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It has been the intention of this brief paper to help dentists respond quickly and effectively to patients with TMD. (In lieu of a detailed bibliography, a brief list of articles and books that deal with diagnosis and therapy for TMD follows.) Several present actual guidelines for practice, while others discuss concepts in greater detail. Knowing how to help these troubled patients by using contemporary basic principles of pain management should make every practicing dentist feel a well-deserved sense of fulfillment.
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PMID:Managing TMD patients: initial therapy is the key. 140 83

Four assessment instruments--a 10-item cervical pain questionnaire, a 10-item TMJ pain questionnaire, the Cervical Range of Motion (CROM) instrument, and the Craniomandibular Index--were used to evaluate 25 consecutive patients presenting to a physical therapy clinic for evaluation and treatment of cervical hyperextension-hyperflexion injuries. The assessment tools were tested for internal consistency between the cervical and stomatognathic measures as well as between the two sets of measures. The cervical questionnaire was strongly correlated to the CROM measurements. Tenderness to palpation of the superficial neck muscles was not correlated to the cervical questionnaire nor to measures of cervical flexion-extension or lateral flexion. It was, however, correlated to cervical rotation. The TMJ questionnaire was a useful predictor of muscular tenderness and self-reported symptoms in the stomatognathic system, but it was not related to the intra-articular signs of TMD. The flexion-extension and rotation measures of cervical mobility were useful predictors of masticatory muscle tenderness. These assessment tools are valid indicators of cervical or stomatognathic status and, when used together, provide a comprehensive description of jaw and neck status.
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PMID:The validity and predictive value of four assessment instruments for evaluation of the cervical and stomatognathic systems. 181 65

Over the last 75 years, a variety of etiologic factors has been suggested as the cause of pain and dysfunction in the temporomandibular system. The earliest and still-popular etiologic theory proposed that temporomandibular disorders are induced by abnormal structure, usually described as a malocclusion of the teeth or jaws. The fact that this theory was based on mechanical concepts, ignored biologic diversity, and had limited factual experimental evidence to support it as well as extensive evidence in opposition did not seem to matter to its proponents. In the late 1960's and early 1970's, the structural occlusal model for TM Disorders was challenged and has yielded ground to a more multifactorial model of TMD causation. Other etiologic factors for TM disorders--such as anatomical susceptibility of TM tissues to trauma, polyarthritic diseases, joint laxity, repetitive parafunctional behaviors, and stress-related muscle dysfunction--need to be recognized and quantified. Unfortunately, many practicing dentists demonstrate a very poor understanding of and often fail to recognize these etiologic factors as agents that produce TM disorders. This failure is largely due to the fact that the dental profession has spent the last 90 years dealing with a variety of misconceptions about the etiology of temporomandibular disorders. In the 1990's, one of the more formidable challenges we face is acquiring the ability to segregate and define validly the specific TM Disorder of concern and then correctly identify and measure the specific etiologic factors that produce it. Until these problems are solved, it is unlikely that we will be able to prevent disease of the TM apparatus.
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PMID:Etiologic theory and the prevention of temporomandibular disorders. 181 85

It is important for the dentist to differentiate between subclinical and clinically significant symptoms of TMD. The TMJ Scale tests for clinical significance of pain report, palpation pain, perceived malocclusion, joint dysfunction, and range of motion limitation. To evaluate the accuracy of test results in a patient, the predictive values for each scale must be known. The positive and negative predictive values are calculated and found to produce an increase in diagnostic accuracy of the TMJ Scale compared to pre-test predictions throughout most of the base rate range found in clinical practice. The use of predictive values to interpret test results correctly and to confirm or rule out clinically significant symptoms is described.
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PMID:Predictive value of the TMJ scale in detecting clinically significant symptoms of temporomandibular disorders. 209 93

A stress-muscle hyperactivity-pain (SMP) model has been proposed to explain the etiology of certain musculoskeletal pain disorders. According to this model, subjects should show physiological arousal during periods of stress relative to periods of rest. In a test of this prediction, 31 subjects performed a reaction time task that has been used in previous laboratory studies. Multiple psychophysiological variables were monitored during initial and final 10-minute baselines, during performance on nine 2-minute reaction time tasks, and during 36-second rest intervals following each of the 2-minute tasks, Results showed small but statistically significant differences generally supporting the SMP model when masseter EMG was averaged over time periods of 12 seconds to 2 minutes, but not when masseter EMG was averaged over 10- to 18-minute blocks. These results demonstrated the importance of carefully selecting time intervals for analysis. Additional analyses that compared TMD with symptom-free subjects revealed small differences in EMG that supported the SMP model. Analyses of EMG over shorter time intervals also showed, however, that masseter EMG increased during the 36-second rest interval following performance on a 2-minute stress task; this result suggested that a modification of the SMP model may be necessary.
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PMID:Psychophysiological responsivity on a laboratory stress task: methodological implications for a stress-muscle hyperactivity pain model. 240 Jul 93

