Management of Temporomandibular Disorders

37
Management of
Tempor omandi bul ar
Di sor der s
Na t ion a lI n st it ut e sofHe a lt h
Te ch n ologyAsse ssme n t Con fe r e n ce St a t e me n t
Apr il29 Ma y1,1996
38
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Ma n a ge me n t ofTe mpor oma n dibula r Disor de r s.NI HTe ch n ol
Asse ssSt a t e me n t 1996Apr 29 Ma y1;1 31.
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35
Management of
Tempor omandi bul ar
Di sor der s
Na t ion a lI n st it ut e sofHe a lt h
Te ch n ologyAsse ssme n t Con fe r e n ce St a t e me n t
Apr il29 Ma y1,1996
Abstract
Obje ct i ve .Topr ovide ph ysicia n sa n dt h e ge n e r a lpublicwit h a
r e spon sible a sse ssme n t ofma n a ge me n t a ppr oa ch e st ot e mpor oma n -
dibula r disor de r s( TMD) .
Pa rt i ci pa nt s .An on -Fe de r a l,n on a dvoca t e ,15-me mbe r pa n e lr e pr e -
se n t in gt h e fie ldsofclin ica lde n t ist r y,me dicin e ,sur ge r y,ce llula r a n d
mole cula r biology,e pide miology,biost a t ist ics,immun ology,be h a vior
a n dsocia lscie n ce s,pa in ma n a ge me n t ,a n dt issue e n gin e e r in g.I n
a ddit ion ,23e xpe r t sin clin ica lde n t ist r y,me dicin e ,sur ge r y,ce llula r
a n dmole cula r biology,e pide miology,biost a t ist ics,immun ology,be h a v-
ior a la n dsocia lscie n ce s,pa in ma n a ge me n t ,a n dt issue e n gin e e r in g
pr e se n t e dda t a t ot h e pa n e la n da con fe r e n ce a udie n ce of1,083.
Evi de nce .Th e lit e r a t ur e wa sse a r ch e dt h r ough Me dlin e a n da n
e xt e n sive bibliogr a ph yofr e fe r e n ce swa spr ovide dt ot h e pa n e la n d
t h e con fe r e n ce a udie n ce .Expe r t spr e pa r e da bst r a ct swit h r e le va n t
cit a t ion sfr omt h e lit e r a t ur e .Scie n t ifice vide n ce wa sgive n pr e ce -
de n ce ove r clin ica la n e cdot a le xpe r ie n ce .
Cons e ns us Proce s s .Th e pa n e l,a n swe r in gpr e de fin e dque st ion s,
de ve lope dit scon clusion sba se don t h e scie n t ifice vide n ce pr e se n t e din
ope n for uma n dt h e scie n t ificlit e r a t ur e .Th e pa n e lcompose da dr a ft
st a t e me n t t h a t wa sr e a din it se n t ir e t ya n dcir cula t e dt ot h e e xpe r t s
a n dt h e a udie n ce for comme n t .Th e r e a ft e r,t h e pa n e lr e solve dcon flict -
in gr e comme n da t ion sa n dr e le a se da r e vise dst a t e me n t a t t h e e n dof
t h e con fe r e n ce .Th e pa n e lfin a lize dt h e r e vision swit h in a fe wwe e ks
a ft e r t h e con fe r e n ce .
Concl us i ons . Con se n sush a sn ot be e n de ve lope da cr osst h e pr a ct ic-
in gcommun it yr e ga r din gwh ich TMDpr oble mssh ouldbe t r e a t e d,a n d
wh e n a n dh owt h e ysh ouldbe t r e a t e d.Th e pr e pon de r a n ce oft h e da t a
don ot suppor t t h e supe r ior it yofa n yme t h odofin it ia lma n a ge me n t
ofmost TMDpr oble ms.Th e e ffica cyofmost t r e a t me n t a ppr oa ch e sis
un kn own ,a smost h a ve n ot be e n a de qua t e lye va lua t e din lon g-t e r m
st udie sa n dvir t ua llyn on e in r a n domize dcon t r olle dt r ia ls.Alt h ough
n on in va sive t h e r a pie sa r e cle a r lypr e fe r r e dfor t h e va st ma jor it yof
TMDpr oble ms,a sma llpe r ce n t a ge ofpa t ie n t swh oh a ve pe r sist e n t
a n dsign ifica n t pa in a n ddysfun ct ion a n dfor wh ommor e con se r va t ive
t r e a t me n t h a sfa ile dma ybe con side r e dfor sur gica lin t e r ve n t ion .
Pr ofe ssion a le duca t ion isn e e de dt oe n sur e pr ope r a n dsa fe pr a ct ice
in t h e t r e a t me n t ofTMD,e spe cia llywit h r e ga r dt oph a r ma cologica l,
sur gica l,a n dbe h a vior a la ppr oa ch e s.
