The Evolution of TMD
From Syndrome to Specific Disease...
And How That Affects Treatment
By Jerry Simon, DDS, FAGD

For most of my professional career two questions stand out more than any other as being mired in controversy and despite great efforts unable to be definitively answered in the eyes of many, “Is occlusion a causative factor in TMD?” And the nearly parallel question, “How should tempro mandibular disorders be treated, and by whom?” There are so called “experts” on both sides of the answer. As a result, the medical and dental profession as a whole has been stymied in making significant progress in treating this disease, despite wealth of research and thousands of practitioners’ decades of success in treating tens of thousands of patients.

The problem is that we have really been asking the wrong question. The question that we needed to be asking first was, “What are tempromandibular disorders?” Once that question is posed and answered it is likely that the rest of the controversy, largely one of semantics, will resolve.

Tempero mandibular disorders (TMD) have evolved like most diseases. First there were initial signs and symptoms that were observed and reported without causality or understanding. Next it evolved to syndrome status after tenuous relationships between the symptoms were observed, assumptions proposed and treatments suggested. Finally through research and clinical experience TMD’s have developed to the third phase of the third step of evolution, a mature disease which is typified by clear understanding of the scope of disorders, their unique causes and individual treatment protocols.

Why does the controversy continue? For a variety of reasons a majority of the dental, medical and patient communities have failed to join us in the educational and research journey that has facilitated effective diagnosis and predictable care.

It is our responsibility as members of the AACFP and doctors of the tempro mandibular system to share our knowledge, understanding and research with the rest of the dental and medical professional to facilitate care for the millions of patients in need of treatment.

The goal of this article is two fold, first to consider the journey from syndrome to disease. Second to demonstrate how the two step gold standard of deprogramming and load testing is essential for diagnosis and treatment among TMD experts as well as helping less experienced clinicians transition their understanding of TMD from syndrome to disease.

The Evolution from Syndrome to Mature Disease Syndrome

• A series of loosely associated signs and symptoms that cannot be defined, tested for, or measured.
• There is confusion about the etiology and treatment is symptomatic and based on trial and error.
• Methods of treatment are variable and outcomes are not predictable.
• Often patients and practitioners are frustrated by failed treatment and lack of professional agreement. Failure of treatment is sometimes blamed on the patients’ psychological issues.

The quote below, from the current Pennsylvania State College of Medicine Faculty Research / Faculty Expertise Database web page demonstrates the lack of many professionals ability to understand TMD. This definition closely resemblances the outdated definition of TMD popular in the 1950s.

“Tempromandibular Joint Dysfunction Syndrome syn. Myofacial Pain Dysfunction Syndrome, TMJ Syndrome; Tempromandibular Joint Syndrome; Costen' s Syndrome; n.
A symptom complex consisting of pain, muscle tenderness, clicking in the joint, and limitation or alteration of mandibular movement. The symptoms are subjective and manifested primarily in the masticatory muscles rather than the tempromandibular joint itself. Etiologic factors are uncertain but include occlusal disharmony and psycho-physiologic factors.” Source: Penn State University Web Site, July, 2005

Notice in the early syndrome stage practitioners, by definition, have little understanding of the disease process. It is also important to note that there is an emphasis on the psychological causality and deficiency in, and blaming the patient, for the symptoms, versus placing the diagnostic responsibility on the professional. Finally notice the vagueness of language. Sadly this is the leading definition of TMD published by a major university in 2005. This reflects the unfortunate lack of understanding of TMD in the minds of many researchers, faculty and medical professionals.

Transition To Disease

• Specific signs and symptoms become better understood and measurable resulting in a homogenous disease.
• Practitioners still disagree with terminology.
• Causality remains unclear.
• Treatment methods are improved but and outcomes are variable, inconsistent and unpredictable.

Mature Disease

• A series of specific sub categories of separate and individually defined disease states.
• Each of these sub categories contains its own agreed causality, measurable signs and symptoms as well as their individual treatments.
• Disagreement among practitioners becomes more specific as methods of treatment become more consistent in methodology, consistency and results.

As a disease matures the definition of course becomes more refined and specific. Compare the common definition of the mature disease TMD below to the syndrome definition provided earlier in the article. Notice the greater specificity and definability.

Tempero mandibular disease n.

1. series of different signs and symptoms that result from an abnormal / unbalanced relationship between the maximum intercuspation of the teeth and the position of the condyles in the fossa,
2. degenerative, inflammatory or infectious diseases of the mandibular condyle, fossa, disc or articular eminence.