A total of 2033 university students (1161 boys, 872 girls, ages ranged from 17 to 32 years) were examined according to an examination form. Pain and functional disorders of the head and neck muscles and TM joints, as well as the dental occlusal conditions were recorded. Questionnaires relating to personal history, oral habits, experience of pain and disorder, and psychoemotional status were also given and replied. It was found that 42.9% of the students had one or more signs of TMD, and girls suffered slightly more often. The prevalence was not as high as in junior college students, and was about the same as in teenagers reported in the previous two years. Occlusal factors like slide in centric, balancing side contact, dental restoration and molar guidance during protrusion were more often found in the TMD group, while missing teeth, incisal overlap, attrition and cross bite were not. About 34% of the students had a previous experience of TM joint pain and/or clicking while only 20% of them had such symptoms during the examination. More than 60% of the students having joint clicking were not aware of this symptom. The oral habit and bruxism were not found to be more often in the TMD group. Emotional factors such as Type A personality, emotion, stress, anger, etc. had a higher score in the TMD group while tension, anxiety, and competition did not. It could be concluded that TMD is a fairly common syndrome in the youth of Taiwan although not serious or treatment demanded. Psychoemotional factors are as important as dental factors in relation to the TMD symptomatology, if not more important.
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PMID:[Prevalence of temporomandibular disorder syndrome (TMD) in university students--a third year report of the epidemiological study in Taiwan]. 248 92

This is a descriptive study to establish the profile of 120 consecutive patients seeking relief from symptoms and dysfunction of the masticatory system at the Dental Clinic, Singapore General Hospital from February 1988-September 1988. The mean age of the patients was 29.4 years and females outnumber males by 2:1. The patients complained of TMJ clicking (66%), TMJ pain (55%), painful chewing (47%), headaches (42%), painful opening (37%), jaw locking (33%), and jaw muscle pain (23%). The possible etiological factors were recorded: macrotrauma (27%), stressful episodes (24%), unilateral mastication (53%), clenching (28%), grinding (26%) and excessive chewing habits (10%). Unilateral chewing was significantly associated with pain on opening (p less than 0.05) and joint pain (p less than 0.05). A statistical relationship was found between night grinding and laterotrusive wear of teeth (p less than 0.001). There was evidence that tension headache reported by TMD sufferers was related to temporalis muscle/tendon dysfunction (p less than 0.001).
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PMID:A profile of patients with temporomandibular disorders in Singapore--a descriptive study. 262 16

Most population-based studies of TM disorders report a discrepancy between the frequency of symptoms and the frequency of signs of functional disturbances of the temporomandibular joint. In addition, studies have reported varying relationships between subjectively perceived symptoms and signs found on clinical examination. This study examines this relationship in 148 Canadian adults who were part of a larger sample of 677 subjects who completed a telephone administered symptom questionnaire. Symptoms were reported by 63.5% and signs were found in 88.1%. While a degree of discordance was observed, there was a close and statistically significant association between symptoms and signs. This was the case whether summary variables or individual symptoms and signs were used as the dependent variable and whether proportions with or absolute numbers of symptoms and signs were examined. The validity of the symptom questionnaire was examined in order to assess its ability to identify "cases" of TMD. Validity tests showed a sensitivity of 81.4% and a specificity of 48.3%. When "false" positives and "true" positives were compared, the former were found to be significantly less likely to report pain.
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PMID:Association of symptoms and signs of TM disorders in an adult population. 273 96

Ten female subjects with no history of temporomandibular disorders performed five exercises designed to induce masticatory muscle pain. Three of the exercises were replications of Christensen's tooth-clenching (1970) and tooth-grinding (1971) studies and Scott and Lundeen's mandibular protrusion (1980) study. The other two exercises were designed to induce specific unilateral masticatory muscle pain. The amount of muscle pain as well as the time of onset and the duration were assessed by a clinical palpation exam and a pain questionnaire. These five pain-inducing methods did not consistently produce masticatory muscle pain in non-pain subjects. However, certain individuals appeared to be very susceptible to developing pain during or after most of the exercises. These susceptible individuals demonstrated a bilateral muscle pain pattern after the unilaterally stressful exercises. None of the five exercises produced a statistically significant amount of site-specific masticatory muscle pain as determined by either the palpation examination or the pain questionnaire, even when the exercise was intended to produce such specificity. The fact that some subjects did develop masticatory muscle pain is indicative that muscle exercise and fatigue may lead to TMD-like symptoms.
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PMID:Experimental masticatory muscle pain. 347 76

A review of the current literature regarding the interaction of morphologic and functional occlusal factors relative to TMD indicates that there is a relatively low association of occlusal factors in characterizing TMD. Skeletal anterior open bite, overjets greater than 6 to 7 mm, retruded cuspal position/intercuspal position slides greater than 4 mm, unilateral lingual crossbite, and five or more missing posterior teeth are the five occlusal features that have been associated with specific diagnostic groups of TMD conditions. The first three factors often are associated with TMJ arthropathies and may be the result of osseous or ligamentous changes within the temporomandibular articulation. With regard to the relationship of orthodontic treatment to TMD, the current literature indicates that orthodontic treatment performed during adolescence generally does not increase or decrease the odds of developing TMD later in life. There is no elevated risk of TMD associated with any particular type of orthodontic mechanics or with extraction protocols. Although a stable occlusion is a reasonable orthodontic treatment goal, not achieving a specific gnathologically ideal occlusion does not result in TMD signs and symptoms. Thus, according to the existing literature, the relationship of TMD to occlusion and orthodontic treatment is minor. Signs and symptoms of TMD occur in healthy individuals and increase with age, particularly during adolescence; thus, TM disorders that originate during various types of dental treatment may not be related to the treatment but may be a naturally occurring phenomenon.
J Orofac Pain 1995
PMID:Occlusion, Orthodontic treatment, and temporomandibular disorders: a review. 758 Dec 9


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