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Downloaded from <a href=jada.ada.org on March 30, 2010 Management of temporomandibular disorders. National Institutes of Health Technology Assessment Conference Statement J Am Dent Assoc 1996;127;1595-1606 The following resources related to this article are available online at jada.ada.org ( this information is current as of March 30, 2010 ): This article appears in the following subject collections : Endodontics http://jada.ada.org/cgi/collection/endodontics Information about obtaining reprints of this article or about permission to reproduce this article in whole or in p art can be found at: http://www.ada.org/prof/resources/pubs/jada/permissions.asp © 2010 American Dental Association. The sponsor and its products are not endorsed by the ADA. " id="pdf-obj-0-6" src="pdf-obj-0-6.jpg">
Downloaded from <a href=jada.ada.org on March 30, 2010 Management of temporomandibular disorders. National Institutes of Health Technology Assessment Conference Statement J Am Dent Assoc 1996;127;1595-1606 The following resources related to this article are available online at jada.ada.org ( this information is current as of March 30, 2010 ): This article appears in the following subject collections : Endodontics http://jada.ada.org/cgi/collection/endodontics Information about obtaining reprints of this article or about permission to reproduce this article in whole or in p art can be found at: http://www.ada.org/prof/resources/pubs/jada/permissions.asp © 2010 American Dental Association. The sponsor and its products are not endorsed by the ADA. " id="pdf-obj-0-8" src="pdf-obj-0-8.jpg">

Management of temporomandibular disorders. National Institutes of Health Technology Assessment Conference Statement

J Am Dent Assoc 1996;127;1595-1606

The following resources related to this article are available online at jada.ada.org ( this information is current as of March 30, 2010 ):

This article appears in the following subject collections:

Endodontics

http://jada.ada.org/cgi/collection/endodontics

Information about obtaining reprints of this article or about permission to reproduce this article in whole or in part can be found at:

© 2010 American Dental Association. The sponsor and its products are not endorsed by the ADA.

NATIONAL INSTITUTES OF HEALTH TECHNOLOGY ASSESSMENT CONFERENCE STATEMENT emporomandibulardisorders(TMD) refertoacollectionofmedicaland * |dental n conditionsaffectingthetem- flM _
NATIONAL INSTITUTES OF HEALTH TECHNOLOGY
ASSESSMENT CONFERENCE STATEMENT
emporomandibulardisorders(TMD)
refertoacollectionofmedicaland
*
|dental
n
conditionsaffectingthetem-
flM _ poromandibularjoint(TMJ)and/or
themusclesofmastication,
as wellas
Downloaded from jada.ada.org on March 30, 2010
contiguoustissuecomponents.
Although specificetiologiessuch as degenerativearthritis and
trauma underlie some TMD, as a group these conditions have no
common etiologyorbiological explanation and comprise a heteroge-
neous group ofhealthproblems whose signs and symptoms are
overlapping, but not necessarilyidentical. Depending on the practi-
tionerand the diagnosticmethodology, the term TMD has been
used to characterize a wide range ofconditions diverselypresented
Management
of
Temporomandib~ular
as pain inthe face orjawjointarea, headaches, earaches, dizzi-
ness, masticatory musculature hypertrophy, limitedmouth open-
ing,closedoropen lockoftheTMJ, abnormal occlusalwear, click-
ingorpopping sounds inthejawjointand othercomplaints. The
severityofthese presentingconditions may range from noticeable
but clinicallyinsignificantsigns to seriouslydebilitatingpain or
dysfunction.
Given thisvariation among the problems labeledTMD, itisnot
surprising thatcontroversyhas emerged. Even the name TMD is
not universally endorsed. Generally accepted, scientificallybased
guidelines fordiagnosis and management ofTMD are stillunavail-
able. Even so,practitioners representing a varietyofdisciplines
and specialtieshave responded totheirpatients'needs by develop-
ingand employing abroad range oftreatment approaches thatin-
clude educational orbehavioral counseling, pharmacological orme-
chanical approaches, occlusal therapies and avarietyofsurgical
procedures, orcombinations thereof. In many cases, patients have
JADA, Vol. 127,November 1996 1595
COVERSTORY- improved, and inothers-forex- Management ofTemporo- provide abasisforinitiating ample, incases involvingthe use ofcertainalloplasticim- plants-the resultshave been
COVERSTORY-
improved, and inothers-forex-
Management ofTemporo-
provide abasisforinitiating
ample, incases involvingthe
use ofcertainalloplasticim-
plants-the resultshave been
disastrous. Forthe majorityof
mandibular
Disorders, withthe
therapeuticinterventions?
encouragement ofpatient-based
-
What are effective ap-
supportgroups. The conference
~~~~on
proaches totheinitialmanage-
was cosponsored bythe
ment and treatment ofpatients
TMD patients, the absence of
National InstituteofArthritis
withvarious TMD subtypes?