1
Introduction
Te mpor oma n dibula r disor de r s( TMD) r e fe r t oa colle ct ion of
me dica la n dde n t a lcon dit ion sa ffe ct in gt h e t e mpor oma n dibula r
join t ( TMJ ) a n d/ or t h e muscle sofma st ica t ion ,a swe lla scon t iguous
t issue compon e n t s.Alt h ough spe cifice t iologie ssuch a sde ge n e r a t ive
a r t h r it isa n dt r a uma un de r lie some TMD,a sa gr oupt h e se con dit ion s
h a ve n ocommon e t iologyor biologica le xpla n a t ion a n dcompr ise a
h e t e r oge n e ousgr oupofh e a lt h pr oble mswh ose sign sa n dsympt oms
a r e ove r la ppin g,but n ot n e ce ssa r ilyide n t ica l.De pe n din gon t h e
pr a ct it ion e r a n dt h e dia gn ost icme t h odology,t h e t e r mTMDh a sbe e n
use dt och a r a ct e r ize a wide r a n ge ofcon dit ion sdive r se lypr e se n t e d
a spa in in t h e fa ce or ja wjoin t a r e a ,h e a da ch e s,e a r a ch e s,dizzin e ss,
ma st ica t or ymuscula t ur e h ype r t r oph y,limit e dmout h ope n in g,close d
or ope n lockoft h e TMJ ,a bn or ma locclusa lwe a r,clickin gor poppin g
soun dsin t h e ja wjoin t ,a n dot h e r compla in t s.Th e se ve r it yoft h e se
pr e se n t in gcon dit ion sma yr a n ge fr omn ot ice a ble but clin ica lly
in sign ifica n t sign st ose r iouslyde bilit a t in gpa in or dysfun ct ion .
Give n t h isva r ia t ion a mon gt h e pr oble msla be le dTMD,it isn ot
sur pr isin gt h a t con t r ove r syh a se me r ge d.Eve n t h e n a me TMDisn ot
un ive r sa llye n dor se d.Ge n e r a llya cce pt e d,scie n t ifica llyba se dguide -
lin e sfor dia gn osisa n dma n a ge me n t ofTMDa r e st illun a va ila ble .Eve n
so,pr a ct it ion e r sr e pr e se n t in ga va r ie t yofdisciplin e sa n dspe cia lt ie s
h a ve r e spon de dt ot h e ir pa t ie n t sn e e dsbyde ve lopin ga n de mploy-
in ga br oa dr a n ge oft r e a t me n t a ppr oa ch e st h a t in clude e duca t ion a l
or be h a vior a lcoun se lin g,ph a r ma cologica lor me ch a n ica la ppr oa ch e s,
occlusa lt h e r a pie s,a n da va r ie t yofsur gica lpr oce dur e s,or combin a -
t ion st h e r e of.I n ma n yca se s,pa t ie n t sh a ve impr ove d,a n din ot h e r s
for e xa mple ,in ca se sin volvin gt h e use ofce r t a in a llopla st icimpla n t s
t h e r e sult sh a ve be e n disa st r ous.For t h e ma jor it yofTMDpa t ie n t s,
t h e a bse n ce ofun ive r sa llya cce pt e dguide lin e sfor e va lua t ion a n d
dia gn osiscompr omise st h e goa lsofcon sist e n t a n dcon se r va t ive
t h e r a py.Th e la ckofst a n da r dt r e a t me n t pr ot ocolsa cce pt e da cr oss
pr ofe ssion a lspe cia lt ie sme a n st h a t ma n ypa t ie n t sa n dpr a ct it ion e r s
ma ya t t e mpt t h e r a pywit h in a de qua t e lyt e st e da ppr oa ch e s.
Alt h ough e pide miologica lda t a a r e in a de qua t e ,t h e t ot a ln umbe r
ofTMDsuffe r e r sin t h iscoun t r yca n be r ough lye st ima t e da t mor e
2
t h a n 10million ,a n dcon ce r n a bout t h e sa fe t ya n de ffica cyoft h e ir
ca r e r e quir e st h a t we a ch ie ve a be t t e r un de r st a n din goft h e se h e a lt h
pr oble ms.Not on lymust va lida n dr e lia ble cr it e r ia for dia gn osisa n d
me a sur e me n t be de ve lope d,but t h e r a t ion a le sfor a n de ffe ct ive n e ss
ofa va r ie t yoft r e a t me n t scur r e n t lyin use must be e xa min e da swe ll.
Toa ddr e sst h e se issue s,t h e Na t ion a lI n st it ut e ofDe n t a lRe se a r ch
a n dt h e NI HOffice ofMe dica lApplica t ion sofRe se a r ch con ve n e d
a Te ch n ologyAsse ssme n t Con fe r e n ce on Ma n a ge me n t ofTe mpor oma n -
dibula r Disor de r s,wit h t h e e n cour a ge me n t ofpa t ie n t -ba se dsuppor t
gr oups.Th e con fe r e n ce wa scospon sor e dbyt h e Na t ion a lI n st it ut e of
Ar t h r it isa n dMusculoske le t a la n dSkin Dise a se s,t h e Na t ion a lI n st i-
t ut e ofNe ur ologica lDisor de r sa n dSt r oke ,t h e Na t ion a lI n st it ut e of
Nur sin gRe se a r ch ,a n dt h e NI HOffice ofRe se a r ch on Wome n sHe a lt h .
Th iscon fe r e n ce br ough t t oge t h e r spe cia list sin clin ica lde n t ist r y,
me dicin e ,sur ge r y,ce llula r a n dmole cula r biology,biost a t ist ics,
e pide miology,immun ology,be h a vior a la n dsocia lscie n ce s,pa in
ma n a ge me n t ,t issue e n gin e e r in g,a n dr e pr e se n t a t ive soft h e public,
in cludin gTMDpa t ie n t sa n da dvoca cygr oups.Aft e r 1
1
/ 2da ysof
pr e se n t a t ion sa n da udie n ce discussion ,t h isin de pe n de n t ,n on -Fe de r a l
t e ch n ologya sse ssme n t pa n e lwe igh e dt h e scie n t ifice vide n ce a n dt h e
e xpe r ie n ce ofpa t ie n t sa n dpr a ct it ion e r sa n dde ve lope da dr a ft
st a t e me n t t h a t a ddr e sse dt h e followin gque st ion s:
Wh a t clin ica lcon dit ion sa r e cla ssifie da st e mpor oma n dibula r
disor de r s,a n dwh a t occur sift h e se con dit ion sa r e le ft un t r e a t e d?
