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 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 16  |  Issue : 2  |  Page : 146-150

Current trends in temporomandibular disorder management: A prosthodontist's perspective


Department of Prosthodontics and Crown and Bridge, Army Dental Center (Research and Referral), New Delhi, India

Date of Submission02-Mar-2021
Date of Decision30-Nov-2021
Date of Acceptance01-Sep-2022
Date of Web Publication21-Dec-2022

Correspondence Address:
Ranjoy Hazra
Department of Prosthodontics and Crown and Bridge, Army Dental Center (Research and Referral), New Delhi - 110 010
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jodd.jodd_8_21

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  Abstract 


Temporomandibular disorders (TMDs) are a collective term that embraces a number of clinical conditions that involve the masticatory musculature and/or temporomandibular (TM) joints and associated musculoskeletal structures. TMDs are one of the most common causes of facial pain after odontogenic origin. The TMDs are of multifactorial etiology and characterized by multiplicity of clinical signs and symptoms, making its diagnosis and management very difficult for the clinician. Diagnostic criteria are used from a clinician standpoint to reach into an exact diagnoses based on a multiaxial diagnostic model. The stress is on a medical multidisciplinary model similar to ones used for other musculoskeletal disorders that involve the patient in the physical and behavioral management of his or her own problem. A majority of TMD patients achieve good relief of symptoms with noninvasive reversible treatment. Detailed knowledge of the disease and its etiopathology is mandatory to formulate an effective treatment plan. The primary objective for the prosthodontist as a member of a TMD team is to regain patient comfort and occlusal stability.

Keywords: Occlusal splints, occlusal therapy, orthopedic therapy, temporomandibular disorders


How to cite this article:
Hazra R, Srivastava A, Kumar D, Khattak A. Current trends in temporomandibular disorder management: A prosthodontist's perspective. J Dent Def Sect. 2022;16:146-50

How to cite this URL:
Hazra R, Srivastava A, Kumar D, Khattak A. Current trends in temporomandibular disorder management: A prosthodontist's perspective. J Dent Def Sect. [serial online] 2022 [cited 2023 Jan 31];16:146-50. Available from: http://www.journaldds.org/text.asp?2022/16/2/146/364526




  Introduction Top


Temporomandibular joint (TMJ) disorders occur when the muscles of mastication and the TMJ fail to work in coordination with each other.[1] The TMJ disorders may have any number of causes, a few among them being habits such as clenching or grinding the teeth (bruxism), malocclusion (poor bite) that puts muscles under stress, accidents that damage the bones of the face or jaw and occasionally, or diseases such as arthritis. A combination of dental and medical therapy is most effective in the treatment of TMJ disorders. Temporomandibular disorders (TMDs) are one of the most frequently occurring nonodontogenic-related chronic orofacial pain conditions.[1] The responsibility of the dental profession in the management of head-and-neck pain symptoms is of paramount importance.

The entity, TMJ disorders, is an umbrella term, which combines those with the true pathology of the TMJ and those with the involvement of the muscles of mastication (myofascial pain dysfunction).

Epidemiologic studies report that approximately 75% of the population have at least one sign of TMJ dysfunction and approximately 33% have at least one TMD symptom. Women are affected four times more than the men, and TMJ dysfunction is found infrequently in the pediatric population. Signs and symptoms of TMD usually increase in frequency and severity from the second through the fourth decade of life.[2] Prevalence figures may exaggerate the clinical significance of this problem, because many researches include individuals with mild temporary signs and symptoms that may not require intervention. Indeed, of the large percentage of the population who have clinical manifestations, it is estimated that only approximately 5%–6% are in need of treatment.

Prosthodontic management of TMDs has been a controversial topic. Most practitioners earlier used to believe that there is a significant role of occlusion as an etiologic factor, but there have been an increasing number of clinicians considering occlusion to be a minor factor and thus irreversible occlusal therapy should only be performed if absolutely indicated. There has been a paradigm shift in the concepts in the prosthodontic management of TMDs; hence, this literature review was planned and tries to go through the evolving phases of the TMD management.