universallyacceptedguidelines
forevaluationand diagnosis
and Musculoskeletal and Skin
-
What are effectiveap-
Diseases, the
National Institute
proaches tomanagement and
compromis-
ofNeuro-
treatment ofpatientswith per-
esthegoals
logical
Downloaded from jada.ada.org on March 30, 2010
ofconsistent
Disorders
sistentTMD pain and dysfunc-
tion?
and conser-
and
-
What arethemost pro-
vative ther-
Stroke,
apy. The
the
lackofstan-
National
ductive directionsforfuturere-
search, and what types ofnew
collaborations and partnerships
dardtreat-
Institute
shouldbe developedforpursu-
ment proto-
ofNursing
ingthese directions?
colss
Research
accepted
and the
WHAT CLINICAL
across pro-
NIH
fessional
_
u
_
~~~~Officeof
CONDITIONS ARE
CLASSIFIED AS
TEMPOROMANDIBULAR
specialties
Research
means that
DISORDERS, AND WHAT
OCCURS IF THESE
CONDITIONS ARE LEFT
UNTREATED?
many pa-
_
~~~Women's
|_E ~~~Health.
tients and
practition-
This
ersmay at-
conference
tempttherapywithinadequate-
broughttogetherspecialistsin
lytestedapproaches.
clinicaldentistry, medicine,
surgery, cellularand molecular
Classification ofclinical
conditions. From theinforma-
tionprovided, the clinicalcondi-
tionsusuallyclassifiedas TMD
includethosewithpain ordys-
A thoughepidemiological
data are inadequate, the
biology,biostatistics,epidemiol-
functioninthejointorcontigu-
ogy,immunology, behavioral
ous structures. These conditions
totalnumber ofTMD suf-
ferersinthiscountry can be
roughlyestimated atmore than
10 million, and concern about
the safetyand efficacyoftheir
and social sciences, painman-
agement and tissue engineering
and representatives ofthepub-
lic,includingTMD patients and
advocacygroups. Afterone and
are linkedintheirpresentation
bytheircommon signsand
symptoms. Giventhelackof
epidemiologicalinformation and
the collectionofas yetunde-
care requiresthatwe achieve a
betterunderstandingofthese
healthproblems. Not onlymust
validand reliablecriteriafordi-
agnosis and measurement be
developed, buttherationalesfor
and effectivenessofa varietyof
one-halfdaysofpresentations
and audience discussion,this
independent, nonfederaltech-
finedetiologiesthatare likely
nologyassessment panel
weighedthe scientificevidence
tobe describedas TMD, a con-
ventional disease classification
system wouldbe difficultto de-
scribe,possiblymisleadingand
and theexperience ofpatients
unlikelyto receivebroad accep-
treatments currentlyinuse
must be examined as well.
To address theseissues,the
and practitioners and developed
a draftstatement thatad-
dressedthefollowingquestions:
tance. For thetime being,there-
fore,classificationmust depend
primarilyon the detailedde-
-
National Institute ofDental
Research and theNational
What clinicalconditions
are classifiedas temporo-
mandibular disorders,and what
Institutes ofHealth Officeof
MedicalApplications ofRe-
occurs ifthese conditions are
leftuntreated?
scriptionofsymptoms and un-
derlyingconditions.
"Parameters ofCare forOral
and Maxillofacial Surgery"
(1995), developedbythe
search convened a technology
assessment conference on
What types ofsymptoms,
signs and otherassessments
-
AmericanAssociationofOral
and Maxillofacial Surgeons,
1596
JADA, Vol. 127, November 1996
COVERSTORY _ provides usefulinformation of ticipationofmultiple disciplines orspecialties. What occurs ifthese con- ditions are leftuntreated? Well-designed,
COVERSTORY
_
provides usefulinformation of
ticipationofmultiple disciplines
orspecialties.
What occurs ifthese con-
ditions are leftuntreated?
Well-designed, representative,
cross-sectional and longitudinal
few longitudinal clinicalstudies
thistype.
supportthesefindings. There is
Conditions primarilyaffect-
ingthe muscles ofmastication
include systemic diseases of
muscles, such as polymyositis,
no information on ethnicor
racialvariationinthese rates.
Inclinicalcase seriesstudies
inwhichconservative, re-
dermatomyositis, hereditary
studies are scarce.
myopathies and changesinthe
musculature secondarytofunc-
tional disturbances. Conditions
versible,noninvasive therapy
was emphasized,thepresenting
Downloaded from jada.ada.org on March 30, 2010
affectingtheTMJ include
arthritis, ankylosis, growth dis-
orders,recurrent dislocation,
neoplasia, condylefracture and
systemic illness.With respectto
bothmuscular andjoint
Consequently, thenaturalhis-
toryofTMD isnotwell-defined.
