstnces, the ptient would ttend with his/her mouth stuck open nd devited cross towrds one side nd would e in considerle pin. The other common joint sound is crepittion. This is crunching or grting sound nd is indictive of either degenertive joint disese, such s osteorthrosis or, less frequently, of cute inflmmtion. Crepittion ssocited with osteorthrosis is joint sound which my e present with or without pin. It is indictive of degenertion of the joint surfces, either of the condyle, of the foss or of the intrrticulr disc itself. Rdiogrphic findings my or my not e present (Figure 6). This sound cn lso e ttriutle to vriety of other degenertive joint diseses, such s psoritic rthritis nd rheumtoid rthritis. It should e rememered, however, tht if either of the ltter two dignoses is involved, the ptient will usully present with the systemic disese lredy estlished. Q. Does click need treting? A. No. Not lwys! Clicking cn e relted to myofcil pin nd dysfunction when the click is intermittent. An lterntive presenttion is when the click is consistently present nd is ssocited with true internl derngement of disc displcement with reduction. If ptient presents t the surgery with pinless click tht is completely symptom free, there is no pin nd there never hs een ny experience of locking, there my e no need to tret the condition. 12 Tretment of click, however, my e pproprite if the click is pinful, if there is tendency to lock or if it is udile to others nd socilly emrrssing. In these Figure 5. () Verticl exmintion of lterl pterygoid muscle ginst resisted movement. () Lterl exmintion of lterl pterygoid muscle ginst resisted movement. Figure 6. DPT of () right TMJ nd () left TMJ. Sme ptient showing degenertive joint disese. Novemer 2013 DentlUpdte 747

4 TMDMngement circumstnces, the tretment of choice is n nterior repositioning splint (Figure 7). These pplinces re successful in out 85% of ptients The cid chirside test is when the ptient is sked initilly to open his/her mouth nd then to protrude the lower jw nd then close. On susequent opening nd closing movements, he/she is sked to keep the mndile forwrds with the incisors in n edge-to-edge reltionship nd the click should dispper. In some ptients, for instnce with Clss II division 1 one nd dentl reltionship, it my not e necessry to ttin n edge-to-edge position. If the click is herd on protrusive mndiulr movement, record this position s the one to work to. If protrusion elimintes the click, this is indictive tht n nterior repositioning splint would hve high chnce of success. When the ptient postures forwrds onto his/her incisor teeth (Figure 8, ), the hed of the condyle projects downwrds nd forwrds so tht the displced disc ssumes more norml functionl reltionship to the hed of the condyle. Opening nd closing from this position without cusing the click therey elimintes trum to the disc nd the nturl elsticity of the posterior prt of the disc grdully repositions it. An nterior repositioning splint must e worn 24 hours dy for pproximtely 12 weeks followed y grdul wening off period until the splint is eventully dispensed with. The temporry protrusive position of the mndile reverts to norml, the occlusion will return to its pre-tretment stte nd, if splint tretment is successful, with the disc ck in position. 21 These pplinces work well when the ptient hs click on opening in the verticl dimension. If the click is only present on lterl movements, this is much less esy to tret nd n nterior repositioning splint is less successful. The joint sound of crepittion is different to mnge. If you see ptient who hs recently developed crepittion, the chnces re tht for up to period of 9 12 months this will persist. The temporomndiulr joint, however, does retin the cpcity to repir nd remodel throughout life. The undifferentited germintive mesenchyme cell lyer cn e stimulted y irrittion. The direct effect of this, in response to degenertive joint disese, is for the hed of the condyle to reshpe, remodel nd resurfce. This reprtive cycle cn tke nything from 18 months to three yers to occur. Q. Should I record the rnge of jw movements? A. Yes, this is importnt. Assess