TMJCHICAGO.COM

A WEBSITE ABOUT HEADACHES, 
"TMJ" AND FACIAL PAIN

ALLEN J. MOSES, DDS

THE NEW TMJ / TMD PERSPECTIVE

When doctors discuss a disease, they usually assume a common understanding of the medical model and disease process, and that they are discussing the same point of view. Within the dental profession, however, there is controversy as to whether TMD/TMJ is a physiological or a psychological problem, whether it is a disease or an illness, and whether it has anything at all to do with the way the teeth meet in occlusion.

TMJ (Temporomandibular Joint Syndrome), also referred to as TMD (temporomandibular disorders) has long posed many questions for dentists and other health professionals. The panel statement at a 1996 NIH/ NIDR Technology Assessment Conference on Management of Temporomandibular Disorders determined the following:

* The term "TMD" has been used to characterize conditions as diversely presented as pain in the face or jaw joint area, headaches, earaches, dizziness, masticatory musculature hypertrophy, limited opening, closed or open lock of the TMJ, abnormal occlusal wear, clicking or popping sound in the jaw joint, and other complaints.

* Temporomandibular disorders have no common etiology (cause) or biological explanation and comprise a heterogeneous group of health problems whose signs and symptoms are overlapping but not necessarily identical.

* The name "TMD" or "TMJ" is not universally endorsed. Generally accepted, scientifically based guidelines for diagnosis and management of "TMD" are unavailable.

* There are significant problems with present diagnostic classifications of "TMD" or "TMJ" in that these classifications appear to be based on signs and symptoms rather than on etiology.

* Validated diagnostic methods for identification and classification of "TMD" patients are needed.

* A classification system based on measurable criteria should be developed as the first step in a rational approach developing diagnostic protocols and appropriate methodologies. This should lead to a labeling of subtypes that could permit the elimination of the term "TMD," which has become emotionally laden and contentious.

Given the above, perhaps a paradigm shift is in order. Logic dictates that the variables which figure into a diagnosis for orofacial pain must be organized into categories and presented in a manner that can be reasonably comprehended by human minds. It is suggested that clinicians consider themselves not TMJ experts but diagnosticians and treaters of orofacial pain. A diagnostic flow chart is suggested (the Orofacial Pain Diagnostic Hierarchy). It is a result of a search of the medical/dental literature for all diseases and disorders that have orofacial pain as a symptom but no observable pathological lesion. The term "Temporomandibular Disorder" or "Temporomandibular Joint Syndrome" has been eliminated.

Generally, the area of treatment expertise for most dentists is in the "masticatory" category, in which all diseases and disorders involve dysfunctional movement of the masticatory or chewing apparatus, and the odontogenic (or dental) category, in which dysfunctional movement is a factor, but not a primary identifying characteristic.

A diagnosis of TMD or TMJ Syndrome is no longer appropriate. All signs, symptoms, and patient characteristics that constitute clinical data must be considered in order to arrive at a correct diagnosis. Doctors must adjust their thinking to be more specific; the treatment must be appropriate for the specific condition or conditions diagnosed.

Most important, within this redefinition doctors are dealing largely with physiologic problems. All conditions on the Orofacial Pain Diagnostic Hierarchy except those few in the "psychogenic" category have a physiologic basis. They are characterized by pathophysiologic findings as diagnostic criteria. They are diseases, not illnesses. They can be stress-related, but psychological stress is not the primary etiology. Most patients with orofacial pain are not psychological misfits.

When a patient asks, "Doc, have I got TMJ?", it is imperative that the doctor consider all the possibilities in making a differential diagnosis. A patient obviously feels pain and/or dysfunction in the head, face or joint area. It would be beneath a reasonable standard of care to treat all patients for TMJ and miss the occasional diagnosis of infectious disease, cancer, or a neurological or vascular problem.

There are about 253 diseases and disorders that can have head pain as a symptom. Of these 253 possibilities, expert authors consider about 18 categories of factors, or rubrics, in arriving at a diagnosis (The Rubric Sheet). Each of these rubrics has between 5 and 27 possible responses, most of which are not mutually exclusive. This means that while a disease cannot be both painful and not painful at the same time, it can simultaneously be sharp, continuous, throbbing, unilateral, preauricular, infraorbital, and severe. Actually, the number of permutations and combinations one might consider in making such a differential diagnosis is huge. Unfortunately, however, psychological studies have shown that the human mind can consider only a few variables (in the range of 4-7) in making complex decisions. Thus a clinician is faced with a very difficult task in diagnosing diseases and disorders manifesting pain in the area of the head, face, and jaws.

According to the Diagnostic Hierarchy for Orofacial Pain, each condition has distinct diagnostic criteria. Pain without the criteria necessary for any diagnosis may be psychogenic. Pain in the presence of the appropriate diagnostic criteria indicates a pathophysiologic-based condition. A pathophysiologic condition in the absence of pain may or may not necessitate treatment. That decision is based on the clinical judgment of the doctor and the understanding and willingness of the patient to undergo treatment. Often risk/reward considerations and, frequently, financial considerations are involved, but the diagnosis does not change and should be based on scientific criteria.

The term "TMD" or "TMJ" has been used to characterize the generalized nonspecific symptoms of headache, neck ache, ear pain, face pain, tenderness of muscles to palpation, sensation of bite change, difficulty chewing and/or swallowing, gross joint sounds, and limited range of jaw motion. Because this cluster of symptoms is shared by so many diseases, it is not diagnostic of any.

Dentistry's predicament is that reproducible identification is necessary for scientific diagnosis of any disease. Definitive, measurable, reproducible, objective disease criteria must be documented for identification of TMJ or any disease or disorder categorized as a TMJ. No such disease criteria for an entity called TMJ have ever been suggested. Indeed, the emerging consensus in dentistry seems to be that TMJ is a collective term embracing a number of clinical problems involving masticatory dysfunction, the temporomandibular joints, and associated structures.

The problem, simply stated, is this: Can the clinician get beyond the nonspecific components common to all temporomandibular disorders to diagnose specifically, and direct more effective treatment at the specific etiological component of each disorder? Each of the 25 or so masticatory disorders discussed in the literature has specific definitive diagnostic criteria that differentiate or define it. These unique identifiers also suggest treatment that is disease-specific.

If dental clinicians are to be diagnosticians and treaters of head pain, on any given patient, they must make a differential diagnosis from approximately 253 possibilities. Dentists have been taught that "an accurate diagnosis is the first step in the treatment of any TMD and the process cannot be abridged." A diagnosis should do the following: properly identify and classify the disorder, establish the mechanism of dysfunction and the source of pain, determine the etiology (if possible) and provide a basis for prognosis in the light of effective therapy. The treatment should specifically and appropriately relate to the diagnosis. It seems self-evident, then, that no knowledgeable, self-respecting clinician would treat muscle spasm or disc displacement the same as rheumatoid arthritis. Thus it would seem that in orofacial pain doctors must concern themselves with the specific diagnosis.
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