In addition, most studiesare
descriptive, with analysesthat
are predictiveorexplanatory
virtuallyabsent. The limited,
signsand symptoms appearedto
improve inthevastmajorityof
patients. Inremainingpatients,
symptoms may persist,recuror
worsen. Few data are available
population-basedepidemiologi-
changes, thoseclassifiedas
functional afflictionofthemus-
cleorpathologyofthejointor a
combination ofboth are most
caldata availableindicatethat
theprevalence ofself-reported
signsand symptoms isbetween
5 and 15 percent, with peak
prevalence inyoung adults(20
to40 years ofage).Although
oftencategorizedas TMD. It
signsassociatedwithTMD have
shouldbe noted thataffliction
ofeitherthejointorthemuscle
may leadto secondary changes
inthe other structure thatbe-
been reported with equalfre-
quencies
thatassessthelong-termcourse
ofthesepatients'conditionsin
the absence ofan intervention.
Limiteddataindicatethatmany
symptomaticpeopledonot seek
treatment. Similarly, minimal
dataare availablefromwhichto
assessthenaturalhistoryof
thisgroup ofpatients.Although
ithas been
formen
suggested
and
thatsocietal
come a furthersource ofpain
women,
barriers and
and functionalimpairment.
some iX- i ,;
prejudices
studies
<i
oftenpre-
A though current diagnos-
show
vent appro-
ticclassifications ofTMD
are based on signsand
symptoms ratherthan on etiolo-
gy, these signsand symptoms
shouldbe classifiedinthelarg-
er context ofothermuscle and
greater
priatetreat-
preva->_
_l
~~~mentof
lence
of
:rXMi
TMD
pa-
symp--
tients,these
toms
(for
relationships
example,
have not
jointdisorders orinthecatego-
self-re-E
been docu-
ryofpain disorders. Lessons
can be learnedfrom diagnostic
portedfa-
_
~~~~mentedin
cialpain)
theresearch.
and therapeutic approaches to
otherjointand muscle diseases.
Forexample, lesscontroversy
inwomen
ofchild-
WHAT
TYPES OF
exists inhipjointdiagnosisor
SYMPTOMS, SIGNS AND
OTHER ASSESSMENTS
PROVIDE A BASIS FOR
treatment, where etiologicclas-
sificationsare betterestab-
lished. On the otherhand, there
INITIATING THERAPEUTIC
INTERVENTIONS?
appears tobe similarcontrover-
syinconditions ofthe lumbo-
sacral spine, such as lowback
bearingage, and a number of
clinicalcase series studieshave
reflectedan overwhelming pre-
dominance ofwomen inthe
thirdand fourthdecades. The
reported discrepancies ingen-
derdifferencesrequire explana-
tion. The lowerprevalence of
pain.As with TMD, diagnosis
TMD signs and symptoms at
and treatment oflowback pain
may involve a number ofpoten-
tialetiologiesthat are difficult
olderages as reportedincross-
Any initiationoftherapymust
be based on a thorough and sen-
sitive analysisofthe patient.
Although some signs and symp-
toms associatedwith certain
intra- and extracapsular disor-
sectional dataisconsistentwith
the self-limitingnature ofsuch
to differentiate andrequire par-
signs and symptoms, and the
ders are well-established, the
etiologyofothersremains am-
biguous and a challengetothe
JADA, Vol. 127, November 1996
1597
COVER STORY practitioner.Althoughnumer- ousassessmentmethods are available,lackofevidenceofthe diagnosticvalueofthesetools must strivetodevelopatreat- ment planthatisevidence- basedandpatient-centered. In devisinganytreatmentplan, (thatis,theirvalidity,reliabili- ty,specificity,sensitivityand
COVER STORY
practitioner.Althoughnumer-
ousassessmentmethods are
available,lackofevidenceofthe
diagnosticvalueofthesetools
must strivetodevelopatreat-
ment planthatisevidence-
basedandpatient-centered. In
devisinganytreatmentplan,
(thatis,theirvalidity,reliabili-
ty,specificity,sensitivityand
cost-effectiveness)contributes
tothisambiguity. Diagnosis
andinitialtreatment,therefore,
thepractitionermustweighthe
patient'sperceptionofpainand
dysfunctionandtheimpactof
be afrighteningand disabling
experienceforpatients.The
TMJ isimportantfunctionally
withregardtospeech, socialin-
teractions,mastication, swal-
lowingandotheroralfunctions,
aswellashearing,insome
theseonthepatient'squalityof
cases.Patientsseekingcarede-
life.Intheabsenceofovert
oftendependonthepractition-
Downloaded from jada.ada.org on March 30, 2010
er'sexperienceandphilosophy,
ratherthanon scientificevi-
pathology, some patientsand
practitionersmay worktogether
servecarefulattention,given
theimportance ofthisareaof
thebody.
toimplementaprogramofpa-
The initialmanagement of
dence.
tientself-managementwithed-
TMD describedbelowassumes
Nonetheless,theconsensusis
ucationandanunderstanding
thatunderlyingsystemicor
thatdiagnosisandinitiationof
oftheroleofpersonalfactors.If
overtjointdiseaseshavebeen
treatmentshouldbebasedon
thepatientdoesnotobtainade-
identifiedandaddressed.
datafromthephysicalexami-
quaterelieffromthesemea-
Patientswithjointarthrop-
nationand shouldincludemedi-
caland dentalhistory;informa-
sures,anumberofconservative,
noninvasive andreversible
athiesandpainfuljawmuscle
conditionsassociatedwithsys-
tionaboutaudiological, speech
treatments cannextbeconsid-
ered.
temicdiseaserequiretreatment
and swallowingproblems;de-
scriptionsofanypainand dys-
function; and considerationof
psychosocialfactors;aswellas
fortheunderlyingdisease.
