September 1, 2005
by Oral Health
Dr. Marangos’ introductory remarks note the history of controversy in the diagnosis and treatment of temporomandibular disorders. Having lived through it I can confirm that he is correct. When I began treating patients with TMD in the 1970s, there were no textbooks on the subject. The only way to achieve insight into the condition was to sit at the feet of the gurus. I traveled to the centres of influence, which at that time, were in New York, Florida, California and Washington and when I completed that cycle I was totally confused. They all presented their cases with evangelical conviction, based only upon their own empirical evidence, and generally there approaches were all different. However, because of the research that has been done over the last decade, or so, and the decision to employ only evidence based treatments the controversies have diminished, but have not disappeared.
In an effort to eliminate that controversy, in 1995 the Royal College of Dental Surgeons of Ontario (RCDSO) established “practice parameters and standards” (evidence based–my words) for the diagnosis and management of temporomandibular disorders. The College made clear that they “should be considered by all Ontario dentists in the care of their patients.” because “these guidelines may be used in determining whether appropriate standards of practice and professional responsibilities have been maintained.” Clearly, not complying with these standards could leave the dentist exposed to sanction by the College and/or legal proceedings by the patient.
Dr. Rondeau’s diagnostic and treatment protocols discussed in his article, do not comply with those of the RCDSO. He states that if a patient has an internal derangement, (in the TM joint) repositioning and functional appliances, to advance the mandible and capture the anteriorly displaced disc, are the treatments of choice. However, Pulinger1 found that while disc displacements are usually associated with a posterior condylar position, as many as 20% were found to be concentric and 9% anteriorly positioned. Therefore mandibular advancement can’t be right for everyone. This treatment paradigm flies in the face of the RCDSO guidelines and I quote; “the decision to treat should be based on a detailed history, a careful clinical examination and centered on conservative, reversible therapies. Anterior repositioning appliances could be used in rare cases with subsequent stepping back or weaning the patient off their use.”
Dr. Rondeau goes on to say that the resultant open bite, created by the treatment, will be closed orthodontically, restoratively or prosthetically. In my youth I attempted several mandibular advancing treatments, which provided symptom relief for the patient, but the mandibular position was unstable. I was reluctant to do a full mouth rehabilitation, on sound teeth and at great cost and discomfort for the patient, and opted for an orthodontic solution instead. However, much to my surprise, I could not find one orthodontist in Toronto, or the surrounding area, who was willing to take on the case. On that subject the RCDSO paper says, “Permanent anterior repositioning of the mandible with orthodontics or fixed/removable prosthodontics is not validated by well-controlled, well designed scientific research.” It goes on to say that, “Irreversible procedures should only be considered after attempts at treatment with more conservative measures have failed, and only if the severity and/or persistence of the patient’s symptoms warrants it.”
Dr. Rondeau talks about the work of Woodside and McNamarra, whose treatment for Class II skeletal patients with an under developed mandible, was to develop the maxillary arch to a normal size and then reposition the mandible to it’s correct forward position From those works began to see a definite correlation between orthodontics and TMD and he began to practice the “functional philosophy”. From what I recall about the work of Woodside and McNamara, it was designed to harness the growth potential of children and adolescents in order to develop a normal facial anatomy. Because growth was a major factor for the desired outcome it was not attempted in mature adults.
I do not understand what he means when he says that he could see a definite correlation between orthodontics and TMD . Studies have shown that orthodontic treatment, with or without extractions, does not cause TMD. Or is he associating malocclusion with TMD? Shiffman and Fricton2 stated that, “no causal relationship is yet to be established between occlusion and crainiomandibular disorders.” Others have shown that “85% of the population has non physiologic occlusions” (malocclusions) and the greatest majority of them do not have TMD. According to Okeson3 the most common malocclusion associated with TMD is Skeletal Class II, deep bites, where the condyle is more posteriorly positioned in the fossa than normal, yet all patients with those Class II malocclusions do not present with disc derangement disorders. Some studies show no relationship between Class II malocclusions and these disorders. Still others show no association between the horizontal and vertical relationship of the anterior teeth and disc derangement disorders.” Therefore, based upon the evidence it is difficult to see any definite correlation between orthodontics and TMD.