the rnge of jw movement in oth the verticl nd horizontl plnes (Figure 9, ). The lower limit of norml verticl movement for femle ptients is pproximtely 38 mm nd 45 mm for mle ptients. The normlly ccepted rnge of lterl movement is 8 mm from midline to midline. Assess not only the pin-free rnge of movement, ut lso the mximum forced rnge of movement. This will negte ny suconscious ptient Figure 7. Anterior repositioning splint. Figure 8. () Mndiulr position without nterior repositioning splint (ARPS). () Mndiulr position with ARPS. gurding, which might reduce the rnge of movement to within his/her pin-free comfort zone. Aprt from the clinicl mesurement of the rnge nd pttern of movement, which is the one ojective mesurement tht cn e undertken, much cn e gined from wtching the ptient during his/her norml functionl movements. Restricted jw movement in TMD ptient is either due to pin in the muscles or physicl ostruction within the joint, such s disc displcement. If there is reduced lterl movement, the ptient will e le to move wy from the ffected side to lesser distnce thn towrds the ffected side. When moving towrds the symptomtic side, the ffected condyle is rotting, Figure 9. () Mesurement of incisl opening. () Mesurement of lterl jw movement. 748 DentlUpdte Novemer 2013

5 TMDMngement wheres when moving wy from the ffected side, the condyle will e oriting nd will hve rnge of movement ostructed y the displced disc. Devition in the pthwy of movement is est seen y stnding in front of the ptient. If the pthwy of movement is stright (Figure 10), then oth joints re cting synchronously. A temporry devition to one side (Figure 10) or the other implies tht there hs een n ostruction to smooth movement, possily indicting disc displcement with reduction. If the mndile moves oliquely from the strt of opening to mximum opening (Figure 10c), then this might imply dhesions within the joint. If the mndile moves verticlly only susequently to devite mrkedly to one side (Figure 10d), this might indicte disc displcement without reduction in tht the condyles move to certin point when movement of one side is locked. Q. How do I rect to complint of decresed rnge of movement? A. Think out the possile cuse. A decresed rnge of movement cn e due to vriety of cuses, the most frequent of which re muscle pin or n Figure 10. ( d) Digrmmtic representtion of mndiulr movements. internl derngement of disc displcement, without reduction when there is physicl ostruction. Restricted mouth opening cn, on rre occsions, e due to medil pterygoid hemtom following n ID lock. This, however, occurs with totlly different presenttion nd could e dismissed without germne history. When considering the former, it is sensile to ddress the cuse of the muscle tenderness. This could e secondry to prfunction, secondry to trum or, s hppens frequently, my rise spontneously with the ptient hving done nothing tht he/she ws wre of to cuse the onset of the symptoms. NSAIDs, such s Iuprofen, do hve plce. A more effective wy of ddressing this, however, is with n immedite nd intensive course of outptient electro-physiotherpy in comintion with soft diet nd ntiinflmmtory gel, preferly contining oth Iuprofen nd Levomenthol. When the pin is cute, hot nd cold compresses cn e used, such s frozen pes for minute wrpped up in towel followed y hot wter ottle for 2 3 minutes, repeting this cycle two or three times (Figure 11, ). If ptient presents with specific re of cute muscle spsm, which is redily identifile y digitl plption, vpo-coolnt spry, such s ethyl chloride cn e used for temporry relief (Figure 12). This should e dministered in the surgery environment. In some instnces, when jw reltionship recording is eing ttempted, such s Centric Reltion or Retruded Contct Position, the muscles cn e very uncomfortle nd unforgiving nd prevent redy mnipultion of the mndile. In these circumstnces, smll nterior crylic iteplne my e used to prevent the posterior teeth meeting nd this in itself my e enough to induce muscle relxtion. This should e used s dignostic id only nd should not e given to the ptient to use t home ecuse of its poor retention. If the restricted movement is due to physicl ostruction (disc displcement without reduction), the uthors consider n intensive course of outptient physiotherpy, either megpulse or ultrsound, directed t relxing the superior pterygoid muscle, to e helpful. 