Whilethesepatientsmay also
A tpresent,theevidenceis
insufficienttowarrant
needtherapydirectedspecifi-
datafromimagingandotherdi-
prophylacticintervention
agnostictests.Evaluation
shouldencompass examination
oforofacialtissues,musculature
formanagement ofTMD, nor
aretheredataprovidingclear
callytotheTMJ andrelated
structures, suchtreatment
mustbecarefullycoordinated
withthatprovidedforsystemic
evidencethatorthodontictreat-
andneurologicalfunction.
mentprevents,predisposesone
disease.When thereisdisease
oftheTMJ itself(suchasneo-
Particularattentionshouldbe
paidtodeterminations offunc-
tionalrangeofmotion,occlusal
status,existence ofparafunc-
toorcausesTMD. Even so,
some practitionershavecarried
plasias,whichfrequentlyre-
outocclusaladjustments, exten-
quiresurgicaltherapy),that
diseasemustbetheprimary
siverestorationsormanage-
tionalconditions(forexample,
clenching,grinding)andthe
ment ofdisplaceddisksorjoint
soundsintheabsenceofpainor
focusoftreatment.
Although avastarrayof
therapeuticmodalitieshave
presenceofjointormuscleten-
dernessand cutaneous hyperal-
lossoffunction.
Givencurrentevidence, spe-
cialemphasis shouldbeplaced
beenofferedtoTMD patients,
thereisapaucityofclinical
gesia.Psychosocialassessments
studies,andespeciallyrandom-
shoulddetermine theextentto
ontheavoidanceofextensive
ized,controlledclinicaltrials,to
whichpainanddysfunctionin-
restorativeprocedurestotreata
guidemanagement ofthesepa-
terferewithordiminishthepa-
disorderthatmay changeover
tient'squalityoflife.However,
time.
tients.Giventhatmostpatients
have aself-limiteddisorderand
theconsiderationofpsychoso-
thatavarietyofdifferentthera-
WHAT ARE EFFECTIVE
cialfactorshasthepotentialfor
piesappeartoresultinsimilar
APPROACHES TO THE
inappropriateuse,anditisim-
INITIAL MANAGEMENT
improvementsinpainanddys-
AND TREATMENT OF
perativethatsuch assessments
function,cautionisurgedwith
PATIENTS WITH VARIOUS
bemanagedbyskilledprofes-
TMD SUBTYPES?
regardtouseofinvasiveand
sionalsusingvalidatedinstru-
otherirreversibletreatments,
ments.
Initialmanagementisdefined
particularlyintheinitialman-
Currentlyavailableepidemi-
asthefirsttreatmentthepa-
agementofTMD.
ologicalevidencesuggeststhat
TMD isfrequentlyself-limiting.
The practitionerandthepatient
tientreceivesafterseeking
A number ofnoninvasiveand
care. Painand dysfunctionof
reversibletherapiesarewidely
themasticatoryapparatus can
usedandappeartohelpmany
1598
JADA,Vol. 127,November 1996
COVERSTORY _ patients. Optimally, these inadvertently occur as a result therapies should have low morbidity and
COVERSTORY
_
patients. Optimally, these
inadvertently occur as a result
therapies should have low
morbidity and minimal alter-
ation ofunderlying anatomic
structures. These therapies in-
been commonly used in other
neurological and muscu-
loskeletal disorders. These
therapies generally are conser-
vative and noninvasive.
Benefits toTMD patients have
ofrestorative procedures.
A ftertheseinitialthera-
peuticinterventions, a
clude the following:
Supportive patient edu-
cation. Initial attention
should be given tothe issue of
patient education on what is
known about TMD and the fact
thatmost ofthese problems
follow a benign course. Many
experts recommend thatpa-
tientsundergo education di-
rected at eliminating certain
behaviors perceivedto be
harmful, such as clenching and
grinding. Some experts recom-
mend exercise and stress man-
agement. Rest and dietary
modifications may help some
patients.
-
been described, although few
mallnumber ofpatients
may continuetoexhibitsymp-
data are availableto document
these results.
toms associatedwiththeTMD
constellationofconditions.
-
Downloaded from jada.ada.org on March 30, 2010
Intraoral appliances.