In this article a variety of diagnostic instruments were used i.e. the Joint Vibrating Analysis unit; the Pharyngometer; the Rhinometer; the Boipak Measuring System. The RSDSO addresses the subject of esoteric diagnostic tools. In it’s position paper, it says that, “the clinical value of a number of diagnostic aids currently in use has not been demonstrated in well-controlled and scientifically based studies. These include jaw tracking devices, EMG recording and sonography (joint sounds). These aids may have some use for research purposes but may not necessarily facilitate diagnosis or patient treatment.”
I also take exception to the comment that the anterior deprogrammer eliminates the habits of clenching and grinding because”if the back teeth don’t touch the masseter and temporalis muscles are unable to contract excessively.” While it’s true that the force of the mandibular elevators is reduced with the anterior deprogrammer in place, it has only a minor effect on bruxism because bruxism does not have a dental etiology. Although the exact etiology of bruxism isn’t completely understood, it has been accepted that stimulation of the limbic system, whether by physical or psychological stressors, predisposes a person to developing bruxism. Studies have even shown neuronal connections between the limbic system and the trigeminal motor nucleus, which controls the function of the muscles of mastication. With nocturnal bruxism there are also alterations in sleep cycle architecture, which either contributes to or results from bruxism. While the cause of bruxism is not dental, the effects, (i.e. tooth wear, muscle pain and intraarticular disorders of the TM joints) are seen in the stomathognathic system.
Dentists in Ontario would be wise to follow the diagnostic and treatment recommendations of the RCDSO, which are also widely accepted in the dental community. They include the use of stabilization occlusal appliances that do not forcefully alter the mandibular rest position or permanently alter the occlusion; involvement of physiotherapists and psychologist when needed, appropriate medications that you can prescribe or those that must be prescribed by a physician, the use of trigger point injections when necessary and patient education.
Dr. Barry M. Laibovitz, D.D.S. North York, ON
1.Book: Perspectives in Temporomandibular Disorders; Clark G.T.; Solberg W.K It’s .Quintessence Publishing 1987; Chapter 6; pg 89-103.
2.Chapter: Epidemiology of TMJ and Craniofacial Pain: Schiffman E.; Fricton J. R. TMJ and Craniofacial Pain: Diagnosis and Management Fricton J R. DDS., MS.; Kroening M.D., PhD.;Hathaway, PhD.
3.Book; Management of Temporomandibular Disorders and Occlusion Jeffery
P. Okeson Third Edition Moseby year book 1993 pg. 205.
Re: How to Stabilize the TMJ Prior to Treatment, Oral Health, June, 2005
The executive of the Ontario Society of Oral and Maxillofacial Surgeons (OSOMS) felt it was essential to voice our concern with respect to the above article that appeared in the June 2005 issue of Oral Health.
As a specialist group that is often asked to assess and treat this varied group of patients we feel that this article presented a unidimensional approach to the management of a multifaceted problem like TMD.
Many of our specialty will recall clearly the concept that developed in the late 1970s and gathered tremendous momentum through the 1980s of surgically managing the displaced disk in an almost proactive or preventive fashion. With our enthusiasm came the eventual realization that much of this treatment did not stand up to the test of time. Much of our specialty’s literature today has in fact lead to the opposite “less is more” approach to the management of the TMD patient. Most of the perceived experts in our specialty strongly advocate that with few exceptions, the TMD patient deserves every opportunity to receive the full scope of “reversible” treatment modalities before moving on to the “irreversible” approaches.
We would encourage all readers to compare the stance presented in this article with the Guidelines for the Diagnosis and Management of Temporomandibular Disorders (initially published by the Royal College of Dental Surgeons of Ontario, and presently being updated).