TMD Is Not A Diagnosis

TMD is not a disease, it is a joint that every one has, and actually, we all have two of them. There are three main systems of the T M Joint that are affected by a dysfunction. They are: the teeth and oral structures, the muscles and the internal aspects of the joints including the soft tissues of the disc and the bony structures. A great deal of misunderstanding, poor research and failed treatment results from a failure to diagnose, differentiate, communicate about and treat the specific disease and its etiology.

Old Diagnosis:

• Patient suffers from tempromandibular dysfunction.

Mature Diagnosis: (A few but not all examples are provided below)<

• Dental damage subsequent to clenching or grinding their teeth (i.e. worn, broken loosened teeth or abfractures, which might cause pain or not).
• Muscle contraction pain secondary to tooth clenching and grinding.
• Secondary migraine that has been triggered due to the central sensitization in the brain from pain from muscles.
• Displaced disc resulting in reciprocal click
• Compromised condylar perfusion (CCP) resulting in degeneration or lack of growth from blockage of blood flow to the condyle.
• Alteration in occlusion due to change in condyle anatomy or position.
• Crepetice in the joint.
• Hyperplasia of the condyle.
• Muscle trigger points in the head or neck.
• Hypoplasia of the condyle.
• Fractures of the condyle.
• Pain in the disc due to retro discitis secondary to tooth clenching.
• Pain in the condyles due to AVN or osteo arthritis secondary to tooth clenching.
• Pain in the joint due to an infection, a cyst or a neoplasm in the joint.
• Pain referred to the T M Joint from something else like a myocardial infarction.

Figure: Prism.jpg, Caption: 3 fundamental manifestations of TMD Figure: Circle.jpg, Caption: Symptoms of TMD

Summary of Cases Presented At AACFP Annual Meeting 2005>

Case reports including histories, photographs and TM joint MRIs of 7 patients were presented at the AACFP Meeting. After diagnosis it was determined that:

• Six of the seven patients presented with pain.
• Five of the seven patients presented with internal derangement of the T M Joints, but only two had any pain from that condition.
• Four of the seven patients presented with pain that was from muscle.
• Two of the patients presented with pain that was from the internal joint structures.

For this collection of patients, a common cross section of people commonly seen in a general dental practice, it was impossible to develop a correct diagnosis and treatment protocol based on the MRI and the clinical history alone. That is because many patients do have degenerative joint disease, or occlusal imbalances or pain, but they are not always connected in a causal relationship. The additional steps of deprogramming and load testing are always required. While these procedures are not new, but most dentists are not adequately trained to perform them correctly and in such as way as to consistently obtain reliable diagnostic data.

Deprogramming

When the condyles are centered in the joint socket, minimal muscle energy in required to stabilize the joint. Often the position of maximum intercuspation of the teeth does not coincide with the centered position of the condyles. Any conflict between a centered position of the condyles and the maximum intercuspation of the teeth will force the condyles to be distracted from that centered position in the glenoid fossa. This will occur each time the patient bites completely together such as during swallowing or in the final stages of the chewing cycle. This distracted position will always require additional muscle energy to stabilize the joint structures. As a result, some patients experience chronic muscle strain or spasm , with or without symptoms of pain. Other patients experience tooth clenching and / or grinding which leads to degeneration of the disc. In some cases relieving the influence of occlusal interferences on the muscles can produce a remarkably rapid reduction in symptoms , both in cases where muscles are the primary cause of pain or a trigger for a secondary pain.

In order to center the joints, the muscles must completely relax. In order for the muscles to relax, the joints must completely center, but the joints will not completely center if the muscles will not relax. The biggest problem is that most practitioners use too much force to attempt to get the joints centered and as a result they cause the muscles to engage in the natural motor response of “pushing back” which prohibits the jaw joints from centering. This problem is not a new one and the solution to break the cycle of spasm and pain has been to separate the teeth and deprogram the muscles with a deprogramming device. Among the first reported deprogrammers were the leaf gauges developed by Dr. Long in the 1930’s. Dr. Peter Neff published his work about deprogrammers in his book “TMJ, Occlusion and Function.” and Dawson wrote of constructing a chair side anterior deprogrammer in his text “Evaluation, Diagnosis and Treatment of Occlusal Problems.” Many others have taught various deprogramming techniques.