A literature search in the PubMed database was performed on February 2021, to shortlist the relevant clinical trials on the above topic. The search queries were done with that the medical subject heading (MeSH) term “prosthodontics” be combined with either the MeSH term “temporomandibular joint disorders.” As a first step, the limit was set to clinical trials and reviews, and inclusion in the review was tentatively reserved for investigations assessing the role of prosthodontics as either a treatment for TMD, as well as assessing the clinical effectiveness of different prosthodontic treatments/protocols to solve prosthetic problems in patients with TMD. The exclusion criteria were non-English articles, unavailability of full article, and case reports articles.


  Temporomandibular Joint Top


The TMJ is the most unique joint in the whole body as one joint may influence the function of the other joint. It is a synovial joint of condylar variety. It is a part of the stomatognathic system that comprises several internal and external structures. It is one of the most complex joints in the body, performing multiple vital functions.

Because the mandible is fused in the midline, one joint cannot be moved without moving the other. The two joints can differ in their properties and even a problem in one joint can have the symptoms expressed in the other.

The second factor making this joint unique is that the teeth dictate its function. The teeth are passive members of the maxilla and mandible, but they have a specific way they must occlude and interrelate.


  Temporomandibular Disorders Top


According to the American Academy of Orofacial Pain, TMD is defined as “a collective term embracing a number of clinical problems that involve the masticatory musculature, TMJ and associated structures or both.”[3]

TMDs are one of the most common causes of facial pain after odontogenic origin. The TMDs are of multifactorial etiology and characterized by multiplicity of clinical signs and symptoms, making its diagnosis and management very difficult for the clinician. TMD should be considered in the differential diagnosis of headache and orofacial pain in the absence of specific attributable organic cause. Noninvasive methods are preferred in the management of TMD. These include occlusal, behavioral, physical, and pharmacological treatment. Medical and dental practitioners should consider TMJ disorders as a possible cause in the diagnosis of orofacial pain including headaches, shoulder and neck pain, vertigo and associated pain, blurring of vision, disorders of hearing, nausea, vomiting, and disturbances in concentration, in the absence of any specific, attributable, or organic cause.[4] Orofacial pain and headache related to jaw muscle function and dental structures should be ideally managed by dentists, while those which are unrelated to it should be referred to an appropriate medical care specialist for management. Treatment of occlusal-related disorders is often a challenge for both the dentist and the patient as the diagnosis is often quite complex.


  Diagnostic Classification of Temporomandibular Disorders Top


Temporomandibular joint disorders[1]

Congenital or developmental disorders:

  • Aplasia
  • Hypoplasia
  • Hyperplasia
  • Neoplasia.


Disk derangement disorders:

  • Disk displacement with reduction
  • Disk displacement without reduction.


Joint dislocation

Inflammatory conditions:

  • Capsulitis/synovitis
  • Polyarthritides.


Noninflammatory (osteoarthrosis):

  • Osteoarthritis: Primary
  • Osteoarthritis: Secondary.


Ankylosis:

  • Fibrous
  • Bony.


Fracture (Condylar process).

Signs and symptoms

It is characterized by the signs such as tenderness and stiffness of the joint and the muscles, increasing dull pain on mouth opening, reduced and deviated mouth opening, referred pain to the angle of mandible and muscles of the neck. Otologic symptoms such as fullness of the ear and tinnitus, cervical pain and head ache are also commonly associated with TMDs.[5]

Etiology

The etiology of TMD has not been fully understood; in general, it is considered multifactorial.[6] There are numerous factors that can contribute to TMD, namely the predisposing factors. There are factors that cause onset of TMD, called as initiating factors, and factors that interfere with the healing or enhance the progression of TMD called as perpetuating factors.