Other excellent references could include the AAOMS Parameters of Care, the CAOMS position paper on the management of TMD, and the Research Diagnostic Criteria for TMD (RDCTMD).
Also, we can speak as a specialty with substantial experience, both positive and negative, in this area of patient management when we say that there is no cookbook treatment for these patients. Careful, thorough diagnosis followed by an individualized treatment plan for each patient will avert frustration for both patients and practitioners.
G.M. Cousens, DMD, FRCD(C) President, OSOMS
Dr. Rondeau’s article is worrisome in its one-dimensional explanation of TMJ intra-articular pathology and the recommendation of jaw advancement with occlusal revamping (Phase I and II therapy) as the correct recommended treatment modality. The author’s interpretation of the scientific literature as support for this recommendation is open to debate.
TMJ Disorders are a group of neuromuscular and intra-articular disorders currently described as “biopsychosocial” in nature. The author theorizes that compression of the neurovascular structures of the retrodiscal tissues are the cause of pain in TMJ IJD. This is a purely mechanistic theory. These disorders however are not purely structural phenomena. There are several current theories that describe the pathophysiology of these disorders at the biomolecular level. The common pathway for them all is compressive loading (micro-trauma or macro- trauma) with a resultant veritable biomolecular pot pouri of inflammatory mediators, pain mediators and degradative enzymes (Milam, Dijkgraaf and deBont are excellent authors on this subject).1 A goal in TMD therapy is therefore the control of compressive loading of the intra-articular surfaces, and the ultimate enhancement of biological adaptive changes.
Nitzan has demonstrated, with the use of intra-articular pressure measurement, that flat plane occlusal appliances can reduce articular surface load. This may help to explain why flat plane occlusal splints can be helpful in managing these cases.7
“Long-term outcomes of repositioning splint therapy are not as promising as once theorized. Studies have shown that the recapturing of a disk by use of a splint does not guarantee its correct position permanently, except in a very small percentage of patients. In other studies, the actual recapturing event is questioned.”2-6
Sollecito perhaps best summarizes the current thinking on this topic:
“At this time the literature is quite inconclusive in guiding the clinician as to which splint to use. If an anterior repositioning appliance or a functional splint is utilized, it is important to do frequent monitoring and frequent reevaluation to assess occlusal changes. This is absolutely required. If a patient is noncompliant or has a history of being lax in follow-up treatments, than an anterior repositioning appliance should not be considered. The majority of intracapsular disorders, including anteriorly displaced disk with reduction and without reduction, can be effectively treated with stabilization splints and other modalities. There are many articles to suggest that a flat stabilization splint reduces the symptoms of pain associated with those disorders. Because the nature of temporomandibular joint internal derangements and osteoarthrosis is nonprogressive in a majority of cases there is no true rationale for disk repositioning procedures via splint therapy. This makes the use of anterior reposition appliances (which only in minority of the cases reposition the disk) very limited in the way it should be prescribed.”2
This consensus is also reflected in the Guidelines for the Diagnosis and Management of Temporomandibular Disorders (initially published by the Royal College of Dental Surgeons of Ontario in 1995 and currently being updated).8
David J. Psutka DDS, FRCD(C) Mississauga, ON Consultant Surgeon TMJ Reconstructive Surgery Program, Mt. Sinai Hospital The University of Toronto Faculty of Dentistry Oral and Maxillofacial Surgery
1.Milam SB: Pathophysiology of Articular Disk Displacements of the Temporomandibular Joint. In Fonseca, Oral and Maxillofacial Surgery. Temporomandibular Disorders. Bays and Quinn. Philadelphia, Pennsylvania. W. B. Saunders. 2000.
2.Sollecito Thomas: Pathophysiology of Articular Disk Displacements of the Temporomandibular Joint. In Fonseca, Oral and Maxillofacial Surgery. Temporomandibular Disorders. Bays and Quinn. Philadelphia, Pennsylvania. W. B. Saunders. 2000.