For the aforementioned cases the author selected a prefabricated customizable anterior deprogrammer (Best-Bite Discluder, Best-Bite Inc.) The device is a semi customizable, one size fits virtually all patients with out alteration that is fixed onto the upper front teeth with polyvinyl siloxane bite registration material and provides an 8 degree inclined surface for the lower incisors to occlude against to separate any interfering cuspal inclines and to gently guide the condyles into a centered, free of muscle bracing position.
Figure: Anteriordep.jpg “Anterior deprogrammer centers jaw joints”

Load Testing, a technique described by Dr. Peter E. Dawson in his book “Evaluation, Diagnosis, and Treatment of Occlusal Problems,” is used to verify the health of the joint /disc assembly. The technique is accomplished by placing the thumbs in the crease of the chin and the index and third fingers in the gonial notch of the mandible. Next a twisting motion is applied to simultaneously push down in the front and lift up at the rear to apply pressure up through the condyle into the joint capsule. Comfort during this procedure indicates a healthy jaw joint.

If a pain free load test can be achieved when the jaw joints are centered, that indicates that the muscles are not actively bracing the condyles and that there is no pain coming from within the joint capsule. In that case a bite splint fabricated with a bite jaw taken at this position with anterior guidance will be predictably effective in relieving the patient’s pain.
Figure: Loadtest.jpg, Caption: “Load testing”

Case 1: This patient presented with head, neck and facial pain. It based on the MRI it would be easy to jump to the conclusion that the pain was from the damaged joints and not from occlusion. The correct diagnosis was obtained by deprogramming which relieved headache pain.

Diagnosis: Osteochondrosis and muscle pain due to occlusion
Treatment: Centering bite splint, anti oxidants and natural joint supplements CS and GA.
Result: Headache pain relieved.
Future: Concern of AVN due to large displaced disc.

Figure: MattMRI.jpg, Caption: “X-Ray shows severe condylar breakdown”

Case 2: This patient presented with the inability to open more than 6mm. Her previous dentist diagnosed a closed lock based on her MRI. She was referred for surgery. The correct diagnosis was obtained by a combination of deprogramming which increased range of motion to 39mm in 12 minutes and load testing to verify the health of the bony structures.

Diagnosis: Limited range of motion due to severe muscle spasm.
Treatment Deprogram, bite splint and equilibration.
Result: Full range of motion restored.


MichelleMRI.jpg, Caption: “Anterior displaced disc when closed” MichelleMRI2.jpg, Caption: “Disc recaptures with opening”

Case 3: If a pain free position cannot be achieved to load testing, that means that either the muscles are still splinting, or if they are indeed relaxed, that there is pain coming from within the joint from the disc or the bony structures. To determine that the patient is allowed to slightly protrude the mandible a millimeter at a time. If the patient can achieve a pain free load test after moving forward of the centered position, but load testing in the centered position still causes pain it indicates that the source of the pain is likely to be from damage in the retro discal tissues (from edema often secondary to trauma). A treatment protocol for this patient may include a forward posturing bite splint to be worn 24/7 for 2-6 weeks to allow the tissues to heal. After that period it is generally possible for the condyles to be taken back from the treatment position to the centered position.

Biterecord.jpg, Caption: “Anterior position bite record” Fowardsplint.jpg, Caption: “Anterior positioning bite splint”

If after forward posturing is utilized a pain free load test cannot be obtained, then it is likely that pain is from the bony structures and the author recommends an MRI and CAT scan to evaluate the joint structures. This type of patient might exhibit osteo arthritis or AVN and a course of treatment utilizing a centering bite splint with mild anterior guidance and posterior point contacts only with as much freedom of movement as possible along with non steroidal anti inflammatory drugs, anti oxidants such as vitamin C and E, Co – enzyme A, and drugs to enhance joint lubrication such as glucosamine and chondroiten sulfate as well as a soft diet to attempt to get the patient through a period of osseous breakdown.

Evaluation of the disc in position and size if displaced is essential to achieve a diagnosis of the joint. In some cases a surgical procedure may be appropriate and consultation with an appropriate practitioner may be indicated. A verified diagnosis should always be obtained and a therapeutic outcome determined in advance before undertaking any type of procedure, surgical or other wise.

Another important point to remember, especially in the light of recent findings with the very significant adverse side effects of NSAID’s, in terms of causing strokes, heart attacks, liver and kidney damage the old “conservative treatment is best”.

Summary

A great deal of confusion still exists today as to the nature of TMD pain and as a result many patients fail to receive the treatment they require. If practitioners would carefully consider the diagnosis and carefully target their treatment in both clinical care and research by applying the time honored protocol of deprogramming and load testing along with appropriate imaging when indicated I am confident the quality of care, research and level of understanding of tempro mandibular disorders will rapidly increase.

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