The TM joint is forced by the muscles to move so that the teeth will occlude properly. This can potentially cause a malalignment within the joint capsule. If this happens, the muscles are put in a compromising situation causing them to spasm and resulting in pain. Many of the problems that patients may be experiencing are the result of muscle spasm, but the cause is not a muscle problem. Occlusal contact patterns of teeth have significant influence on the activity of the masticatory muscles. Problems of bringing the teeth in contact are answered by the muscles. Therefore, a high contact can induce masticatory muscle pain.

Keys in making a differential diagnosis

Since TMDs overlap with various other serious problems, differentiating them from TMDs becomes extremely important.

Furthermore, muscle and joint disorders have many common clinical findings, so it is pertinent to perform few specific tasks to reach to a final diagnosis.

These keys in diagnosis are the following:[7]

  1. History,
  2. Mandibular restriction,
  3. Mandibular interference,
  4. Acute mal occlusion,
  5. Loading of the joint,
  6. Functional manipulation,
  7. Diagnostic anesthetic blockade.


Management

Despite the large percentages of the population having signs and symptoms of TMD, it has been estimated that only 2% or less of the general population seek treatment for a TMD symptom.

Treatment methods generally are of two types:

  • Definitive treatment refers to modalities that are directed toward managing or eliminating the etiologic factors that have created the disorder
  • Supportive therapy refers to treatment methods that are directed toward reducing patient symptoms.


The initial phase of treatment protocol consists of a splint therapy, counseling, physiotherapy and occasionally nonsteroidal anti-inflammatory drugs. These has shown to have achieved relief of pain and reduction of dysfunction in most cases.

Treatment with intraoral appliances is often used in patients with advanced TMD. Selective grinding can be done in “occlusally sensitive” patients with symptoms. Replacing the lost posterior teeth by prostheses in some cases results in unloading of the joints. When displaced discs are part of the diagnosis, anterior repositioning splints can be used which are specifically designed to achieve a healthy condyle-disc-fossa relation.[8]

Once the cause of occlusal-related problem is identified, this reversible, noninvasive therapy provides both diagnostic information and relief without the problems that acts as an adjunct to other modalities, i.e. surgery and drug therapy.[9] Occlusal splints may be soft or hard and may be full or partial tooth coverage. Some splints are designed in a way to reposition the mandible in a new maxillomandibular relation (repositioning splints). Soft appliances are probably as effective as hard splints but are difficult to adjust and repair. Repositioning appliances have been used extensively to treat internal derangements (IDs) of the TMJ and are designed to recapture the disc. While these appliances may be able to treat ID with reduction in the short term, they fail to do so at all for ID without reduction or osteoarthritis. Moreover, long-term stability of successful treatment is usually not good and clicks or abnormal disc positions tend to recur. Repositioning appliances have no significant benefit over stabilization appliances, and moreover, they may induce irreversible occlusal changes. In the management of TMJ disorders, splints are sometimes constructed to reduce TMJ loading by providing occlusal contacts in the posterior region only. Flat occlusal splints (relaxation or stabilizing splints) are in widespread use and provide even occlusal contacts; these may be constructed for the upper or lower jaw.

Stabilization splints are effective in the management of TMJ arthralgia. There seems to be no difference in effect between flat splints and splints designed to provide canine guidance on lateral excursions in the mandible. Partial coverage splints have the inherent potential to cause permanent occlusal changes and the lack of evidence for any advantage over flat splints. To avoid occlusal changes, all patients with any appliance must be instructed not to wear it all the time and also the appliance should be evaluated for alterations regularly to avoid adverse consequences.

Types of splints

According to Okeson:[7]

  1. Muscle relaxation appliance/stabilization appliance used to reduce muscle activity
  2. Anterior repositioning appliances/orthopedic repositioning appliance.


Other types:

  1. Anterior bite plane
  2. Pivoting appliance
  3. Soft/resilient appliance.


According to Dawson:[10]

  1. Permissive splints/muscle deprogrammer
  2. Directive splints/nonpermissive splints
  3. Pseudo-permissive splints (e.g. Soft splints, hydrostatic splint).