Stabilization splints are con-
sidered noninvasive and re-
These patientswillrequire con-
siderationforlonger-term
and/ormore
invasivetherapies.
versible and are recommended
by many experts forearly
treatment ofthese patients. It
isimportant thatthese appli-
ances are ofa type that does
not lead to major alteration of
WHAT ARE EFFECTIVE
APPROACHES TO
MANAGEMENT AND
TREATMENT OF
PATIENTS WITH
PERSISTENT TIVD PAIN
AND DYSFUNCTION?
the patient's occlusion. Reposi-
tioning appliances may appear
An importantminorityofTMD
patientsprogresstopersistent
to be noninvasive but have the
potential forcreatingirre-
versible changes in occlusion
painand/ordysfunction. This
minorityrepresents aheteroge-
neous group ofdisorders. There
Pharmacologic pain con-
trol. Medication may be useful
forinitial symptom manage-
ment. The medications useful
forTMD are similartothose
useful forother painful muscu-
loskeletal conditions. Nonster-
-
and, consequently, the possi-
bilityofprecipitatingother
problems.
arefewrandomized controlled
clinicaltrialstogiveus guid-
ance regardingthetreatment of
-
Occlusal therapy. Much
controversy surrounds the use
ofocclusaltherapy. The advo-
cates argue thatocclusal ab-
normalities and/orjointmanip-
patientswithpersistentpain.
Althoughmany ofthe conserva-
tivemodalitiesthatwere imple-
mented intheinitiationof
oidal anti-inflammatory drugs
treatment may continue tobe
(NSAIDs) and opiates are the
mainstay ofpharmacologic
ulationprecipitatethe
development ofTMD. Occlusal
therapies are aimed atmodifi-
used, otherstrategiesmay re-
pain treatment. Some clini-
quireconsideration duringthis
phase oftreatment.
cians alsohave found muscle
relaxant medications and low-
cation ofthe occlusionitself
through alterationofthe tooth
Forthepatientwithepisodic
dose antidepressants ofa se-
datingtype tobe useful in ini-
tialmanagement ofTMD.
structure orjaw position.
Other medications alsohave
been used forspecificindica-
tions. In allcases, the clinician
Given thatthislattertherapy
isirreversible, and giventhat
the superiority ofthistreat-
signsand symptoms, anoninva-
sive,conservative approach
shouldbeimplemented. Forthe
patientwithpersistent,non-
remittingsignsand symptoms,
must weigh the riskofside ef-
ment over reversible therapies
has notbeen demonstratedin
randomized, controlled
fects against potentialbene-
fits,alongwith his orher own
prospective trials,thisform of
occlusal adjustmentprobably
a stepwiseapproachshouldbe
implemented. In some cases,
thesetreatments areintended
toprovidesymptomatic care,
whereasinotherstheyarein-
professional competence inthe
administration and manage-
willnot representthe best
tendedtoalterthecourseofthe
practiceforinitialmanage-
condition.Althoughsometreat-
ment ofsuch medications.
ment ofTMD. However, assess-
mentsrestrictedtotheTMJ and
Physical therapy.
Physical therapy applications
to TMD include a wide variety
ofevaluative techniques and
treatment modalities thathave
-
ment ofocclusion isnecessary
as part ofthe initialoral exam-
ination toidentifyand elimi-
oralstructureshavebeenoverem-
phasized,othertreatmentssuch
aspharmacotherapeuticsappear
nate gross occlusal discrepan-
tohavebeenunderutilized,orin-
cies such as those thatmay
appropriatelyused.
JADA, Vol. 127,November 1996 1599
-COVER STORY Downloaded from jada.ada.org on March 30, 2010 cracksof edicineandd- %Wo Compenstionand tistry.Conseqely, th aw
-COVER STORY
Downloaded from jada.ada.org on March 30, 2010
cracksof edicineandd-
%Wo
Compenstionand
tistry.Conseqely,
th aw
SocialSecurity.Thelossofpro-
jointshavenotreceivedaptro-
ductivity,asaresultofthepa-
priat resec andattention
fromheathcareproviders
tients'chronicpainand/ordys-
andthemedia. Fromlackof
function,affectstheentire
community. Indeed,thesitua-
As theinterventionbecomes
careofpatientswithpersistent
painpatients,treatedwithade-
increasinglyaggressive,invasive
quatedosesofopiates,can
andirreversible,thepatientand
TMD painand dysfunction.
Pharmacologic therapies.
achievesuccessfulcontrolof
practitionershouldshareacom-
Theprinciplesformanagement of
symptoms withoutadverseef-
mon understandingofthescien-
thepainassociatedwithpersis-
fects.
tificbasis,indications,goals,
tentTMD arethesame asthose
risksandbenefits,andhistoryof
theproposedintervention. It
fortreatment ofotherchronic
painconditions.Opiatesand
shouldbeclearlyrecognizedthat
NSAIDs arerecognizedasmain-
surgeryisindicatedinonlya
smallpercentage ofpatients.
staysforanalgesicmanagement
Adjuvant analgesics repre-
sent a diverse group ofdrugs,
includingtricyclics, antidepres-
sants, anticonvulsants, mem-
brane stabilizers, sympatholytic
and shouldbeusedcommensu-
ratewiththelevelofpain.
agents and others. These
FFrom thedataprovided,no
A majorconcernregardingthe
groups ofdrugs are likelytobe
more efficaciousin neuropathic
singletreatmentorcombi-
use ofopiatesinthepasthas
nationofprocedureswas
beenthepotentialofaddiction,
pain states but may be consid-
eredforpatientswho respond
demonstratedtobeeffectivein
analgesictolerance,uncontrolled
poorlyto or are unable to toler-
randomized,controlledclinical
trials.Giventhelackofevidence,
no specificrecommendations can
sideeffectsandtoxicityassociat-
edwithlong-termuse. More re-
centwork,however,suggests
ate NSAIDs and opiates.