Wh a t t ype sofsympt oms,sign s,a n dot h e r a sse ssme n t spr ovide a
ba sisfor in it ia t in gt h e r a pe ut icin t e r ve n t ion s?
Wh a t a r e e ffe ct ive a ppr oa ch e st ot h e in it ia lma n a ge me n t a n d
t r e a t me n t ofpa t ie n t swit h va r iousTMDsubt ype s?
Wh a t a r e e ffe ct ive a ppr oa ch e st oma n a ge me n t a n dt r e a t me n t
ofpa t ie n t swit h pe r sist e n t TMDpa in a n ddysfun ct ion ?
Wh a t a r e t h e most pr oduct ive dir e ct ion sfor fut ur e r e se a r ch ,
a n dwh a t t ype sofn e wcolla bor a t ion sa n dpa r t n e r sh ipssh ould
be de ve lope dfor pur suin gt h e se dir e ct ion s?
3
Ques t i on 1: What Clinical Conditions Are Classified
as Temporomandibular Disorders, and What Occurs If
These Conditions Are Left Untreated?
Classification of Clinical Conditions
Fr omt h e in for ma t ion pr ovide d,t h e clin ica lcon dit ion susua lly
cla ssifie da sTMDin clude t h ose wit h pa in or dysfun ct ion in t h e join t
or con t iguousst r uct ur e s.Th e se con dit ion sa r e lin ke din t h e ir pr e se n -
t a t ion byt h e ir common sign sa n dsympt oms.Give n t h e la ckofe pide -
miologica lin for ma t ion a n dt h e colle ct ion ofa sye t un de fin e de t iolo-
gie st h a t a r e like lyt obe de scr ibe da sTMD,a con ve n t ion a ldise a se
cla ssifica t ion syst e mwouldbe difficult t ode scr ibe ,possiblymisle a d-
in g,a n dun like lyt or e ce ive br oa da cce pt a n ce .For t h e t ime be in g,
t h e r e for e ,cla ssifica t ion must de pe n dpr ima r ilyon t h e de t a ile d
de scr ipt ion ofsympt omsa n dun de r lyin gcon dit ion s.Pa r a me t e r s
ofCa r e for Or a la n dMa xillofa cia lSur ge r y( 1995) ,de ve lope dbyt h e
Ame r ica n Associa t ion ofOr a la n dMa xillofa cia lSur ge on s,pr ovide s
use fulin for ma t ion oft h ist ype .
Con dit ion spr ima r ilya ffe ct in gt h e muscle sofma st ica t ion in clude
syst e micdise a se sofmuscle ssuch a spolymyosit is,de r ma t omyosit is,
h e r e dit a r ymyopa t h ie s,a n dch a n ge sin t h e muscula t ur e se con da r y
t ofun ct ion a ldist ur ba n ce s.Con dit ion sa ffe ct in gt h e TMJ in clude
a r t h r it is,a n kylosis,gr owt h disor de r s,r e cur r e n t disloca t ion ,n e opla sia ,
con dyle fr a ct ur e ,a n dsyst e micilln e ss.Wit h r e spe ct t obot h muscula r
a n djoin t ch a n ge s,t h ose cla ssifie da sfun ct ion a la fflict ion oft h e mus-
cle or pa t h ologyoft h e join t or a combin a t ion ofbot h a r e most oft e n
ca t e gor ize da sTMD.I t sh ouldbe n ot e dt h a t a fflict ion ofe it h e r t h e
join t or t h e muscle ma yle a dt ose con da r ych a n ge sin t h e ot h e r st r uc-
t ur e t h a t be come a fur t h e r sour ce ofpa in a n dfun ct ion a limpa ir me n t .
Alt h ough cur r e n t dia gn ost iccla ssifica t ion sofTMDa r e ba se don
sign sa n dsympt omsr a t h e r t h a n on e t iology,t h e se sign sa n dsympt oms
sh ouldbe cla ssifie din t h e la r ge r con t e xt ofot h e r muscle a n djoin t
disor de r sor in t h e ca t e gor yofpa in disor de r s.Le sson sca n be le a r n e d
fr omdia gn ost ica n dt h e r a pe ut ica ppr oa ch e st oot h e r join t a n dmuscle
dise a se s.For e xa mple ,le sscon t r ove r sye xist sin h ipjoin t dia gn osis
or t r e a t me n t ,wh e r e e t iologiccla ssifica t ion sa r e be t t e r e st a blish e d.
On t h e ot h e r h a n d,t h e r e a ppe a r st obe simila r con t r ove r syin con di-
t ion soft h e lumbo-sa cr a lspin e ,such a slowba ckpa in .Aswit h TMD,
4
dia gn osisa n dt r e a t me n t oflowba ckpa in ma yin volve a n umbe r of
pot e n t ia le t iologie st h a t a r e difficult t odiffe r e n t ia t e a n dr e quir e
pa r t icipa t ion ofmult iple disciplin e sor spe cia lit ie s.