22 If this is of recent onset, there is high chnce of success of llowing the disc to reposition. This must e n intensive course (3x per week for 3 weeks). If the disc displcement is recent nd ssocited with cute muscle spsm of the superior pterygoid, then prescription of Temzepm orl suspension should lso e considered. 23 This must e done in conjunction with the ptient s medicl prctitioner nd should e given s 10 mg dose t night for period of out dys. The ptient should e counselled to tke this hlf n hour efore going to sleep t night. The dose must not e incresed eyond 10 mg nd idelly should e Figure 11. (, ) Hot nd cold compresses cn e used to tret cute pin. Novemer 2013 DentlUpdte 751

6 TMDMngement grdully reduced. This drug is not licensed s muscle relxnt ut s n nxiolytic. It does, however, hve recognized phrmcologicl muscle relxnt effect. It is not licensed for use in children under 12 yers of ge. If locking is of very recent onset, it is sometimes possile to mnipulte the mndile to free the disc. This is done y sking the ptient to ite with wooden tongue sptul etween the molr teeth on the ffected side for pproximtely one minute (Figure 13). This cuses the muscles on the contr-lterl side to pull the condyle up while the condyle on the ffected side is fixed. The ptient is then sked to open the mouth gently nd the opertor plces his/ her thums on the molr teeth nd exerts gentle downwrds nd posterior pressure on the ffected side, while rotting the other side upwrds nd slightly forwrds. This does work on occsion in freeing the disc ut the ptient should e told tht the disc is unstle. This must e followed y period of strict soft diet nd reduction of mouth opening s fr s possile. Q. Should I look for signs of ruxism for ptients with TMD? A. Yes. An wreness of ruxism cn e reported ut direct cuse nd effect reltionship is difficult to estlish. Mild forms of ruxism rrely hve severe consequences for orl structures. Bruxism is prfunctionl oromotor hit, tht cn occur during sleep or dytime, tht cn sometimes pose thret to the integrity of the structures of the mstictory system if the mgnitude nd direction of the forces exerted exceed the system s dptive cpcity. 1 In extreme cses, however, ruxism cn cuse tooth structure rekdown nd it hs een suggested tht this cn ply role in the development of TMD. The two most relile signs of ctive ruxism re sclloping of the lterl mrgins of the tongue (Figure 14) nd ridging of the uccl cheek mucos long the occlusl plne (Figure 15). Both sclloping of the tongue nd ridging of the cheek mucos dispper when prfunction ceses, usully within 2 3 weeks. Attrition or norml wer fcets my lso e seen ut will oviously remin fter ctive prfunction hs cesed. Q. Do I need n X-ry or will n MRI scn e etter? A. Specil tests re hugely overprescried nd re normlly unjustified. Specil tests re rrely necessry in the dignosis or tretment plnning of ptient with temporomndiulr disorder. Rdiogrphic nd other investigtions re not indicted s prt of ptient s routine exmintion Q. Is specific dignosis importnt? A. Yes, vitl. Tretment for one condition might e ineffective t est or detrimentl t worst for nother. The dignosis should e mde in reltion to the ptient s history nd his/ her sujective complints nd the clinicl findings. The dignostic criteri for the individul disorders re well known nd do not merit repetition here. Q. Should I dvise the ptient to exercise, especilly when there is restricted movement? A. No. Aggressive exercise during n cute TMD phse is est voided owing to the potentil for possile further dmge to displced disc or inflmed muscle. If the cute symptoms hve resolved nd there is residul devition or restriction on opening, closing or on protrusion, then remedil exercises cn e dvised to correct the devition. These should e done in the verticl, lterl nd ntero-posterior directions. The ptient should stnd in front of mirror, plce one hnd over