Pain disorders may resultin
impaired sleep. Hypnotics may
bemade. However,thefollowing
thattheseconcerns oftenarenot
wouldbeusefultoadvancethe
warrantedandthatmany chronic
be usefulto improve sleeppat-
terns, which inturn benefitthe
1600
JADA, Vol. 127, November 1996
COVERSTORY patient's overall health status. theuse ofany implants.Atthe ments for patientswho haveen- Many pain experts believe
COVERSTORY
patient's overall health status.
theuse ofany implants.Atthe
ments for patientswho haveen-
Many pain experts believe that
same time,itisrecognizedthat
teredthe
phaseofTMD
charac-
a major comorbidity associated
certainpatientsare inneedofim-
terized
bypersistentpainand
with chronic pain isdepression
and that medical treatment of
plants,andnewer implantde-
dysfunction,although
some such
signsneedtobefullyassessedas
approaches
are under
develop-
depression may conferbenefit
quicklyas possible.Forpatients
ment.
Alongwithfunctionalim-
to such patients.
pairment,patientswithTMD
Occlusal therapies. Some
who alreadyhavehadimplantor
otherinvasivesurgery, additional
may experienceaesthetic
impair-
experts believe occlusal adjust-
surgicalinterventions(withthe
ment associatedwithfailedinter-
possibleexceptionofimplantre-
ventionsand/orpersistentpain.
Downloaded from jada.ada.org on March 30, 2010
ment may be helpfulinthis
group ofpatients, and some ex-
moval)shouldbeconsideredonly
The
resultingnegativeself-
perts alsoargue thatocclusal
adjustment shouldbe performed
before surgicalprocedures.
Randomized trialsare needed to
withgreatcaution,sincetheevi-
image,disappointmentandfrus-
denceindicatesthattheprobabil-
trationaddtothestressassociat-
ityofsuccess decreaseswitheach
edwithTMD.
Psychological
additionalsurgicalintervention.
establishthe effectiveness of
such approaches. Based on
Forsuchpatients,themost
strategiesestablishedforother
chronicconditions may beuseful
promisingimmediatelyavailable
in
supportingpatientswho
are
availableinformation, however,
occlusal adjustments thatper-
treatmentmay bea patient-cen-
tered,multidisciplinary,pallia- tiveapproach.
managingpersistentpain,social
debilitationandtheensuinglife
manently altera patient's occlu-
sion shouldbe avoided.
Surgical approaches.
stressassociatedwithTAM.
Relaxationandcognitivebehav-
ioraltherapieshavebeenshown
Randomized, controlled clinical
Psychosocialissues.Patients
withpersistentTMD problems
may suffer
tobeeffec-
trialsto support the efficacyof
psychologi-
tivein
individualsurgical procedures
have not been performed. A
spectrum ofsurgical interven-
callyandso-
~~~~managing
S
cially be-
_
~~~~~chronic
cause ofpain
pain, al-
tions has been appliedto the
group ofpatients with patholo-
anddysfunc-
though
tion.Failed
datafrom
gy ofthe TMJ. These approach-
treatments
controlled
es include arthrocentesis,
arthroscopy, arthrotomy/arthro-
plasty, condylotomy, orthog-
nathic surgery and even total
andrecur-
studiesare
rentpain
_
not avail-
episodes con-
ablere-
tributetolife
garding
TMJ replacement.
theireffi-
stresses with
Indicationsforsurgery include
a pattern of
cacy in the
one or more ofthefollowing:mod-
frustration,
_
~~~~manage-
erate tosevere pain,dysfunction
hopelessness
w
~~~~mentof
thatisdisablingand/orevidence
ofpathologicalconditions.
Expertswho performtheseproce-
andeven de-_
pain asso-
pression.The
ciated
lifestressas-
withTMD.
duresquote highrates ofsuccess
inthishighlyselectgroup ofpa-
sociatedwithpersistentpainand
dysfunctionrelatedtoTMD has
notbeenadequatelyunderstood
fromthepatient'sperspectiveor
fromtheperspectiveofimpacton
WHAT ARE THE MIOST
PRODUCTIVE DIRECTIONS
tients;however, a smallpercent-
FOR FUTURE RESEARCH,
age ofthesepatientsexperience
deteriorationoftheirconditions.
The use ofcertainalloplastic
AND WHAT TYPES OF NEW
socialfunctioning.
COLLABORATIONS AND
PARTNERSHIPS SHOULD
BE DEVELOPED FOR
PURSUING THESE
implantsinsurgery forTMD has
Psychologicaltreatment
DIRECTIONS?
resultedindisastrousconse-
strategieshavenot alwaysbeen
quences formany patientswho
underwent suchtreatment.