What Occurs If These Conditions Are Left Untreated?
We ll-de sign e d,r e pr e se n t a t ive cr oss-se ct ion a la n dlon git udin a l
st udie sa r e sca r ce .Con se que n t ly,t h e n a t ur a lh ist or yofTMDisn ot
we llde fin e d.I n a ddit ion ,most st udie sa r e de scr ipt ive ,wit h a n a lyse s
t h a t a r e pr e dict ive or e xpla n a t or yvir t ua llya bse n t .Th e limit e d,
popula t ion -ba se de pide miologica lda t a a va ila ble in dica t e t h a t t h e
pr e va le n ce ofse lf-r e por t e dsign sa n dsympt omsisbe t we e n 5a n d15
pe r ce n t ,wit h pe a kpr e va le n ce in youn ga dult s( 20 40ye a r sofa ge ) .
Alt h ough sign sa ssocia t e dwit h TMDh a ve be e n r e por t e dwit h e qua l
fr e que n cie sfor me n a n dwome n ,some st udie ssh owgr e a t e r pr e va -
le n ce ofsympt oms( e .g.,se lf-r e por t e dfa cia lpa in ) in wome n ofch ild-
be a r in ga ge ,a n da n umbe r ofclin ica lca se se r ie sst udie sh a ve r e fle ct -
e da n ove r wh e lmin gpr e domin a n ce ofwome n in t h e t h ir da n dfour t h
de ca de s.Th e r e por t e ddiscr e pa n cie sin ge n de r diffe r e n ce sr e quir e
e xpla n a t ion .Th e lowe r pr e va le n ce ofTMDsign sa n dsympt omsa t
olde r a ge sr e por t e din cr oss-se ct ion a lda t a iscon sist e n t wit h t h e se lf-
limit in gn a t ur e ofsuch sign sa n dsympt oms,a n dt h e fe wlon git ud-
in a lclin ica lst udie ssuppor t t h e se fin din gs.Th e r e isn oin for ma t ion
on e t h n icor r a cia lva r ia t ion in t h e se r a t e s.
I n clin ica lca se se r ie sst udie sin wh ich con se r va t ive ,r e ve r sible ,
n on in va sive t h e r a pywa se mph a size d,t h e pr e se n t in gsign sa n dsymp-
t omsa ppe a r e dt oimpr ove in t h e va st ma jor it yofpa t ie n t s.I n r e ma in -
in gpa t ie n t s,sympt omsma ype r sist ,r e cur,or wor se n .Fe wda t a a r e
a va ila ble t h a t a sse sst h e lon g-t e r mcour se oft h e se pa t ie n t sin t h e
a bse n ce ofa n in t e r ve n t ion .Limit e dda t a in dica t e t h a t ma n ysympt om-
a t icpe ople don ot se e kt r e a t me n t .Simila r ly,min ima lda t a a r e a va il-
a ble fr omwh ich t oa sse sst h e n a t ur a lh ist or yoft h isgr oupofpa t ie n t s.
Alt h ough it h a sbe e n sugge st e dt h a t socie t a lba r r ie r sa n dpr e judice s
oft e n pr e ve n t a ppr opr ia t e t r e a t me n t ofTMDpa t ie n t s,t h e se r e la t ion -
sh ipsh a ve n ot be e n docume n t e din t h e r e se a r ch .
5
Ques t i on 2: What Types of Symptoms, Signs, and
Other Assessments Provide a Basis for Initiating
Therapeutic Interventions?
An yin it ia t ion oft h e r a pymust be ba se don a t h or ough a n dse n si-
t ive a n a lysisoft h e pa t ie n t .Alt h ough some sign sa n dsympt omsa ssoci-
at edwit hcer t ainint r a-andext r acapsular disor der sar ewellest ablished,
t h e e t iologyofot h e r sr e ma in sa mbiguousa n da ch a lle n ge t ot h e pr a ct i-
t ion e r.Alt h ough n ume r ousa sse ssme n t me t h odsa r e a va ila ble ,la ckof
e vide n ce oft h e dia gn ost icva lue oft h e se t ools( i.e .,t h e ir va lidit y,r e li-
a bilit y,spe cificit y,se n sit ivit y,a n dcost -e ffe ct ive n e ss) con t r ibut e st o
t h isa mbiguit y.Dia gn osisa n din it ia lt r e a t me n t ,t h e r e for e ,oft e n de pe n d
on t h e pr a ct it ion e r se xpe r ie n ce a n dph ilosoph y,r a t h e r t h a n on scie n -
t ifice vide n ce .