the side of the mndile towrds which the devition is occurring nd then open, close or protrude the lower jw, pplying hnd pressure to ensure the mndile moves in stright line. These re ll useful corrective exercises. During the cute phse, however, ptient should e told to tret his/her TMD s similr to sprin nd should rest the mndile s much s possile, keep to soft diet nd void vigorous exercise. Q. Is physiotherpy useful in the mngement of TMD ptient? A. Yes! A temporomndiulr disorder is like ny other musculoskeletl disorder. If ny other joint ws injured, the first recourse might e to physiotherpist. The sme is true with TMD, with the cution tht, during the cute phse of condition, exercise nd ctive moiliztion is not desirle owing to the Figure 12. Ethyl chloride cn e used for temporry relief from cute muscle spsm. Figure 13. Asking the ptient to ite on wooden tongue sptul etween the molr teeth on the ffected side for pproximtely one minute followed y mnipultion my e helpful procedure in freeing the disc. Figure 14. Tongue sclloping. 752 DentlUpdte Novemer 2013

7 TMDMngement potentil for further dmge. 22 An intensive course of tretment is est, initilly without trying to improve the rnge of movement forcily. The usully employed modlities of outptient electro-physiotherpy re megpulse nd ultrsound (Figure 16, ). Soft lser is lso used (Figure 17). The idel regime is 2 3 times week for 3 4 weeks, totlling out 10 sessions in ll. If the ttendnces re less frequent, then the enefit is limited. Recent reserch suggests tht either mnul therpy or electricl modlity intervention would e n option for the tretment of TMD to improve functionl outcomes. 29 Physiotherpists re skilled in pssive gentle mnipultion, which hs plce in myofcil pin. The est pproch is to discuss the tretment directly with the physiotherpist s he/she is the expert in the field nd est plced to give dvice. Q. Should I lwys provide splint? A. Not necessrily. There re mny different vrieties of splint. Some re frequently mde, such s soft vcuum-formed splints (Figure 18). In our clinicl experience, it should e orne in mind tht pplinces such s these, if the ptient is n ctive ruxist, cn ctully mke mtters worse, s they re suconsciously wre of hving something compressile etween their teeth. If the ptient is n ctive ruxist, it is not uncommon for them to destroy such n pplince in firly short spce of time nd this cn e ccompnied y n excertion of their symptoms. An occluslly lnced stiliztion splint (Figure 19) is the idel splint of choice, if there ppers to e n occlusl component in the etiology of the ptient s symptoms of myofcil pin, such s is found with prfunction. The use of n nterior repositioning splint hs lredy een discussed. An in-depth tretise on splint therpy is outwith the remit of this pper nd such informtion cn e redily sought elsewhere. Q. Cn I use prtil coverge pplince for TMD mngement? A. No, NEVER. There is no indiction in the mngement of ptients with temporomndiulr disorders for use of prtil coverge pplinces. These permit Q. Is there ny evidence to support the use of cupuncture in TMD mngement? A. Yes, ut it is inconclusive. It is climed tht cupuncture hs eneficil role in TMD mngement, principlly of myofcil pin, nd tht the use of cupuncture hs success rte similr to tht of occlusl splints nd other tretments in relieving symptoms. 30,31 However, owing to severl methodologicl flws, evidence remins inconclusive nd the efficcy of cupuncture cnnot e scertined sed on current literture. Figure 15. Cheek ridging. Figure 17. Soft lser pprtus in use. Q. Should I prescrie drugs for ptients with TMD? A. In some instnces, yes. Non-steroidl nti-inflmmtory drugs (NSAIDs) hve limited success. Iuprofen is mild NSAID, ut hs only mild side-effects. It cn e useful in the mngement of chronic pin ut its use is limited nd, if tken on n s needed sis, is no etter thn prcetmol. Temzepm orl suspension hs een mentioned s eing useful for short-term use for ptients who hve suffered n cute disc displcement without reduction (locking), if ccompnied y cute pterygoid muscle pin. 23 Figure 16. () Megpulse pprtus in use. () Ultrsound pprtus in use. Figure 18. Soft vcuum-formed splint. Figure 19. Occluslly lnced stiliztion splint. 754 DentlUpdte Novemer 2013

