New evidence-based techniques to get lasting results for patients suffering from TMD

With the exception of toothache, TMDs (Temporomandibular disorders) are the most common pain presentation dentists, orthodontists, and oral therapists will see. 5% - 20% of the population suffer with this condition today.

Yet despite the prevalence of this condition, patients consistently find that the professionals who are suppose to help them are only able to provide limited solutions and uncertain advice. (1)

New functional treatments for TMD

What do you mean 'limited solutions'?

When I say limited I am saying that most interventions do not provide lasting relief.

Botox - On rare occasions botox provides a lasting outcome, but typically needs to be administered every 3-6 months. The problem with this approach is that using a toxin to paralyse a muscle may alleviate pain but quickly leads to muscle atrophy, compromising orofacial function and ultimately weakening the orofacial structures needed to overcome the condition in a lasting way. (2)

Splints - In a similar way, a split will modify occlusion and inhibit muscle load providing some relief, yet once again the large body of systematic reviews and meta-analysis is resoundingly clear that the effect of split therapy for the majority of sufferers is temporary. (3)

Likewise, interventions such as physical therapy, pharmaceutical medication and low-level laser are often provided as regular band-aid rather than a lasting solution.

What do you mean 'uncertain advice'?

Many of us as professionals will give TMD sufferers advice, yet those of us that are really honest with ourselves give advice with a healthy dose of uncertainty. Why? Because we know, or have been told, that temporomandibular disorders are highly complex. It is true that TMDs are multifactorial, which can make diagnosis and assessment seem overwhelming but I am convinced that many professionals feel uncertain about TMD treatment simply because so many patients have spent so much time, effort and thousands of dollars looking for relief.

As such, our uncertainty leads to referral - as it should - but even this rarely leads to lasting solutions. Patients are typically referred from doctor to dentist to specialist only to be prescribed dated treatment options or even surgical interventions, when the correct conservative education and treatment may have worked well.

Clinically, based on the percentage of lasting outcomes with chronic TMD patients (who have been referred from maxillofacial surgeons and neurologists) myself and my colleagues witness on a regular basis, we can tell you that the majority of TMD sufferers can find lasting results with simple conservative interventions.

But ... the most important step is the first step. The correct diagnosis.

What are 'the right questions'?

You may not be aware, but there is a revolution happening in the world of pain science. Whether we're talking about chronic pain due to injury, arthritis or ergonomics the evidence-based research has demonstrated conclusively and consistently that chronic pain and mechanical asymmetry or degeneration are not causatively related. This has been demonstrated now in mountains of research and is most simply summarised through publications from the NOI group. (4)

In order to start asking the right questions, you need to know that TMDs are no exception. To put it simply, muscle asymmetry, poor occlusion and even disc displacements are NOT the 'cause' of your patients' ongoing pain.

As such, the questions you need to be asking in order to direct your patient to the fastest possible solution do not pertain to mechanical factors but to functional factors.

Historically our interventions have centred around mechanical factors - resolving asymmetry, restoring muscle balance and even surgically modifying temporomandibular joints or occlusal surfaces. But those days are gone. If we are to follow evidence-based practice our solutions must be functional rather than mechanical. And the good news is, functional interventions work in a lasting way.

What are the right interventions?

Firstly, we must prescribe interventions that empower the patient with strategies that will strengthen the affected area, rather than interventions that will act as a crutch or compensation for the pain. Early research has shown myofunctional exercises to be effective (5), and we prescribe them often.

Secondly, skilled manual soft tissue therapy will compliment the myofunctional exercises and speed up improvement considerably. We can teach you a 5-minute hands-on soft tissue assessment that is a powerful adjunct that every dentist and OHT should know. (link to get the exercise)

Thirdly, interventions must empower the patient with education pertaining to the multiple contributing factors such as sleep, posture, airway and parafunctional habits. It is THESE that perpetuate your patients' pain, not asymmetry or joint dysfunction.

Now I know that multiple contributing factors can make TMDs sound complicated, and it can feel daunting knowing where to start, but assessment and treatment do not have to be complex.

Start with this free assessment checklist

Begin to ask your patients if they have head, jaw or face pain. (Often they won't mention it, unless you ask). If they do, get them to fill out this assessment sheet. This form will ensure that you are integrating all of the factors that may be contributing to your patient's pain, and enable you to flat the areas that your patient may need to address first, in order to start gaining relief.

Long term solutions are entirely possible for the majority of TMD sufferers with a functional therapy approach. We see it clinically every day...

References

1. Horst, Ov et al: Prevalence of Pain in the Orofacial Regions in Patients Visiting General Dentists in the Northwest  Practice-based Research Collaborative in Evidence-based Dentistry Research Network. JADA, Dec 2015, Vol.146(12), pp 874-878.

2. Jessica, P., Mikkel, S., Torsten, L., Kristian, R., Martin, B., Tine, A., . . . R, F. (2017). Injection of high dose botulinum-toxin-A leads to impaired skeletal muscle function and damage of the fibrillar and non-fibrillar structures. Scientific Reports, 7(1), 1-14.
Keenan, J. R. (2015). Unclear results for the use of botulinum toxin therapy for TMD pain. Evidence-Based Dentistry, 16(4), 122.
Download a review of Botox for TMD here.

3. Al-Moraissi, E. A., Farea, R., Qasem, K. A., Al-Wadeai, M. S., Al-Sabahi, M. E., & Al-Iryani, G. M. (2020). Effectiveness of occlusal splint therapy in the management of temporomandibular disorders: network meta-analysis of randomized controlled trials. International Journal of Oral and Maxillofacial Surgery, 49(8), 1042–1056.
Ebrahim, S., Montoya, L., Busse, J. W., Carrasco-Labra, A., Guyatt, G. H., & Medically Unexplained Syndromes Research Group (2012). The effectiveness of splint therapy in patients with temporomandibular disorders: a systematic review and meta-analysis. Journal of the American Dental Association, 143(8), 847–857.
Kuzmanovic Pficer, J., Dodic, S., Lazic, V., Trajkovic, G., Milic, N., & Milicic, B. (2017). Occlusal stabilization splint for patients with temporomandibular disorders: Meta-analysis of short and long term effects. PloS One, 12(2), e0171296.

4. Butler, D. S., & Moseley, G. L. (2003). Explain pain. Adelaide: Noigroup Publications.

5. Melis, M., Di Giosia, M., & Zawawi, K. (2019). Oral myofunctional therapy for the treatment of temporomandibular disorders: A systematic review. CRANIO®, 1-7.
de Felício, C., Melchior, M., & da Silva, M. (2010). Effects of Orofacial Myofunctional Therapy on Temporomandibular Disorders. CRANIO®, 28(4), 249-259.

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