Non e t h e le ss,t h e con se n susist h a t dia gn osisa n din it ia t ion oft r e a t -
me n t sh ouldbe ba se don da t a fr omph ysica le xa min a t ion a n dsh ould
in clude me dica la n dde n t a lh ist or y;in for ma t ion a bout a udiologica l,
spe e ch ,a n dswa llowin gpr oble ms,pa in ,a n ddysfun ct ion ;a n dcon side r -
a t ion ofpsych osocia lfa ct or s,a swe lla sda t a fr omima gin ga n dot h e r
dia gn ost ict e st s.Eva lua t ion sh oulde n compa sse xa min a t ion ofor o-
fa cia lt issue s,muscula t ur e ,a n dn e ur ologica lfun ct ion .Pa r t icula r a t t e n -
t ion sh ouldbe pa idt ode t e r min a t ion soffun ct ion a lr a n ge ofmot ion ,
occlusa lst a t us,e xist e n ce ofpa r a fun ct ion a lcon dit ion s( e .g.,cle n ch -
in g,gr in din g) ,a n dt h e pr e se n ce ofjoin t or muscle t e n de r n e ssa n d
cut a n e oush ype r a lge sia .Psych osocia la sse ssme n t ssh ouldde t e r min e
t h e e xt e n t t owh ich pa in a n ddysfun ct ion in t e r fe r e wit h or dimin ish
t h e pa t ie n t squa lit yoflife .Howe ve r,t h e con side r a t ion ofpsych osocia l
fa ct or sh a st h e pot e n t ia lfor in a ppr opr ia t e use ,a n dit isimpe r a t ive
t h a t such a sse ssme n t sbe ma n a ge dbyskille dpr ofe ssion a lsusin g
va lida t e din st r ume n t s.
Cur r e n t lya va ila ble e pide miologica le vide n ce sugge st st h a t TMD
isfr e que n t lyse lf-limit in g.Th e pr a ct it ion e r a n dt h e pa t ie n t must st r ive
t ode ve lopa t r e a t me n t pla n t h a t ise vide n ce ba se da n dpa t ie n t ce n t e r e d.
Indevisinganyt r eat ment plan,t hepr act it ioner must weight hepat ient s
pe r ce pt ion ofpa in a n ddysfun ct ion a n dt h e impa ct oft h e se on t h e
pa t ie n t squa lit yoflife .I n t h e a bse n ce ofove r t pa t h ology,some pa t ie n t s
a n dpr a ct it ion e r sma ywor kt oge t h e r t oimple me n t a pr ogr a mofpa t ie n t
se lf-ma n a ge me n t wit h e duca t ion a n da n un de r st a n din goft h e r ole of
pe r son a lfa ct or s.I ft h e pa t ie n t doe sn ot obt a in a de qua t e r e lie ffr om
6
t h e se me a sur e s,a n umbe r ofcon se r va t ive ,n on in va sive ,a n dr e ve r sible
t r e a t me n t sca n n e xt be con side r e d.
At pr e se n t t h e e vide n ce isin sufficie n t t owa r r a n t pr oph yla ct ic
in t e r ve n t ion for ma n a ge me n t ofTMD,n or a r e t h e r e da t a pr ovidin g
cle a r e vide n ce t h a t or t h odon t ict r e a t me n t pr e ve n t s,pr e dispose st o,
or ca use sTMD.Eve n so,some pr a ct it ion e r sh a ve ca r r ie dout occlusa l
a djust me n t s,e xt e n sive r e st or a t ion s,or ma n a ge me n t ofdispla ce ddisks
or join t soun dsin t h e a bse n ce ofpa in or lossoffun ct ion .
Give n cur r e n t e vide n ce ,spe cia le mph a sissh ouldbe pla ce don t h e
a voida n ce ofe xt e n sive r e st or a t ive pr oce dur e st ot r e a t a disor de r t h a t
ma ych a n ge ove r t ime .
7
Ques t i on 3: What Are Effective Approaches to the
Initial Management and Treatment of Patients With
Various TMD Subtypes?
I n it ia lma n a ge me n t isde fin e da st h e fir st t r e a t me n t t h e pa t ie n t
r e ce ive sa ft e r se e kin gca r e .Pa in a n ddysfun ct ion oft h e ma st ica t or y
a ppa r a t usca n be a fr igh t e n in ga n ddisa blin ge xpe r ie n ce for pa t ie n t s.
Th e TMJ isimpor t a n t fun ct ion a llywit h r e ga r dt ospe e ch ,socia lin t e r -
a ct ion s,ma st ica t ion ,swa llowin g,a n dot h e r or a lfun ct ion s,a swe lla s
h e a r in g,in some ca se s.Pa t ie n t sse e kin gca r e de se r ve ca r e fula t t e n -
t ion ,give n t h e impor t a n ce oft h isa r e a oft h e body.
Th e in it ia lma n a ge me n t ofTMDde scr ibe dbe lowa ssume st h a t
un de r lyin gsyst e micor ove r t join t dise a se sh a ve be e n ide n t ifie da n d
a ddr e sse d.Pa t ie n t swit h join t a r t h r opa t h ie sa n dpa in fulja wmuscle
con dit ion sa ssocia t e dwit h syst e micdise a se r e quir e t r e a t me n t for t h e
un de r lyin gdise a se .Wh ile t h e se pa t ie n t sma ya lson e e dt h e r a pydir e ct -
e dspe cifica llyt ot h e TMJ a n dr e la t e dst r uct ur e s,such t r e a t me n t must
be ca r e fullycoor din a t e dwit h t h a t pr ovide dfor syst e micdise a se .Wh e n
t h e r e isdise a se oft h e TMJ it se lf( such a sn e opla sia s,wh ich fr e que n t ly
r e quir e sur gica lt h e r a py) ,t h a t dise a se must be t h e pr ima r yfocusof
t r e a t me n t .
