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Aug 16
​​What's that clicking sound?

Considerations for management of TMD

Some recent complaint investigations have reinforced the need for careful evaluation of the temporomandibular joint (TMJ) complex.

​Cases

​A male patient presented for a specific exam with an acutely painful non-restorable tooth. To provide immediate resolution of the patient’s pain, the dentist extracted the tooth during the same appointment. The patient complained when he developed symptoms of temporomandibular disorder (TMD) following the procedure. Unfortunately, because there had been no pre-op assessment of the muscles or joints it was impossible to determine if there was a pre-existing condition, and if so, the nature of the pre-existing pathology.

​Another patient complained when she developed symptoms following extensive prosthodontic treatment provided during a four-hour appointment. This raised the question of whether it was an acute exacerbation of a chronic condition or an acute episode resulting from new or undiagnosed pathology.

​A number of other complaints have also reported exacerbation of existing symptoms following treatment with orthotic appliances. Upon review, these cases raised the following questions:

• What was the differential diagnosis?
• Was an orthotic actually indicated for this patient?
• What factors were considered before deciding on the type of orthotic?
• What follow-up care was planned and provided?
• What other treatments were considered as alternatives or as adjunctive therapy?

​In one very sobering case, a 24-year-old patient presented with severe left-sided jaw pain, associated trismus and a palpable lump in the area of her left masseter muscle. The prescribed panoramic radiograph did not include the left TMJ and a portion of the left ramus and body of the mandible in the field of view. The radiograph was not repeated. The patient was treated with an orthotic to address her joint symptoms and reassessed over the following few months.

A second opinion determined that the appearance of a large irregular radiolucency in the ramus of her mandible and the palpable lump were signs and symptoms of an osteogenic sarcoma, misdiagnosed as TMD. In this case treatment with an orthotic was contraindicated and immediate referral for management of her suspected and potentially life-threatening tumour was indicated.


Lessons

These cases serve as reminders for all of us as practitioners that any examination needs to be comprehensive, followed by development of a differential diagnosis and a treatment plan based on solid clinical and radiographic findings.

  • Always consider evidence-based conservative treatment first
  • An orthotic is not a panacea
  • Consider that chronic pain management is often indicated
  • Always carefully consider a differential diagnosis


Pre-treatment assessment

While all practitioners know that any treatment may exacerbate symptoms, it is difficult to defend the diagnosis and the subsequent treatment provided when there is an inadequate or non-existent pre-treatment assessment.

Dentists are expected to provide a pre-treatment comprehensive TMJ and muscle assessment and document any pre-existing condition. Not only does it provide the best opportunity for an accurate diagnosis and treatment plan, it also ensures optimum care will be provided. This approach protects both the patient and the practitioner.

A TMJ and muscle assessment should be a part of any routine new patient examination, before any treatment is provided, and has particular significance for surgical extractions, long appointments and orthotic (splint) therapy. If a patient experiences an acute episode of TMD without being presented with the facts before treatment, it becomes difficult to explain, defend or establish that there was a pre-existing condition. The patient will often conclude that the dentist is at fault.

An appropriate initial examination or pre-operative assessment includes:

  • A review of the past medical and dental history, including a discussion regarding parafunction, namely clenching, bruxing, tongue thrusting, nail biting, pain associated with the TMJs, joint sounds or episodes of locking and/or pain associated with the muscles of the jaw, head and neck.
    • If the record clearly documents the specific details of a pre-existing musculoskeletal condition, such as TMD, it can help to explain the significance or progression of any changes that may occur following treatment.
  • Palpation of the TMJs – pain should be rated and recorded as mild, moderate or severe.
  • Palpation of all the muscles of mastication (e.g. masseter and temporalis muscles) – pain should be rated and recorded as above.
  • Assessment of TMJ sounds – e.g. clicking, popping, crepitation, which may be noted as fine or coarse.
  • Maximum range of motion – measured from the maxillary to the mandibular incisal edge, most accurately with a millimeter ruler. Note if this is with or without associated joint sounds.
  • Opening pattern – e.g. straight, deflections to left or right, corrected deviation to left or right.
  • Lateral excursions – with or without associated joint sounds and/or limitation of movement.

An incorrect diagnosis, resulting in the wrong treatment being prescribed, may cause significant and irreversible harm to the patient. Patients cannot provide full and informed consent without a discussion of the benefits as well as the risks of any treatment. The corollary of this statement is that a dentist has a much weaker defense in the absence of this information.

Remember, in the patient’s mind: before treatment any discussion is an explanation, following treatment it is an excuse.

A note about orthotics: When it is determined an orthotic is the optimum treatment option, appropriate follow-up appointment(s) are a critical component of the treatment. Confirming the adequacy of the working impression for fabrication of the orthotic and follow-up adjustments of intraoral orthotics are the responsibility of the dentist alone. They may not be delegated to your staff, CDAs or dental hygienists.

Inform the patient

When the record clearly documents the specific details of a pre-existing musculoskeletal condition, such as TMD, it can help to explain the significance or progression of any changes that may occur following treatment.

It is important to advise the patient of any pre-existing degenerative or pathological changes diagnosed during the pre-treatment clinical examination and any risks of the proposed treatment. Without this information the patient cannot provide legitimate informed consent to proceed with the recommended treatment. 

When significant joint pathology is identified, consider the wisdom of a referral, before providing any treatment.

From the desk of Dr. Meredith Moores (mmoores@cdsbc.org)