Despite continuing research, which is providing an increasing evidence base, the dental profession still does not have a standard of care for diagnosing or managing temporomandibular disorders (TMDs). Although guidelines have been published by organizations including the American Academy of Orofacial Pain1 and the American Academy of Oral Medicine, which has published a handbook2 for managing various orofacial conditions causing pain, these are not officially recognized as authoritative documents by national associations. The Canadian Dental Association and American Dental Association have not established clinical guidelines for this segment of dental practice. To our knowledge, the only North American dental organization that has published TMD guidelines—in 1999, revised in 2009—is the Royal College of Dental Surgeons of Ontario.3
In 1996, the American Association of Dental Research (AADR) published a science information statement on TMDs, based on recommendations submitted by its Neuroscience Group.4 This document, which was based on evidence at that time, provided guidelines for the diagnosis and management of TMDs. In 2010, the statement was revised in light of continuing research and the strengthened evidence base.5 After a broad literature review by the AADR’s Neuroscience Group and a lengthy process of administrative review and revision, the updated official AADR TMD statement was approved in March 2010 (Fig. 1).
The main question regarding the diagnosis of TMDs was related to the use of electronic diagnostic devices, such as electromyography, jaw movement trackers and sound recorders. Although various imaging modalities have been developed and validated for their use in diagnostic assessment of the temporomandibular joint, their value is mainly limited to the discovery of intracapsular pathologic conditions.1,6 Most technological devices proposed for TMD diagnosis have failed to meet standards of reliability and validity: they do not satisfy the sensitivity and specificity requirements or produce the positive and negative predictive values required for individual diagnosis in a clinical setting.7,8
In terms of management of TMDs, controversy has been primarily related to structural and mechanistic issues, such as occlusal relationships, condylar positions, neuromuscular balance and similar mechanistic concepts. Based on various concepts of “ideal,” many dentists believed these variations to be essential etiologic factors in the development of TMDs. These beliefs and opinions have resulted in the delivery of extensive and invasive treatment plans to manage TMDs.
The current literature has clearly shown that the use of adjunctive diagnostic devices (except for various imaging procedures) does not contribute to the ability to correctly diagnose orofacial pain problems (including TMDs) beyond that arising from a thorough history and comprehensive examination.1,6,9,10 Instead, their use poses a relatively high risk of false-positive findings, which may lead the provider to mechanistic therapies. In addition, patients with non-TMD orofacial pain may be wrongly classified as TMD patients, and their real diagnosis may be obscured by subsequent management for TMDs.
Management of TMDs by conservative and reversible interventions has been shown to be both appropriate and successful.11 Controlled studies have revealed little or no evidence of a need to change occlusal relationships or condylar positions permanently.12-14 In addition, internal derangements of the temporomandibular joint usually do not need to be “corrected”; instead, most symptomatic patients with internal derangements will respond well to pain management and physical medicine approaches.
Furthermore, the importance of biopsychosocial variables, which tend to be minimized when focusing on mechanistic approaches, has been emphasized throughout the medical pain management literature. Because TMDs are similar to other musculoskeletal pain conditions (e.g., low back pain, knee problems), it is obvious that dentists should incorporate this perspective into patient care. This is especially true when pain becomes chronic, because of the increasing recognition of the impact of psychosocial factors on persisting pain, and vice versa.
The 1996 AADR statement was updated based on the evidence-based scientific findings of the past 14 years, and the revised version includes a number of new elements. The concept of comorbid pain disorders has been added, reflecting current knowledge about pain susceptibility, neuroplasticity and psychosocial consequences of pain. Recognition of these phenomena has changed the field of pain management in general and has affected our understanding of TMDs.15-18
The original language regarding the use of adjunctive tests and devices has been modified, based on data from continuing research.8,19,20 TMDs are now recognized as a subset of orthopedic and rheumatologic musculoskeletal disorders and, therefore, require similar approaches in diagnostic testing as is conducted in other similar medical disciplines.14,21 In addition, the biopsychosocial perspective about TMDs and many other chronic pain disorders has become widely accepted, which means that assessing the psychosocial issues as they relate to TMD patients must be part of the diagnostic process.22-24
Modifications regarding TMD management approaches are included in the new statement, with emphasis on the need for conservative and reversible strategies as supported by recent treatment literature.1,11,25,26 In-clinic cognitive behavioural therapy and structured home-care programs, in which patients learn to understand their condition and engage in self-management strategies, are an important part of that approach.27-30
The 2010 AADR statement reflects current best knowledge, but undoubtedly it will be reviewed over time and adapted to conform to new evidence as this is developed. Within the scientific community, the new statement reflects widely accepted concepts and is essentially noncontroversial; however, the practitioner community may have mixed reactions to it. We urge all clinicians to read the statement carefully and look at the supporting references to benefit both patients and professionals in the diagnosis and management of problems causing orofacial pain.
- de Leeuw R, editor. Orofacial pain: guidelines for assessment, diagnosis, and management. American Academy of Orofacial Pain. 4th ed. Chicago: Quintessence; 2008.
- Brown RS, Arm RN, Epstein JB, editors. Clinician's guide: diagnosis and treatment of chronic orofacial pain. 2nd ed. Hamilton: B.C. Decker; 2008.