8 TMDMngement unplnned unpredictle nd unwnted tooth movement nd re medico-leglly indefensile (Figure 20 c). Q. If there re occlusl interferences shouldn t I just pick up hndpiece nd remove them? A. NO! If the ptient hs TMD, then the occlusl contcts my not e the sme s when symptom free, especilly if there is n cute disc displcement. Therefore, n occlusl interference my e result rther thn cuse of temporomndiulr disorder. Irreversile occlusl djustment should never e undertken in the presence of cute muscle pin or TMD symptoms. Idelly, occlusl djustments should not e done until fter period of successful splint tretment. If stiliztion splint is worn nd the ptient s symptoms resolve, only to return when the splint is wened off, then there might e logicl reson to ddress the occlusion of the nturl teeth, ut not without further nd detiled occlusl nlysis nd only fter meticulous plnning with rticulted plster csts nd with informed consent. Q. Cn I crry on with extensive restortive tretment if TMD rises prt wy through? A. Not dvisle. It is not sensile to continue with n extensive restortive tretment pln in the presence of n cute disc displcement, if this occurs prt wy through tretment s, when the disc is out of plce, the occlusl contcts etween mxillry nd mndiulr teeth will chnge in oth position nd numer. Get dvice out whether it is necessry to tret the disc displcement first efore plcement of the finl restortions. Q. Should I restore posterior missing units if I thought tht missing molr teeth could compress the TMJ? A. This theory stretches ck mny decdes nd is not sustntited ntomiclly. There is no evidence se to show tht restortion of missing nd posterior units will enefit TMD tretment, unless there re functionl difficulties. Indeed, the shortened dentl rch is now deemed to e tretment of choice in some ptients (Figure 21). Q. My ptient feels tht orthodontic tretment cused the temporomndiulr disorder. Is this right? A. There is nothing in clinicl experience or in the literture which would support such theory when pplied to conventionl orthodontics. The ge tht TMD cn rise is out the sme ge s when dolescents might complete course of orthodontic tretment, so this ppers to e purely coincidentl. Q. Is the do nothing pproch wrong? A. Certinly not. If the ptient hs, for instnce, click or temporrily restricted movement unccompnied y ny other cute symptoms, then there my e no need to tret this. If full discussion with the ptient hs tken plce nd he/she is comprehensively informed s to wht tretment cn e offered should the need rise, the decision not to go down the ctive tretment route my e chosen t tht period in time. The dentist s role is dvising wht tretment should e considered if temporry symptoms do not resolve, or if more intrusive symptoms, such s pin or locking, occur. Tretment of ptient with TMD should e individully plnned. The ptient s expecttions nd wht tretment he/she will ccept will hve een discussed. Wht my e n idel tretment pln on pper my not e prcticl ut, s long s ny suggestions re evidence-sed nd full nd open dilogue tht tretment cn e commenced t ny time is mintined, then the ptient s needs nd est interests re eing fulfilled. References 1. de l Hoz-Aizpuru J, Díz-Alonso E, LTouche-Arizu R, Mes-Jiménez J. Figure 20. Distured occlusion (, c) following tretment with prtil coverge pplince (). Figure 21. Shortened dentl rch is the tretment of choice in this ptient with missing posterior teeth. Novemer 2013 DentlUpdte 755 c

