Manual of Temporomandibular Disorders

Edward F. Wright

• Publisher: Wiley-Blackwell
• Year: 2013
• ISBN:
  9781118816820
• Edition: 3
• Topic: Medicina
• Subtopic: Odontotecnica

Manual of Temporomandibular Disorders, Third Edition, provides comprehensive, evidence-based information on temporomandibular disorders (TMD). Focusing on clinically relevant information throughout, the book allows dentists to diagnose TMD accurately, rule out disorders that mimic TMD, and provide effective therapy for most patients. Useful features, such as frequently asked questions, quick consults, technical tips, and focal points are integrated to help the clinician find precise answers with ease. Case scenarios provide the reader with a way to enhance their clinical reasoning skills, with a focus on solving TMD problems at chairside. Offering comprehensive coverage in a highly-illustrated, compact package, Manual of Temporomandibular Disorders is the ideal source for dentists dealing patients suffering from TMD.

Part I

Initial Evaluation

Temporomandibular disorder (TMD) generally involves many structures with varying degrees of intensity. During the initial evaluation, the involved structures need to be identified and the degree for which each contributes to the patient's symptoms need to be categorized. Additionally, the contributing factors and symptom patterns help to identify which therapies will be the most beneficial for each patient.¹

Hence, the goals of the initial examination are to identify a patient's primary diagnosis; secondary, tertiary, and so on, diagnoses; contributing factors; and symptom patterns.

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Focal Point

The goals of the initial examination are to identify a patient's primary diagnosis; secondary, tertiary, and so on, diagnoses; contributing factors; and symptom patterns.

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The primary diagnosis is the diagnosis for the disorder most responsible for a patient's chief complaint. This diagnosis can be of TMD origin (e.g., myalgia, TMJ arthralgia, or temporomandibular joint [TMJ] disc displacement without reduction with limited opening) or from a different source (e.g., pulpal pathosis, sinusitis, or cervicogenic headache).²

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Focal Point

The primary diagnosis is the diagnosis for the disorder most responsible for a patient's chief complaint.

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Secondary diagnosis, tertiary diagnosis, and so on, are other TMD diagnoses that generally contribute to the TMD symptoms. Typically, the primary diagnosis will be of TMD origin (e.g., myalgia), and the secondary and tertiary diagnoses will be other TMD diagnoses (e.g., TMJ arthralgia and TMJ disc displacement with reduction) that contribute to a patient's chief complaint. When a non-TMD (e.g., fibromyalgia) contributes to a TMD primary diagnosis, the non-TMD disorder is designated as a contributing factor to the TMD diagnosis and not as secondary or tertiary diagnosis.²

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Focal Point

Secondary, tertiary, and so on, diagnoses are additional TMD diagnoses that contribute to the TMD symptoms.

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During the initial exam, we also attempt to identify the perpetuating contributing factors. These are elements that perpetuate the disorder (not allowing it to resolve), for example, nighttime parafunctional habits, gum chewing, daytime clenching, stress, or neck pain.^1–3 Additionally, we attempt to identify the symptom patterns that include the period of the day in which the symptoms occur or are most intense (e.g., worse upon awaking) and the location pattern (e.g., begins in the neck and then moves to the jaw).

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Focal Point

Perpetuating contributing factors are elements that are not allowing the disorder to resolve, for example, nighttime parafunctional habits, gum chewing, daytime clenching, stress, or poor posture.

Symptom patterns include the period of the day in which the symptoms occur or are most intense (e.g., worse upon awaking) and the location pattern (e.g., begins in the neck and then moves to the jaw).

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The following non-TMD examples may help you better understand how these terms are used. A patient complains to her physician about wrist pain. Through palpation of her wrist area, her physician determines the primary cause for her pain is the tenderness within the wrist joint (its diagnosis would be the primary diagnosis). Her physician also finds the muscles around the wrist are painful but less tender than the wrist joint (the muscle diagnosis would be the secondary diagnosis). The physician also knows the patient has a systemic arthritic condition, which he suspects makes her more susceptible to developing the wrist pain (a contributing factor).