Alt h ough a va st a r r a yoft h e r a pe ut icmoda lit ie sh a ve be e n offe r e d
for TMDpa t ie n t s,t h e r e isa pa ucit yofclin ica lst udie s,a n de spe cia lly
r a n domize dcon t r olle dclin ica lt r ia ls,t oguide ma n a ge me n t oft h e se
pa t ie n t s.Give n t h a t most pa t ie n t sh a ve a se lf-limit e ddisor de r a n d
t h a t a va r ie t yofdiffe r e n t t h e r a pie sa ppe a r t or e sult in simila r im-
pr ove me n t sin pa in a n ddysfun ct ion ,ca ut ion isur ge dwit h r e ga r dt o
use ofin va sive a n dot h e r ir r e ve r sible t r e a t me n t s,pa r t icula r lyin t h e
in it ia lma n a ge me n t ofTMD.
An umbe r ofn on in va sive a n dr e ve r sible t h e r a pie sa r e wide lyuse d
a n da ppe a r t oh e lpma n ypa t ie n t s.Opt ima lly,t h e se t h e r a pie ssh ould
h a ve lowmor bidit ya n dmin ima la lt e r a t ion ofun de r lyin ga n a t omic
st r uct ur e s.Th e se t h e r a pie sin clude :
Support i ve pa t i e nt e duca t i on. I n it ia la t t e n t ion sh ouldbe give n
t ot h e issue ofpa t ie n t e duca t ion on wh a t iskn own a bout TMDa n d
t h e fa ct t h a t most oft h e se pr oble msfollowa be n ign cour se .Ma n y
e xpe r t sr e comme n dt h a t pa t ie n t sun de r goe duca t ion dir e ct e da t
e limin a t in gce r t a in be h a vior spe r ce ive dt obe h a r mful,such a s
8
cle n ch in ga n dgr in din g.Some e xpe r t sr e comme n de xe r cise a n d
st r e ssma n a ge me n t .Re st a n ddie t a r ymodifica t ion sma yh e lp
some pa t ie n t s.
Pha rma col ogi c pa i n cont rol . Me dica t ion ma ybe use fulfor in it ia l
sympt omma n a ge me n t .Th e me dica t ion suse fulfor TMDa r e simila r
t ot h ose use fulfor ot h e r pa in fulmusculoske le t a lcon dit ion s.Non -
st e r oida la n t i-in fla mma t or ydr ugs( NSAI Ds) a n dopia t e sa r e t h e
ma in st a yofph a r ma cologica lpa in t r e a t me n t .Some clin icia n sa lso
h a ve foun dmuscle r e la xa n t me dica t ion sa n dlow-dose a n t ide pr e s-
sa n t sofa se da t in gt ype t obe use fulin in it ia lma n a ge me n t ofTMD.
Ot h e r me dica t ion sa lsoh a ve be e n use dfor spe cificin dica t ion s.I n
a llca se s,t h e clin icia n must we igh t h e r iskofside e ffe ct sa ga in st
pot e n t ia lbe n e fit s,a lon gwit h h isor h e r own pr ofe ssion a lcompe -
t e n ce in t h e a dmin ist r a t ion a n dma n a ge me n t ofsuch me dica t ion s.
Phys i ca l t he ra py. Ph ysica lt h e r a pya pplica t ion st oTMDin clude a
wide va r ie t yofe va lua t ive t e ch n ique sa n dt r e a t me n t moda lit ie st h a t
h a ve be e n common lyuse din ot h e r n e ur ologica la n dmusculoske le t a l
disor de r s.Th e se t h e r a pie sge n e r a llya r e con se r va t ive a n dn on in va -
sive .Be n e fit st oTMDpa t ie n t sh a ve be e n de scr ibe d,a lt h ough fe w
da t a a r e a va ila ble t odocume n t t h e se r e sult s.
Int ra ora l a ppl i a nce s . St a biliza t ion splin t sa r e con side r e dn on in va -
sive a n dr e ve r sible a n da r e r e comme n de dbyma n ye xpe r t sfor e a r ly
t r e a t me n t oft h e se pa t ie n t s.I t isimpor t a n t t h a t t h e se a pplia n ce s
a r e ofa t ype t h a t doe sn ot le a dt oma jor a lt e r a t ion oft h e pa t ie n t s
occlusion .Re posit ion in ga pplia n ce sma ya ppe a r t obe n on in va sive
but h a ve pot e n t ia lfor cr e a t in gsuch ir r e ve r sible ch a n ge sin occlu-
sion a n d,con se que n t ly,t h e possibilit yofpr e cipit a t in got h e r
pr oble ms.
Occl us a l t he ra py. Much con t r ove r sysur r oun dst h e use ofocclusa l
t h e r a py.Th e a dvoca t e sa r gue t h a t occlusa la bn or ma lit ie sa n d/ or
join t ma n ipula t ion pr e cipit a t e t h e de ve lopme n t ofTMD.Occlusa l
t h e r a pie sa r e a ime da t modifica t ion oft h e occlusion it se lft h r ough
a lt e r a t ion oft h e t oot h st r uct ur e or ja wposit ion .Give n t h a t t h is
9
la t t e r t h e r a pyisir r e ve r sible ,a n dgive n t h a t t h e supe r ior it yoft h is
t r e a t me n t ove r r e ve r sible t h e r a pie sh a sn ot be e n de mon st r a t e din
r a n domize dcon t r olle dpr ospe ct ive t r ia ls,t h isfor mofocclusa l
a djust me n t pr oba blywilln ot r e pr e se n t be st pr a ct ice for in it ia l
ma n a ge me n t ofTMD.Howe ve r,a sse ssme n t ofocclusion isn e ce ssa r y
a spa r t oft h e in it ia lor a le xa min a t ion t oide n t ifya n de limin a t e
gr ossocclusa ldiscr e pa n cie ssuch a st h ose t h a t ma yin a dve r t e n t ly
occur a sa r e sult ofr e st or a t ive pr oce dur e s.