- Royal College of Dental Surgeons of Ontario. Guidelines: diagnosis & management of temporomandibular disorders & related musculoskeletal disorders. Toronto; 2009. Available: www.rcdso.org/pdf/guidelines/Guidelines_TMD_Jul09.pdf (accessed 2010 Sept. 13).
- American Association of Dental Research. Scientific information statement on temporomandibular disorders. AADR Reports. 1996;18(4).
- American Association of Dental Research. Policy statement: temporomandibular disorders. Alexandria, Va.; 2010. Available: www.aadronline.org/i4a/pages/index.cfm?pageid=3465 (accessed 2010 Sept. 13).
- Okeson JP. Management of temporomandibular disorders and occlusion. 6th ed. St. Louis: Mosby; 2008.
- Lund JP, Widmer CG, Feine JS. Validity of diagnostic and monitoring tests used for temporomandibular disorders. J Dent Res. 1995;74(4):1133-43.
- Klasser GD, Okeson JP. The clinical usefulness of surface electromyography in the diagnosis and treatment of temporomandibular disorders. J Am Dent Assoc. 2006;137(6):763-71.
- McNeill C, Mohl ND, Rugh JD, Tanaka TT. Temporomandibular disorders: diagnosis, management, education, and research. J Am Dent Assoc. 1990;120(3):253, 255, 257 passim.
- Goulet JP, Clark GT. Clinical TMJ examination methods. J Calif Dent Assoc. 1990;18(3):25-33.
- Stohler CS, Zarb GA. On the management of temporomandibular disorders: a plea for a low-tech, high-prudence therapeutic approach. J Orofac Pain. 1999;13(4):255-61.
- Koh H, Robinson PG. Occlusal adjustment for treating and preventing temporomandibular joint disorders. Cochrane Database Syst Rev. 2003;(1):CD003812.
- McNamara JA Jr, Seligman DA, Okeson JP. Occlusion, orthodontic treatment, and temporomandibular disorders: a review. J Orofac Pain. 1995;9(1):73-90.
- Greene CS, Laskin DM. Temporomandibular disorders: moving from a dentally based to a medically based model. J Dent Res. 2000;79(10):1736-9.
- de Leeuw R, Klasser GD, Albuquerque RJ. Are female patients with orofacial pain medically compromised? J Am Dent Assoc. 2005;136(4):459-68.
- Diatchenko L, Nackley AG, Tchivileva IE, Shabalina SA, Maixner W. Genetic architecture of human pain perception. Trends Genet. 2007;23(12):605-13. Epub 2007 Nov 26.
- Sessle B. Sensory and motor neurophysiology of the TMJ. In: Laskin DM, Greene CS, Hylander WL, editors. Temporomandibular disorders: an evidence-based approach to diagnosis and treatment. Chicago: Quintessence; 2006. p. 69-88.
- Reissmann DR, John MT, Schierz O, Wassell RW. Functional and psychosocial impact related to specific temporomandibular disorder diagnoses. J Dent. 2007;35(8):643-50. Epub 2007 June 15.
- Suvinen TI, Kemppainen P. Review of clinical EMG studies related to muscle and occlusal factors in healthy and TMD subjects. J Oral Rehabil. 2007;34(9):631-44.
- Greene CS. The role of technology in TMD diagnosis. In: Laskin DM, Greene CS, Hylander WL, editors. Temporomandibular disorders: an evidence-based approach to diagnosis and treatment. Chicago: Quintessence; 2006. p. 193-202.
- Truelove E. Role of oral medicine in the teaching of temporomandibular disorders and orofacial pain. J Orofac Pain. 2002;16(3):185-90.
- Dworkin SF, Massoth DL. Temporomandibular disorders and chronic pain: disease or illness? J Prosthet Dent. 1994;72(1):29-38.
- Carlson CR. Psychological considerations for chronic orofacial pain. Oral Maxillofac Surg Clin North Am. 2008;20(2):185-95.
- Lindroth JE, Schmidt JE, Carlson CR. A comparison between masticatory muscle pain patients and intracapsular pain patients on behavioral and psychosocial domains. J Orofac Pain. 2002;16(4):277-83.
- Fricton J. Myogenous temporomandibular disorders: diagnostic and management considerations. Dent Clin North Am. 2007;51(1):61-83.
- Okeson JP. Joint intracapsular disorders: diagnostic and nonsurgical management considerations. Dent Clin North Am. 2007;51(1):85-103.
- Carlson CR, Bertrand PM, Ehrlich AD, Maxwell AW, Burton RG. Physical self-regulation training for the management of temporomandibular disorders. J Orofac Pain. 2001;15(1):47-55.
- Dworkin SF, Turner JA, Mancl L, Wilson L, Massoth D, Huggins KH, et al. A randomized clinical trial of a tailored comprehensive care treatment program for temporomandibular disorders. J Orofac Pain. 2002;16(4):259-76.
- Dworkin SF, Huggins KH, Wilson L, Mancl L, Turner J, Massoth D, et al. A randomized clinical trial using research diagnostic criteria for temporomandibular disorders-axis II to target clinic cases for a tailored self-care TMD treatment program. J Orofac Pain. 2002;16(1):48-63.
- Turner JA, Holtzman S, Mancl L. Mediators, moderators, and predictors of therapeutic change in cognitive-behavioral therapy for chronic pain. Pain. 2007;127(3):276-86. Epub 2006 Oct 27.