Consequently, utmost caution
tailoredtotheindividualneedsof
TMD patients.Nordoesthereap-
pear tobe a well-acceptedmodel
Thefollowingdirectionsforfu-
tureresearchshouldbeconsid-
ered:
mustbeutilizedinconsidering
forsupportivetreatmentenviron-
Atpresent,TMD isbestde-
JADA, Vol. 127,November 1996 1601
COVERSTORY scribedanddiagnosedinthecon- tionalapproachtodevelopingdi- basicresearchwithrespectto textofdetailedinformationabout presentingsymptoms andfullas- sessmentofrelatedfactorsand agnosticprotocolsandappropri- TMD. Thisresearchshouldin- atetreatmentmodalities.This cludebothhuman and animalre- approachshouldleadtoalabel-
COVERSTORY
scribedanddiagnosedinthecon-
tionalapproachtodevelopingdi-
basicresearchwithrespectto
textofdetailedinformationabout
presentingsymptoms andfullas-
sessmentofrelatedfactorsand
agnosticprotocolsandappropri-
TMD. Thisresearchshouldin-
atetreatmentmodalities.This
cludebothhuman and animalre-
approachshouldleadtoalabel-
searchintothemechanisms of
conditions.A moreconventional
diseaseclassificationsystem
wouldbedifficulttodevelop,and
couldbemisleading, giventhat
ingof"subtypes"thatcouldper-
persistentpainassociatedwith
mittheeliminationoftheterm
theorofacialregion,theriskfac-
TMD, whichhasbecome emotion-
torsforpersistentpainand/or
allyladenandcontentious.
dysfunction,theriskfactorsand
(a)necessaryepidemiologicalin-
Randomized,controlledclini-
caltrialsareneededtodetermine
-
cost-benefitconsiderationsof
formationislacking,and(b)the
long-termopioiduseinthetreat-
Downloaded from jada.ada.org on March 30, 2010
etiologiesunderlyingthecondi-
tionscalledTMD havenotbeen
theefficacyofTMD treatments.
Thesestudiesshouldinclude
ment ofTMD, theetiologyofgen-
derdifferencesandthebiome-
adequatelydefinedandde-
measures ofbothclinicaloutcome
chanicsoftheTMJ andimplants.
scribed.Carefullydesigned,ana-
andcost-effectiveness.
-
Innovativemethods directed
lytical,cross-sectional,popula-
-
Longitudinalstudiesshouldbe
attheconstructionofprostheses
tion-basedstudieswith
conductedtoidentifyboththenat-
fromlivingtissueshouldbeen-
appropriateclinicalmeasures
uralhistoryofthenonspecific
couraged.Bioengineerscanmake
andbiologicalmarkers shouldbe
signsandsymptomsassociated
importantcontributionstoTMD
conductedtoidentifythepreva-
withTMD andthepotentialrisk
research,includingstudieson
lenceofpresentingsignsand
symptoms forTMD, excluding
factorsusingpredictiveandex-
themechanicalproperties,
planatorystatisticalmethodolo-
biostabilityandbiocompatibility
well-definedsystemicconditions.
gies.Thesestudiesshouldbede-
ofmaterialsusedinimplants.
Thesestudiesshouldidentifyas-
signedtoelucidatetherelationship
CONCLUSIONS
sociations
between
withpoten-
*
~~~signs
and
Evidencepresentedatthetech-
0
tiallypredis-
symptoms,
nologyassessmentconferenceled
posingand
andetiolo-
tothefollowingconclusions:
precipitating
gy.
-
Thereare significantprob-
conditions.
- Treat-
lemswithpresentdiagnostic
Frequently
ment pro-
reported
tocols
genderdif-
shouldbe
classificationsofTMD,because
theseclassifications appeartobe
basedon signsand symptoms
ferences
developed
ratherthanonetiology.
~~~~~forap-
-
warrantfur-
_
Consensushasnotbeende-
therinvesti-
proaches
velopedacrossthepracticing
gation.
aimedat
communityregardingmany is-
-
Validated
fostering
diagnostic
sues,includingwhichTMD
problems shouldbetreatedand
methodsfor
tient's con-
when andhow theyshouldbe
identifica-
troland
treated.
-
tionand
sustaining
classificationofTMD patientsare
needed.The diagnosticvalueof
theseassessmenttechniques
orenhancingsocialfunctioning.
The preponderanceofdata
doesnot supportthesuperiority
Researchshouldalsobedirected
ofanymethodforinitialman-
atunderstandingself-manage-
agement ofmost TMD problems.
shouldbeestablishedwithre-
ment ofTMD signsandsymp-
specttothecriteriaofsensitivity,
toms.