Aft e r t h e se in it ia lt h e r a pe ut icin t e r ve n t ion s,a sma lln umbe r of
pa t ie n t sma ycon t in ue t oe xh ibit sympt omsa ssocia t e dwit h t h e TMD
con st e lla t ion ofcon dit ion s.Th e se pa t ie n t swillr e quir e con side r a t ion
for lon ge r t e r ma n d/ or mor e in va sive t h e r a pie s.
10
Ques t i on 4: What Are Effective Approaches to
Management and Treatment of Patients With
Persistent TMD Pain and Dysfunction?
An impor t a n t min or it yofTMDpa t ie n t spr ogr e sst ope r sist e n t pa in
a n d/ or dysfun ct ion .Th ismin or it yr e pr e se n t sa h e t e r oge n e ousgr oupof
disor de r s.Th e r e a r e fe wr a n domize dcon t r olle dclin ica lt r ia lst ogive
usguida n ce r e ga r din gt h e t r e a t me n t ofpa t ie n t swit h pe r sist e n t pa in .
Alt h ough ma n yoft h e con se r va t ive moda lit ie st h a t we r e imple me n t e d
in t h e in it ia t ion oft r e a t me n t ma ycon t in ue t obe use d,ot h e r st r a t e gie s
ma yr e quir e con side r a t ion dur in gt h isph a se oft r e a t me n t .
For t h e pa t ie n t wit h e pisodicsign sa n dsympt oms,a n on in va sive ,
con se r va t ive a ppr oa ch sh ouldbe imple me n t e d.For t h e pa t ie n t wit h
pe r sist e n t ,n on r e mit t in gsign sa n dsympt oms,a st e pwise a ppr oa ch
sh ouldbe imple me n t e d.I n some ca se s,t h e se t r e a t me n t sa r e in t e n de d
t opr ovide sympt oma t icca r e ,wh e r e a sin ot h e r st h e ya r e in t e n de dt o
a lt e r t h e cour se oft h e con dit ion .Alt h ough some t r e a t me n t sr e st r ict e d
t ot h e TMJ a n dor a lst r uct ur e sh a ve be e n ove r e mph a size d,ot h e r t r e a t -
me n t ssuch a sph a r ma cot h e r a pe ut icsa ppe a r t oh a ve be e n un de r ut il-
ize d,or in a ppr opr ia t e lyuse d.
Ast h e in t e r ve n t ion be come sin cr e a sin glya ggr e ssive ,in va sive ,a n d
ir r e ve r sible ,t h e pa t ie n t a n dpr a ct it ion e r sh ouldsh a r e a common un de r-
st a n din goft h e scie n t ificba sis,in dica t ion s,goa ls,r isksa n dbe n e fit s,
andpr ior hist or yoft hepr oposedint er vent ion.It shouldbeclear lyr ecog-
nizedt h a t sur ge r yisin dica t e din on lya sma llpe r ce n t a ge ofpa t ie n t s.
Fr omt h e da t a pr ovide d,n osin gle t r e a t me n t or combin a t ion of
pr oce dur e swa sde mon st r a t e dt obe e ffe ct ive in r a n domize dcon t r olle d
clin ica lt r ia ls.Give n t h e la ckofe vide n ce ,n ospe cificr e comme n da -
t ion sca n be ma de .Howe ve r,t h e followin gwouldbe use fult oa dva n ce
t h e ca r e ofpa t ie n t swit h pe r sist e n t TMDpa in a n ddysfun ct ion .
Pharmacological Therapies
Th e pr in ciple sfor ma n a ge me n t oft h e pa in a ssocia t e dwit h
pe r sist e n t TMDa r e t h e sa me a st h ose for t r e a t me n t ofot h e r ch r on ic
pa in con dit ion s.Opia t e sa n dNSAI Dsa r e r e cogn ize da sma in st a ysfor
a n a lge sicma n a ge me n t a n dsh ouldbe imple me n t e dcomme n sur a t e
wit h t h e le ve lofpa in .
Ama jor con ce r n r e ga r din gt h e use ofopia t e sin t h e pa st h a sbe e n
t hepot ent ialofaddict ion,analgesict oler ance,uncont r olledsideeffect s,
a n dt oxicit ya ssocia t e dwit h lon g-t e r muse .Mor e r e ce n t wor k,h owe ve r,
11
sugge st st h a t t h e se con ce r n soft e n a r e n ot wa r r a n t e da n dt h a t ma n y
ch r on icpa in pa t ie n t s,t r e a t e dwit h a de qua t e dose sofopia t e s,ca n
a ch ie ve succe ssfulcon t r olofsympt omswit h out a dve r se e ffe ct s.
Adjuva n t a n a lge sicsr e pr e se n t a dive r se gr oupofdr ugs,in cludin g
t r icyclics,a n t ide pr e ssa n t s,a n t icon vulsa n t s,me mbr a n e st a bilize r s,
sympa t h olyt ica ge n t s,a n dot h e r s.Th e se gr oupsofdr ugsa r e like lyt o
be mor e e ffica ciousin n e ur opa t h icpa in st a t e sbut ma ybe con side r e d
for pa t ie n t swh or e spon dpoor lyt oor a r e un a ble t ot ole r a t e NSAI Ds
a n dopia t e s.