3.Zamburlini I, Austin D: Long-term results of appliance therapy using anterior disk displacement with reduction: A review of the literature. Cranio 1991;9(4): 361 – 368
4.LeBell Y, Kirvesdari P: Treatment of reciprocal clicking of the temoromandibular joint with a repositioning appliance and occlusal adjustment: Results after four and six years. Proc Finn Dent Soc 1990; 86(1): 15 – 21
5.Kirk WS Jr: Magnetic resonance imaging on tomographic evaluation of occlusal appliance treatment of advanced internal derangement of the temporomandibular joint. J Oral Maxillofac Surg 1991: 49 (1):9 – 12
6.Chen CW, Boulton J, Gage JP: Splint therapy in temporomandibular joint dysfunction: A study using magnetic resonance imaging. Aust Dent J 1995;40(2): 71 – 78.
7.Nitzam DW: Intraarticular pressure in the functioning human temporomandibular joint and its alteration by uniform elevation of the occlusal plane. J Oral Maxillofac Surg 1994;52:671
8.Guidelines for the Diagnosis and Management of Temporomandibular Disorders; the Royal College of Dental Surgeons of Ontario. 1995.
Re: How to Stabilize the TMJ Prior to Treatment and An Introduction to Joint Vibration Analysis, Oral Health, June, 2005
As a subject of controversy within the dental profession, the topic of temporomandibular disorders has few peers. There are no simple questions related to these conditions, only over-simplified answers. For decades, myriad and scientifically unproven diagnostic and therapeutic devices and techniques have been described and utilized to manage these ubiquitous disorders. The concepts and opinions expressed in Dr. Rondeau’s article are a classic example of the maxim “the way we see the world creates the world we see.” His perception that the pain associated with TMJ internal derangements is the result of condylar compression of the richly innervated posterior attachment tissues and a resultant
anteriorly displaced disk, is a rather simplistic theory that leads to a “one diagnosis (posterior condylar displacement) one treatment (mandibular anterior repositioning)” management philosophy. There is good data to show that there are many pain-free individuals with internal derangements in all known stages and therefore the presence of pain in patients with internal derangements cannot always be explained on the basis of the internal derangement. Current theories of pain production in patients with articular disc displacements include but are not limited to inflammation, accompanied by a variety of inflammatory mediators eg. Cytokines, eg. (Interleukins, tumor necrosis factor) and matrix degrading enzymes. The genesis of the biomolecular sequence of events that ultimately leads to the structural failure in degenerative TMJ disease is “excessive mechanical loading” or “prolonged muscular contraction.”
While Dr. Rondeau tends to emphasize the importance of “disc recapturing” and the re-establishment of the normal anatomical disc-condyle relationship, the successful outcomes reported following arthroscopic lysis and lavage and arthrocentesis, in which there is very little alteration in disc position from its pre- operative state, clearly shows that comfortable TMJ function is not dependent upon the restoration of the normal disc-condyle relationship. Indeed, many patients have been successfully treated “off” the disc. Moreover the long-term outcomes of disc-recapturing procedures with mandibular anterior repositioning appliances are inconsistent and unpredictable and are dependent for the most part upon the integrity of the discal attachments to the condyle and temporal bone, particularly the competency of the “elastic recoil” of the upper stratum of the bilaminar zone and the tenacity of the lower stratum attachment to the nape of the condyle. In addition, there is evidence that the pain dysfunction associated with internal derangements may be self-remitting in approximately 80 percent of cases and that significant spontaneous improvement may occur within three months of initiation. Nickerson and Boering offer the following appropriate conclusion: “Those who attempt to apply remedial treatments directed toward internal derangements must take into consideration that almost all forms of therapy are about 80 percent successful and the same degree of success may result from “natural” events”.