By asking questions, the physician finds that this pain only occurs upon awakening and lasts half an hour; this suggests nocturnal wrist activity is the major contributing factor. Her physician may decide the best initial therapy is to prescribe her a wrist splint to wear at night to ensure the wrist stays in a neutral position during sleep.

In a second example, the patient has the identical diagnoses and systemic arthritic condition, but has a different symptom pattern. In this example, the wrist pain consistently begins approximately half an hour after she starts using the computer and continues as long as she uses the computer, suggesting computer use is the major contributing factor for her wrist pain.

To treat the wrist pain, her physician decides the best initial approach is to (1) refer her to a therapist to teach her about computer keyboard and mouse ergonomics, and (2) prescribe her a nonsteroidal anti-inflammatory drug (NSAID) short term, to provide her with temporary relief until her wrist responds to the computer keyboard and mouse ergonomic instructions. In both situations, the physician decides to not escalate therapy for the systemic arthritic condition because he believes the local therapies will resolve the pain complaint.

In spite of having the identical diagnoses and systemic contributor, the preferred therapy changed with different contributing factors.

The initial TMD evaluation involves interviewing the patient about his or her symptoms, potential contributing factors, and potential non-TMD. The interview most influences the patient's final treatment approach and generally brings to light concerns that the practitioner will need to evaluate during the clinical examination.

The clinical examination will help to confirm or rule out the structures involved in the patient's complaints and other suspected disorders that may contribute to these complaints. Imaging may be appropriate, but, in my experience, it rarely changes the treatment approach derived from the patient interview and examination.

In the late 1980s when I was in the U.S. Air Force, an experience demonstrated that patients with TMD symptoms needed a more thorough evaluation for potential non-TMD than what most dentists provided. A physician asked if I knew that one of the dentists who worked for me had diagnosed someone with TMD when the patient actually had meningitis. After reviewing the patient's dental record, I found she had been referred by the emergency room physician for possible TMD. The patient told the dentist she had been previously diagnosed with TMD, had an occlusal appliance, and believed she was having a relapse of this disorder. The dentist palpated her masticatory muscles and TMJs and found the muscles were tight and tender to palpation. The dentist confirmed for the patient that she had TMD, gave her TMD self-management instructions, and told her she should see her civilian dentist to have her appliance adjusted (as she was not an active-duty military patient). At the time, it appeared to me the dentist performed an appropriate evaluation and drew a fitting conclusion.

The emergency room record was then reviewed to obtain a better perspective of what had transpired. It was documented that the patient also told the emergency room physician that she had previously been diagnosed with TMD, had an occlusal appliance, and believed she was having a relapse of this disorder. The physician found she had firm masticatory and cervical muscles and a fever, and referred her to the dentist for a TMD evaluation and to a neurologist. When the patient saw the neurologist, he did a spinal tap and found she had meningitis.

This disheartening experience inspired me to research everything I could concerning disorders that mimic TMD. Lists were made of how their symptoms differed from TMD and a fairly brief list of questions was finally formulated that dentists can use to warn themselves that a patient may have a non-TMD condition that is mimicking TMD.⁴ This questionnaire has been used ever since and modified as new information became available.^5,6 This questionnaire is certainly not foolproof, but it is the best I can formulate to alert me of potential non-TMD disorders, contributing factors, and symptom patterns.

References

1. American Academy of Orofacial Pain. Diagnosis and management of TMDs. In: de Leeuw R, Klasser GD (eds.). Orofacial Pain: Guidelines for Assessment, Diagnosis and Management. 5th ed. Chicago: Quintessence Publishing Co, 2013:131, 151.

2. Fricton J. Myogenous temporomandibular disorders: diagnostic and management considerations. Dent Clin North Am 2...

Table of contents

• Cover
• Title page
• Copyright page
• Dedication
• Preface
• Introduction
• Part I: Initial Evaluation
• Part II: Common Acute TMD Conditions and Treatments
• Part III: Occlusal Appliance Therapy
• Part IV: Multidisciplinary Treatment Approach
• Part V: Case Scenarios
• Part VI: Fundamentals of Clinical Studies
• Appendices
• Glossary
• Index