Moreover, the superiorityof
suchmethods toplacebocontrols
specificity,reliabilityandcost-ef-
-
Incentives shouldbeprovided
orno treatment controlsremains
fectiveness.
fortheprivatepracticeandaca-
undetermined. Because most in-
When sufficientdataare
available,amultidisciplinary
classificationsystembasedon
-
demiccommunitiestocollaborate
dividualswillexperienceim-
indesigningandconducting
well-controlledclinicaltrialsof
provement orreliefofsymptoms
withconservativetreatment, the
measurablecriteriashouldbede-
treatments fortheseconditions.
vastmajorityofTMD patients
-
velopedasthefirststepinara-
Thereisan obviousneedfor
shouldreceiveinitialmanage-
1602
JADA, Vol. 127,November 1996
COVERSTORY- ment usingnoninvasive andre- versibletherapies. The most promisingap- proachestomanagement and - cate,nonfederalpanelof experts,based on presentationsbyinvestigatorswork- ing
COVERSTORY-
ment usingnoninvasive andre-
versibletherapies.
The most promisingap-
proachestomanagement and
-
cate,nonfederalpanelof
experts,based
on
presentationsbyinvestigatorswork-
ing
inareas
relevanttotheconference
-
The efficacyofmost treat-
treatment ofpatientswithper-
questionsduring two-daypublic
a
ses-
ment ap-
sistent
sion;questionsandstatements
fromcon-
proachesfor
TMD pain
ferenceattendeesduringopendiscussion
TMD isun-
periodsthatare
partofthepublicses-
known,be-
function
sion;andcloseddeliberationsbythe
panelduring
theremainderofthesecond
cause most
may result
dayandmorningofthethird.Thisstate-
havenot
from evi-
ment isan independentreportofthe
been ade-
dence-
panelandisnota policystatementofthe
Downloaded from jada.ada.org on March 30, 2010
quately
based
NIH orthefederal
government.
evaluatedin
Preparation
anddistributionofthis
practice
A_ ~~~~and
statementistheresponsibilityofthe
long-term
pa-
OfficeofMedicalApplicationsofResearch
studies and
tient-cen-
oftheNationalInstitutesofHealth.Free
virtually
teredcare.
copiesofthisstatementandbibliographies
none inran-
Relaxation
preparedbytheNationalLibraryof
domized,
Medicineare availablefromtheOfficeof
I_~~~~~n
cogni-
MedicalApplicationsof Research,
controlled
tive-be-
NationalInstitutesofHealth,ortheNIH
group trials.
havioral
ConsensusProgramInformationCenter
Although
therapies
by24-hourvoicemail.Inaddition,free
clinicalob-
areeffec-
copiesofallotheravailableNIH
servation can providedirection,
theseinsightsmust befollowed
ConsensusStatementsandNIH
tiveapproaches tomanaging
chronicpain. Physicaltherapy
approachesneedtobe scientifi-
TechnologyAssessmentStatementsmay
beobtainedfromthefollowingresources:
byrigorous scientificevaluation.
NIH Consensus
Program
-
There are no datatosupport
some commonlyheldbeliefs.For
example, evidenceisinsufficient
towarrant prophylacticmodali-
callyevaluated,as doalternative
medicinemodalities.
Information Center
P.O. Box 2577
Future advances indiagnosis
andtreatment ofTMD willoccur
-
Kensington,Md. 20891
Telephone: 1-888-NIH-CONSEN-
SUS (644-2667)
tiesoftherapy.Additionally,
Fax: 1-301-816-2494
availabledataare notpersua-
sivethatorthodontictreatment
as theresultofmultidisciplinary
collaborations among a number
prevents, predisposes one toor
causes TMD. Therapiesthatper-
offieldsinvolvingbasicand ap-
pliedscienceandpractice.
NIH Office ofMedicalApplications
ofResearch
Federal Building,Room 618
-
Professionaleducationis
manently alterthepatient'soc-
clusioncannot berecommended
on thebasisofcurrent data.
neededtoensure proper and safe
7550 WisconsinAve. MSC 9120
Bethesda,Md. 20892-9120
practiceinthetreatment of
TMD, especiallywithregardto
Although noninvasivethera-
piesare clearlypreferredfor
-
pharmacologic, surgicalandbe-
This draftsummary and the full
textofotherNIH statements are also
available online throughthe Internet:
most TMD problems,inthe
havioralapproaches. Moreover,
ifpatients aretoknow where to
Gopher
smallpercentage ofpatients
withpersistentand significant
painand dysfunctionwho show
seekhelp,andifinsurancecom-
gopher://gopher.nih.gov/
panies are tofullyacknowledge
theneedfortreatment ofTMD,
Health and Clinical Information
World Wide Web
evidenceofpathologyorthatan
internalderangement ofthe
TMJ isthesource oftheirpain
a consensus must bedeveloped
http://text.nlm.nih.gov/nih/nih.html
regardingtheprofessionalexper-
tiseneededtodiagnoseandtreat
and dysfunction,andforwhom
theseserioushealthproblems.
.
more conservative treatment has
failed,surgicalintervention
shouldbe considered.
NIH TechnologyAssessment
Statementsarepreparedbyanonadvo-
JADA, Vol. 127,November 1996 1603