Regarding the article on “Joint Vibration Analysis” (JVA) by Dr. Marangos, neither I nor a number of my surgical colleagues, all experienced TMJ surgeons, had ever heard of the term. Dr. Marangos presents case reports of two patients, one with a unilateral reducing disc displacement and the other with bilateral non-reducing disc displacements. Both patients had a full radiographic work-up as well as a JVA and Jaw Tracker Test for patient No. l with the reducing disc displacement, in addition to an MRI and BIO PAK for patient No. 2 with the non-reducing disc displacements. Patient No. 1 received therapy that included: a mandibular orthopedic appliance, maxillary deprogrammer, and chiropractic therapy while patient No. 2 received treatment that included mandibular orthopedic repositioning appliance, (MORA), chiropractic therapy, maxillary deprogramming appliance, Pivot appliance, phase 2 MOR.A, referral to chronic pain centre, spray and stretch technique, infra-red therapy, another maxillary deprogrammer, 2 percent Lidocaine injections into temporal tendon and stylomandibular ligament areas, Flexeril 10mg three times daily for 7-10 days and arthrocentesis.
One year follow-up examinations showed that both patients had decreased pain and improved mandibular range of motion. Surely, Dr. Marangos is not implying that the same treatment outcomes would not have resulted had joint vibration analysis not been utilized as part of the diagnostic regimen.
It is well known that most cases of internal derangement can be diagnossd from a thorough history and careful clinical examination. Where the diagnosis is in doubt, it may be confirmed with an MRI examination, direct arthroscopic observation or arthrography. Most importantly and explicitly, joint vibration analysis is not recommended as a “standard of care” in the diagnosis of temporomandibular disorders by the American Association of Oral and Maxillofacial Surgeons in its “Parameters of Care” literature, nor has it been endorsed as a diagnostic aid in the 1995 Royal College of Dental Surgeons of Ontario “Practice Parameters and Standards for the diagnosis and management of temporomandibular disorders”. Joint vibration analysis is simply another in a long list of questionable diagnostic aids whose clinical usefulness has not been shown in scientifically sound, well-controlled studies.
Regarding the TMJ tomograms (Figs. 1 and 4) on pages 49 and 51 of Dr. Marangos’ article that purport to show pre-treatment posteriorly positioned condyles and post-treatment centrally positioned condyles; it is a fact that because of variations in the shape of the bony components of the joint, the condylar position may vary from the lateral to the medial aspect of the same joint. This will result in a lateral tomographic view through the lateral aspect of the joint appearing as a posteriorly positioned condyle, while a lateral tomographic view through the central portion of the same joint will appear as a centrally positioned condyle. Although research has demonstrated a relationship between posteriorly positioned condyles and anterior disk displacement, this evidence was not sound enough statistically to be of predictive value. Joint space measurements therefore are not of reliable diagnostic value.
Concerning the “beaking ” of the condyle in the tomogram (Fig. 4 on page 51) this may not be a pathologic structural alteration (osteophyte) but may simply represent a stage in normal condylar remodeling in response to physical stresses brought to bear on the condyle, or it may represent an extensive fovea giving the false appearance of an osteophyte projecting from the anterior aspect of the condyle. In any case Dr. Marangos does not indicate how his awareness of this “beaking” phenomenon has influenced the diagnosis, management and ultimate treatment outcome of this patient’s condition.
I try to keep an open mind and I certainly have no intention of disparaging those who try new things. I believe in the words of Alexander Pope, “Be not the first on whom the new is tried nor the last to cast the old aside.”
Lastly, few words are more fitting to summarize the issue than those expressed by Charles Greene more than 20 years ago: “a profession has both the right and the responsibility to set appropriate standards for diagnosis and treatment and I cannot think of any better framework for establishing those standards than the classical framework of the scientific method. To the extent that doctors deviate from this framework, they deserve to be judged harshly by their colleagues when they employ unconventional techniques.”