Mandibular orthopedic repositioning appliance

Types of occlusal splints:

  1. A permissive splint
  2. A directive splint.


Indications for the use of splints

  • Improving neuromuscular coordination
  • Treatment of myogenic pain
  • Improving function of the TMJ
  • Treatment of pain arising from the joints
  • Increasing the vertical dimension
  • Securing a definite mandibular position
  • Altering the pattern of mandibular movement
  • Testing the planned occlusal scheme in centric and eccentric positions
  • Splinting of loose teeth
  • Distributing the load in bruxism
  • Clarifying occlusal etiological factors while making a differential diagnosis.



  Discussion Top


In general, literature shows that TMD patients are usually benefitted with oral splints. The most recent meta-analytic review concludes that stabilization splint therapy may be beneficial for reducing pain severity at rest and on palpation and depression when compared to no treatment. Effects of nonoccluding splints on TMJ pain and clicking have been observed. The conservative nature of splints and its success rate are reasons for their extensive use. They can be used in adjunct with self-care.[11] The self-care strategies include relaxation, physical therapy, physiotherapy, stress reduction, and the use of painkillers.[10] The exact mode of action of splints is inconclusive. Splints may reduce sleep bruxism. Currently, splints are considered to act through nonspecific mechanisms probably involving behavior modifying properties. Each patient presents a challenge. Each treatment plan is like others and at the same time unlike any other. Despite the nearly universal prescription of oral splints in the treatment of TMJ disorders or bruxism, the quality of the evidence supporting the mechanisms of action suggested for their presumed efficacy is still questionable. This is not surprising, since their efficacy itself remains unestablished, and the rationale underlying each of the mechanisms proposed is based on unsubstantiated hypothetical etiologies. Although the prospect for curing TMJ disorders and/or bruxism, or trying to eliminate their unknown cause, remains an unrealistic expectation, it still can be argued that improving the patient's perception of well-being, quality of life, and psychological status or changing harmful habits through the judicious application of a noninvasive and cost-efficient management strategy (such as the use of stabilizing splints), may represent an acceptable alternative.

Occlusion is considered a minor etiological factor for TMDs according to the concept in current literature.[12] The concept that irreversible occlusal changes should be the end procedure of any TMD treatment implies that something is deranged with the occlusion and that such abnormality initiates TMD symptoms. Moreover, there are very less evidence supporting this.[13] Most arguments against occlusal equalization for TMD purposes came from orthodontic studies, showing that orthodontic treatment neither reduces nor increases the risk for TMDs.[14],[15] Thus, treating dental occlusion and/or repositioning the mandible for TMD treatment purposes is not medically warranted for.[16],[17],[18] Oral appliances may favor reorganization of muscle fiber recruitment patterns[19],[20] and a shift in the area of maximum joint loading[21] and are the most effective mode of deprogramming. These effects are unrelated to the equilibration of occlusion and are simply due to the thickness of the appliance. In addition, emerging evidence seems to minimize the true efficacy of splints as a treatment option.[22],[23] Prosthodontists should be aware of the temporary effects of the appliances, which are not miraculous devices that position the mandibles ideally but are instead responsible for transient shifts in joint and muscle loading.


  Conclusion Top


Management of TMD may be simple or may require a multidisciplinary approach. Occlusion is one of the factors contributing to TMDs. Hence, dentists, physicians, psychologists, and physical therapists work together to cope with such condition afflicting the patients. Prosthodontists' play a major role as it is imperative that a healthy asymptomatic TMJ is a mandatory requisite to start any rehabilitation procedure.

