Yes, Mrs. Smith, you do. You have two of them and they are both lovely.” How many times have you wanted to say that to a patient who comes in with that comment? This is the same as going to our orthopedic surgeon and being told that we have “Knee.” The TM joint is a vital joint of our body that is necessary for proper mastication, speech and function of the craniomandibular/stomatognathic system. TMJ is not a disease but TMD (Temporomandibular Joint Dysfunction) or Craniomandibular Dysfunction or Orofacial pain can be classified as diseases. Dentists may give a single diagnosis of “TMJ” to keep it simple for the patient. Or, this may reflect the provider’s idea that TMD is a singular, one-dimensional disorder concerning only the joint. TMD pain is a term that embraces a number of clinical problems that involve the masticatory musculature, the nervous system, the skeletal structures, the TMJ and other associated structures.
When a patient presents with pain that they attribute to the TM joint, many of us shudder at the thought of dealing with these patients. If that same patient presented with an acute toothache, we have no problem with isolating the area of concern, treating it successfully and having a happy, healthy patient. This is because we have a good understanding of the mechanisms that cause these disorders. Pain in the mouth is very common and, in fact, is one of the main reasons for patients seeking dental care. Numerous studies report that persistent and chronic pain is more prevalent in the head and neck region than in any other part of the body. Furthermore, 22 percent of the general population experiences orofacial pain in any given six-month period. It is generally accepted that pain that persists for longer than six months is considered chronic. More than 15 percent of Americans suffer from facial pain that is chronic. Suddenly our ability to manage this pain is more difficult. Perhaps we can no longer identify the originating source of the pain and now we are dealing with referred pain. Because of our frustration with these patients, we tell them, “It’s all in your head,” (really, it is, isn’t it?).
There is generalized confusion in our profession today about TMD–it’s treatment and management. There are numerous “camps” out there; the Neuromuscular group, the CR group, the occlusion group, the pharmacological management group, to mention a few. Can they all be right? Can they all be wrong? Is the correct treatment a combination of all the “camps”? The key to successful treatment and management of these patients is diagnosis. Hippocrates stated, “Without diagnosis there can be no treatment”. Therapy has focused on the mechanical aspects ignoring the physiological and psychological. Dentistry must broaden its diagnostic and therapeutic vision. The treatment should be based on the specific needs of the individual patient rather than on a preconceived belief system. Treatment can take on many forms with many options, unfortunately many of these options lack strong scientific or evidence basis. Morton Amsterdam once said, “There may be different ways to cure a disease, but only one correct diagnosis”. When we evaluate these patients we have a moral and ethical obligation to be fair and to give objective information to the patient free from prejudice about a particular theory. We must review the full range of options for a condition. This further implies that if we do not know what to do, then we must refer to the appropriate specialist, medical or dental. Sometimes these patients know what they want i.e. orthodontics, veneers, implants, crowns, surgery as a solution to their problems. If we know that this is not the correct treatment for their diagnosis, we should walk away. We know that patients will visit numerous clinicians in order to find the treatment option that best suits them.
In this issue of Oral Health we have tried to cover as much as possible with respect to the diagnosis of TMD. Articles will cover the imaging of the joint and the use of electro-diagnostics as a tool to have an objective measurement of the status of the joint pre and post treatment. The discussion of joint position in treatment will be reviewed. There are numerous diseases that can mimic TMD pain and two cases will be reviewed. The surgical management of severe TM joint degeneration will also be reviewed. Many times the question arises what to do after appliance therapy. Ideas on the post-orthotic management of TMD cases will also be covered.
As we head down the unmarked road of dentistry/TMD we meet the Cheshire Cat (with apologies to Alice in Wonderland). We ask, “Which is the best road to take?” The Cat replies, “Where do you want to go?” Most dentists say, “We have no idea!” And of course the Cat says, “Then I suggest that you take the road to someplace else.” Hopefully after reading this issue you will have a better idea of which road to take, so that when your patient says “Doctor, I have TMJ…” you will know where to go.
Dr. Marangos is a graduate of the University of Toronto, Faculty of Dentistry, 1986. He maintains a private practice in Toronto with emphasis on aesthetic and restorative dentistry and orthodontics. He is the principal doctor at the Yorkville TMJ Centre, a practice that focuses on the management of head, neck and TMJ related pain. Dr. Marangos is a contributing consultant to Oral Health.
