The Detection and Management of Temporomandibular Disorders in Primary Dental Care
Course Number: 395
For some people, TMD pain and limitations in jaw movement often diminish or go away with little or no treatment. Many patients can experience relief from their TMD symptoms by observing for and changing oral behaviors and habits that can cause jaw muscle tension and fatigue. Other patients will benefit from physical medicine treatments and/or medications. The patient, under the direction of a dental professional, can in most cases self-manage their TMD. The American Association for Dental Research (AADR) Policy Statement on TMD therapy strongly recommends that, unless there are specific and justifiable indications to the contrary, treatment of TMD patients initially should be based on the use of conservative, reversible and evidence-based therapeutic modalities; they provide much less risk of producing harm.10 These are therapies that cause no permanent changes to the TMJ or associated structures. The following are the most commonly used TMD treatment strategies.
Managing Oral Behavior
Patients should avoid opening their mouth wide and moving excessively from one side to another, instead use passive range of motion exercises to gently stretch tight jaw muscles. Intentionally popping or clicking the TMJ should also be avoided. The usual jaw position should be where the jaw muscles are relaxed so the teeth are slightly apart and the tongue is lightly resting just behind the maxillary or mandibular anterior teeth. Frequent self-monitoring and correcting the jaw position and ensuring no clenching or grinding activity is occurring, will help to decrease jaw muscle tension. Some simple diet modifications (e.g., smaller bites, soft diet, avoid opening wide, and avoid hard/crunchy/chewy foods) can also help to decrease jaw muscle tension and fatigue. Because caffeine is a stimulant, it is recommended patients limit their daily caffeine consumption to 8 ounces of normal brewed coffee, 2 cups of tea, or 12 ounces of soda.11
Occlusal appliance therapy can help relax the muscles, decrease muscle tension and aid in habit control. Occlusal appliances (splints) are often used to treat TMD, and typically are hard acrylic or soft vinyl. The flat plane splint should cover all of the teeth in the arch and be adjusted to provide an ideal occlusion, otherwise there is a tendency for teeth to supraerupt. When the flat occlusal splint is made properly, no permanent changes in the bite usually result. Many patients with myalgia do very well using self-care strategies only, without a splint.11 In a large study of patients with myalgia, there were no significant differences in self-reported pain, joint sounds or clinically detected pain whether a patient received a hard acrylic splint, a custom fit soft athletic mouthguard, or usual conservative self-care only without the use of any oral appliance.12
Thermal treatments include applications of heat, cold, and alternating the two. Most patients find heat the most beneficial, but patients should try these and use whichever they find works the best. Patients should apply thermal packs 2 to 4 times a day. Heat pack (e.g., a dry or moist heating pad) should be applied for 15 to 20 minutes, while cold packs (e.g., bag of frozen peas wrapped in a towel) should be applied only until numbness is first felt (usually about 10 minutes). With the alternating technique, use heat for 5 minutes and cold until numbness is first felt.
Passive Range of Motion Exercises
This exercise helps to stretch the muscles without any additional pain or strain. Instructions to the patient are:
Open as wide as possible, without any additional pain, and hold open for about 10-15 seconds, then
Close about halfway and hold for 5 seconds, without touching the teeth, to rest; and then
Steps 1 and 2 are repeated. The patient can repeat the exercise 10-15 times, and perform this series 2 to 4 times per day.
Table 5. Commonly Prescribed Medications.
|Pain||NSAIDs with analgesic properties, e.g., ibuprofen, naproxen, aspirin|
Non-narcotic analgesics, e.g., acetaminophen
|Muscle tension and pain||Muscle relaxants primarily taken at bedtime, e.g., methocarbamol, cyclobenzaprine, tizanidine|
|Pain from TMJ inflammation (arthralgia)||NSAIDs|
Steroids, e.g., a 6-day dosepak
|Central nervous system mediated pain||Tricyclic antidepressants (TCAs), e.g., amitriptyline, nortriptyline|
The most commonly recommended medications for relief of TMD muscle and joint pain are over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs). Dosage regimens vary depending on the NSAID, the pain’s intensity and type of pain the patient is experiencing. A physician consultation may be warranted if the dental professional is considering prescribing a NSAID on a long-term basis.
Non-narcotic analgesics such as acetaminophen may be recommended for TMD pain. Muscle relaxants may be prescribed for patients to take at bedtime, for those who awake with muscle pain. Low doses of tricyclic antidepressants are prescribed for TMD, at doses lower than what will treat depression, but at levels that are beneficial for musculoskeletal pain.4
Helping patients to identify, monitor and change parafunctional habits, such as the ones mentioned above, can be very effective in decreasing muscle tension and pain. For patients who indicate they are stressed, it is helpful for them to identify the stressors and make a plan to reduce and manage them. It is not necessary for the dental professional to know about specific personal stressors, but to guide the patient to identify and manage the stress themselves. For patients who would like assistance with this, clinicians can recommend patients talk with their physicians about a referral to a psychologist who can assist.
Abdominal or “Tension Release” breathing and Progressive Muscle Relaxation (PMR) can be useful tools to help decrease generalized tension and stress, which in turn can help decrease facial muscle tension. Relaxation strategies are commonly used self-management techniques for the control of many pain conditions such as headache and back pain. A state of relaxation is thought to interrupt the body’s physical responses to stress, thus decreasing stress-induced tension and fatigue. With practice, people typically become more aware of when their muscles are tense and the patient can immediately relax their muscles. The patient can explore different techniques to determine which works best.
Infrequently Recommended Non-reversible Treatments
Non-reversible and surgical interventions for TMD are rarely needed and can include repositioning splints, occlusal adjustments, and surgeries such as arthrocentesis, disc repositioning and joint replacement.