In summary, it is critical to identify the cause of orofacial pain and proper differential diagnosis and keep in mind that oral splints do not cure, but they may contribute to the patient's well-being just like crutches, which are useful as a nonspecific “healing aid” during a patient's orthopedic rehabilitation phase, but which are not regarded as a primary or definitive treatment modality until the primary cause is identified and treated.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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American Academy of Orofacial Pain, McNeill C, editors. Temporomandibular Disorders: Guidelines for Classification, Assessment, and Management. Chicago: Quintessence; 1993.  Back to cited text no. 3
    
4.
Isacsson G, Linde C, Isberg A. Subjective symptoms in patients with temporomandibular joint disk displacement versus patients with myogenic craniomandibular disorders. J Prosthet Dent 1989;61:70-7.  Back to cited text no. 4
    
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Okeson JP, editors. Orofacial Pain: Guidelines for Assessment, Diagnosis, and Management. Chicago: Quintessence; 1996.  Back to cited text no. 5
    
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McNeill C, Mohl ND, Rugh JD, Tanaka TT. Temporomandibular disorders: Diagnosis, management, education, and research. J Am Dent Assoc 1990;120:253, 255, 257.  Back to cited text no. 6
    
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Okeson JP. Management of temporomandibular disorders and occlusion. 7th ed. St Louis: Mosby, 2014.  Back to cited text no. 7
    
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Covey EN. The interdental splint. Richmond Med J 1866;1:81.  Back to cited text no. 8
    
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Tsukiyama Y, Baba K, Clark GT. An evidence-based assessment of occlusal adjustment as a treatment for temporomandibular disorders. J Prosthet Dent 2001;86:57-66.  Back to cited text no. 9
    
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Dawson PE. Functional Occlusion: From TMJ to Smile Design. Edinburgh: Elsevier Mosby; 2006.  Back to cited text no. 10
    
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Kaur H, Datta K. Prosthodontic management of temporomandibular disorders. J Indian Prosthodont Soc 2013;13:400-5.  Back to cited text no. 11
    
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Manfredini D, Poggio CE. Prosthodontic planning in patients with temporomandibular disorders and/or bruxism: A systematic review. J Prosthet Dent 2017;117:606-13.  Back to cited text no. 12
    
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Koh H, Robinson PG. Occlusal adjustment for treating and preventing temporomandibular joint disorders. J Oral Rehabil 2004;31:287-92.  Back to cited text no. 13
    
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Michelotti A, Iodice G, Piergentili M, Farella M, Martina R. Incidence of temporomandibular joint clicking in adolescents with and without unilateral posterior cross-bite: A 10-year follow-up study. J Oral Rehabil 2016;43:16-22.  Back to cited text no. 14
    
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Manfredini D, Perinetti G, Stellini E, Di Leonardo B, Guarda-Nardini L. Prevalence of static and dynamic dental malocclusion features in subgroups of temporomandibular disorder patients: Implications for the epidemiology of the TMD-occlusion association. Quintessence Int 2015;46:341-9.  Back to cited text no. 15
    
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Okeson JP. Evolution of occlusion and temporomandibular disorder in orthodontics: Past, present, and future. Am J Orthod Dentofacial Orthop 2015;147:S216-23.  Back to cited text no. 16
    
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Dao TT, Lavigne GJ. Oral splints: The crutches for temporomandibular disorders and bruxism? Crit Rev Oral Biol Med 1998;9:345-61.  Back to cited text no. 17
    
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Klasser GD, Greene CS. Oral appliances in the management of temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:212-23.  Back to cited text no. 18
    
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Van Eijden TM, Blanksma NG, Brugman P. Amplitude and timing of EMG activity in the human masseter muscle during selected motor tasks. J Dent Res 1993;72:599-606.  Back to cited text no. 19
    
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Terebesi S, Giannakopoulos NN, Brüstle F, Hellmann D, Türp JC, Schindler HJ. Small vertical changes in jaw relation affect motor unit recruitment in the masseter. J Oral Rehabil 2016;43:259-68.  Back to cited text no. 20
    
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Ettlin DA, Mang H, Colombo V, Palla S, Gallo LM. Stereometric assessment of TMJ space variation by occlusal splints. J Dent Res 2008;87:877-81.  Back to cited text no. 21
    
22.
Fricton J, Look JO, Wright E, Alencar FG Jr., Chen H, Lang M, et al. Systematic review and meta-analysis of randomized controlled trials evaluating intraoral orthopedic appliances for temporomandibular disorders. J Orofac Pain 2010;24:237-54.  Back to cited text no. 22
    
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