9 TMDMngement Sleep ruxism. 4. Conceptul review nd updte. Med Orl Ptol Orl Cir Bucl 2011; 16(2): Al-Ani Z, Gry R. TMD current concepts: 2. Imging nd tretment options. An updte. Dent Updte 2007; 34(6): Gry RJ, Dvies SJ. Emergency tretment of cute temporomndiulr disorders: Prt II. Dent Updte 1997; 24(5): Gry RJ, Dvies SJ. Emergency tretment of cute temporomndiulr disorders: Prt 1. Dent Updte 1997; 24(4): Tlt AM, el-diny MM, el-grf A. Physicl therpy in the mngement of myofcil pin dysfunction syndrome. An Otolo Rhinolo Lryngolo 1986; 95: Crider AB, Glros AG. Efficcy of electromyogrphic tretment is supported for Temporomndiulr disorders. Evidence-Bsed Dent 2000; 2: Buescher J. Temporomndiulr Joint Disorders. Am Fm Physicin 2007; Smiee A, Szerou D, Edltpjouh F, Clrk G, Rm S. Temporomndiulr joint injection with corticosteroid nd locl nesthetic for limited mouth opening. J Orl Sci 2011; 53: Ash M. Current concepts in the etiology, dignosis nd tretment of TMJ nd muscle dysfunction. J Orl Rehil 1986; 13: Gry RJ, Dvies SJ, Quyle AA. A clinicl pproch to Temporomndiulr disorders. 3. Exmintion of the rticultory system: the muscles. Br Dent J 1994; 177(1): Turp JC, Mingi S. Plption of the lterl pterygoid region in TMD where is the evidence? J Dent 2001; 29(7): Minkuchi H, Kuoki T, Mlsuk Y, Mekw K, Ytni H, Ymshit A. Ptients with nterior disk displcement improve with miniml tretment. Evidence-Bsed Dent 2002; 3: Simmons HC 3rd, Gis SJ. Anterior repositioning pplince therpy for TMJ disorders: specific symptoms relieved nd reltionship to disk sttus on MRI. J Tenn Dent Assoc 2009; 89(4): 22 30; quiz Clrk GT. Tretment of jw clicking with temporomndiulr repositioning: nlysis of 25 cses. Crnio 1984; 2: Lundh H, Westesson P, Kopp S, Tillström B. Anterior repositioning splint in the tretment of temporomndiulr joints with reciprocl clicking: comprison with flt occlusl splint nd n untreted control group. Orl Surg Orl Med Orl Pthol 1985; 60: Clrk GT. The TMJ repositioning pplince: technique for construction, insertion, nd djustment. Crnio 1986; 4: Dvies SJ, Gry RJM. The pttern of splint usge in the mngement of two common temporomndiulr disorders. Prt I: The nterior repositioning splint in the tretment of disc displcement with reduction. Br Dent J 1997; 183: Dvies SJ, Gry RJM. The pttern of splint usge in the mngement of two common temporomndiulr disorders. Prt III: Long-term followup in n ssessment of splint therpy in the mngement of disc displcement with reduction nd pin dysfunction syndrome. Br Dent J 1997; 183: Dvies SJ, Gry RJM. The pttern of splint usge in the mngement of two common temporomndiulr disorders. Prt I: The nterior repositioning splint in the tretment of disc displcement with reduction. Br Dent J 1997; 183: Sntctterin A, Poli M, Perett R, Bmce A, Beltrme A. Repositioning splint more effective thn ite plne in the tretment of TMJ disk disloction with reduction. Evidence-Bsed Dent 2000; 2: Al-Ani Z, Dvies S, Slon P, Gry R. Chnge in the numer of occlusl contcts following splint therpy in ptients with temporomndiulr disorder. Eur J Prosthodont Rest Dent 2008; 16(3): Tlt AM, el-diny MM, el-grf A. Physicl therpy in the mngement of myofcil pin dysfunction syndrome. An Otolo Rhinolo Lryngolo 1986; 95: Dvies S, Gry R. Orl temzepm. Br Dent J 2000; 189(9): Elisson S, Iscsson G. Rdiogrphic signs of temporomndiulr disorders to predict outcome of tretment. J Crniomndi Disord 1992; 6(4): Epstein JB, Cldwell J, Blck G. The utility of pnormic imging of the temporomndiulr joint in ptients with temporomndiulr disorders. Orl Surg Orl Med Orl Pthol Orl Rdiol Endod 2001; 92(2): Pendleury ME, Horner K, Eton KA. Selection Criteri for Dentl Rdiogrphy 2nd edn. London: Fculty of Generl Dentl Prctitioners, Westesson PL, Cohen JM, Tllents RH. Mgnetic resonnce imging of temporomndiulr joint fter surgicl tretment of internl derngement. Orl Surg Orl Med Orl Pthol 1991; 71(4): de Senn BR, dos Sntos Silv VK et l. Imging dignosis of the temporomndiulr joint: criticl review of indictions nd new perspectives Orl Rdiol 2009; 25: Jkuowski Ali. The effects of mnul therpy nd exercise for dults with temporomndiulr joint disorders compred to electricl modlities nd exercise. PT Criticlly Apprised Topics, Pper pcificu.edu/ptcts/ Smith P, Mosscrop D, Dvies S, Slon P, Al-Ani Z. The efficcy of cupuncture in the tretment of temporomndiulr joint myofscil pin: rndomized controlled tril. J Dent 2007; 35: Simm I, Gleditsch JM, Simm L, Piehslinger E. Immedite effects of microsystem cupuncture in ptients with oromyofcil pin nd crniomndiulr disorders (CMD): doule-lind, plceo-controlled tril. Br Dent J 2009; 207(12): E DentlUpdte Novemer 2013

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