Simon Weinberg, Professor Emeritus, Oral and Maxillofacial Surgery Consultant, Editorial Board Oral Health, Toronto
The article concerning stabilization of the temporomandibular joint prior to treatment was worrisome in that it seemed to take a unidimensional approach to temporomandibular joint intra-articular disease. Notably, the recommendation and rationale for jaw advancement with occlusal reconstruction (referred to as Phase I and II therapy in the article) is not based on sound scientific or physiological foundations and as such we respectfully submit that we cannot agree with the author’s interpretation of the scientific literature as support for this recommendation. In addition, we submit that it is critically important to treat patients with any disorder by following the principle, Primum non nocere (First do no harm). It is also worth pointing out that no other joint in the body would be treated in a manner requiring such positional analyses and repositioning to an extent r
epresenting the extremes of its normal envelope of motion. We hold that the temporomandibular joint is no different in this respect from other joints and should therefore not be treated differently, regardless of spurious arguments pertaining to the minor variations in articulation of the dentition and the effect of this on temporomandibular joint function.
Temporomandibular joint disorders are known to cause pain in the jaw and face, with attendant pain with jaw functions such as opening, closing and chewing. In addition, these conditions may be associated with other craniofacial pains including but not limited to headache. In general, the etiology of temporomandibular disorders is not understood fully although some conditions seem to arise following trauma. Nevertheless, what is clear is that temporomandibular disorders cannot be approached in a purely mechanistic manner, but, rather as a chronic pain condition. Regardless, the author, taking a more mechanical approach, suggests that compression of the neurovascular structures of the retrodiscal tissues are the primary cause of pain in patients with temporomandibular disorder. There are patients m whom intra-articular disease is the primary source of pain but in most cases, this is not so because these disorders are not purely structural in nature. Joint pain may be initiated and exacerbated by overproduction of pro-inflammatory mediators including interleukins and prostaglandins suggesting that pain in this structure is largely an inflammatory process. It is notable that painful muscles of mastication also produce similar pain mediators as shown by Sigvard Kop and co-workers. Hence a major goal for treatment of temporomandibular disorders is the reduction of pain, hopefully by reducing inflammatory and pain mediators, a goal that can be accomplished using noninvasive and reversible treatment modalities.
As regards treatment, it has been suggested that intra-articular pressure can be reduced with the use of flat-plane occlusal appliances and that this could explain their apparent effectiveness. However, others have demonstrated improvements in temporomandibular disorder-associated pain following treatment with so-called ‘placebo-appliances’ (Dao et al, Pain. 1994 Jan; 56(1):85-94) suggesting that pain relief is not based solely on physical changes in joint loading or position, or frankly, even in reduction in inflammation. In addition, we must admit that in general, there is still a poor understanding of the etiological factors contributing to the development of temporomandibular disorders. Therefore, one must also recognize and appreciate that the mechanisms of apparently successful treatment modalities are not readily explainable, making the use of irreversible treatments for temporomandibular disorders of questionable merit. For example, we point out that even in cases where intra-articular disease and pain are treated surgically using endoscopic means, significant improvements in both pain and quality of life occur without any demonstrable alterations in joint movement or disk position for that matter (J Orofacial Pain 13(4):285-290, 1999, J Oral Rehabil. 1999 May; 26 (5):357-63), further putting into question the predominantly mechanical approach to treatment suggested by the author.
Finally, we would like to point out that the opinions expressed above are more reflective of the Recommendations for the Diagnosis and Management of Temporomandibular Disorders (Royal College of Dental Surgeons of Ontario).
H. C. Tenenbaum DDS, Dip. Perio., PhD, FRCD(C) Professor, Periodontology
Associate Dean, Biological and Diagnostic Sciences Faculty of Dentistry
Professor, Laboratory Medicine and Pathobiology Faculty of Dentistry
Head of Periodontics, Mount Sinai Hospital University of Toronto
B. V. Freeman DDS, D. Ortho., MSc.,
Wasser Pain Management Center Mount Sinai Hospital
Associate in Dentistry, Faculty of Dentistry, University of Toronto
M. Goldberg DDS, MSc, Dip. Perio.,
Wasser Pain Management Center Assistant Professor, Periodontology
Faculty of Dentistry, University of Toronto
G. Baker DDS, MS, FRCD
Assistant Professor Faculty of Dentistry
Head, Division of Oral and Maxillofacial Surgery, Mount Sinai Hospital, Toronto
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