Pa in disor de r sma yr e sult in impa ir e dsle e p.Hypn ot icsma ybe
use fult oimpr ove sle e ppa t t e r n s,wh ich in t ur n be n e fit t h e pa t ie n t s
ove r a llh e a lt h st a t us.Ma n ypa in e xpe r t sbe lie ve t h a t a ma jor comor bid-
it ya ssocia t e dwit h ch r on icpa in isde pr e ssion a n dt h a t me dica lt h e r a py
ofde pr e ssion ma ycon fe r be n e fit t osuch pa t ie n t s.
Occlusal Therapies
Some e xpe r t sbe lie ve occlusa la djust me n t ma ybe h e lpfulin t h is
gr oupofpa t ie n t s,a n dsome e xpe r t sa lsoa r gue t h a t occlusa la djust -
me n t sh ouldbe pe r for me dbe for e sur gica lpr oce dur e s.Ra n domize d
t r ia lsa r e n e e de dt oe st a blish t h e e ffe ct ive n e ssofsuch a ppr oa ch e s.
Ba se don a va ila ble in for ma t ion ,h owe ve r,occlusa la djust me n t st h a t
pe r ma n e n t lya lt e r a pa t ie n t socclusion sh ouldbe a voide d.
Surgical Approaches
Ra n domize dcon t r olle dclin ica lt r ia lst osuppor t t h e e ffica cyof
in dividua lsur gica lpr oce dur e sh a ve n ot be e n pe r for me d.Aspe ct r um
ofsur gica lin t e r ve n t ion sh a sbe e n a pplie dt ot h e gr oupofpa t ie n t s
wit h pa t h ologyoft h e TMJ .Th e se a ppr oa ch e sin clude a r t h r oce n t e sis,
a r t h r oscopy,a r t h r ot omy/ a r t h r opla st y,con dylot omy,or t h ogn a t h ic
sur ge r y,a n de ve n t ot a lTMJ r e pla ce me n t .
I n dica t ion sfor sur ge r yin clude on e or mor e oft h e followin g:
mode r a t e t ose ve r e pa in ,dysfun ct ion t h a t isdisa blin g,a n d/ or e vi-
de n ce ofpa t h ologica lcon dit ion s.Expe r t swh ope r for mt h e se pr oce d-
ur e squot e h igh r a t e sofsucce ssin t h ish igh lyse le ct gr oupofpa t ie n t s;
h owe ve r,a sma llpe r ce n t a ge oft h e se pa t ie n t se xpe r ie n ce de t e r ior a t ion
oft h e ir con dit ion s.
12
Th e use ofce r t a in a llopla st icimpla n t sin sur ge r yfor TMDh a sr e -

sult e din disa st r ouscon se que n cesfor manypat ient swhohaveunder gone
such t r e a t me n t .Con se que n t ly,ut most ca ut ion must be ut ilize din con -
side r in gt h e use ofa n yimpla n t s.At t h e sa me t ime ,it isr e cogn ize d
t h a t ce r t a in pa t ie n t sa r e in n e e dofimpla n t s,a n dn e we r impla n t de sign s
n e e dt obe fullyassessedasquicklyaspossible.For pat ient swhoalr eady
h a ve h a dimpla n t or ot h e r in va sive sur ge r y,a ddit ion a lsur gica lin t e r ve n -
t ion s( wit h t h e possible e xce pt ion ofimpla n t r e mova l) sh ouldbe con -
side r e don lywit h gr e a t ca ut ion ,sin ce t h e e vide n ce in dica t e st h a t t h e
pr oba bilit yofsucce ssde cr e a se swit h e a ch a ddit ion a lsur gica lin t e r ve n -
t ion .For such pa t ie n t s,t h e most pr omisin gimme dia t e lya va ila ble t r e a t -
me n t ma ybe a pa t ie n t -ce n t e r e d,mult idisciplin a r y,pa llia t ive a ppr oa ch .
Psychosocial Issues
Pa t ie n t swit h pe r sist e n t TMDpr oble msma ysuffe r psych ologica lly
a n dsocia llybe ca use ofpa in a n ddysfun ct ion .Fa ile dt r e a t me n t sa n d
r e cur r e n t pa in e pisode scon t r ibut e t olife st r e sse swit h a pa t t e r n of
fr ust r a t ion ,h ope le ssn e ss,a n de ve n de pr e ssion .Th e life st r e ssa ssoci-
a t e dwit h pe r sist e n t pa in a n ddysfun ct ion r e la t e dt oTMDh a sn ot be e n
a de qua t e lyun de r st oodfr omt h e pa t ie n t spe r spe ct ive or fr omt h e pe r -
spe ct ive ofimpa ct on socia lfun ct ion in g.
Psych ologica lt r e a t me n t st r a t e gie sh a ve n ot a lwa ysbe e n t a ilor e d
t ot h e in dividua ln e e dsofTMDpa t ie n t s.Nor doe st h e r e a ppe a r t obe a
we ll-a cce pt e dmode lfor suppor t ive t r e a t me n t e n vir on me n t sfor pa t ie n t s
whohaveent er edt hephaseofTMDchar act er izedbyper sist ent painand
dysfun ct ion ,a lt h ough some such a ppr oa ch e sa r e un de r de ve lopme n t .
Alon gwit h fun ct ion a limpa ir me n t ,pa t ie n t swit h TMDma ye xpe r ie n ce
e st h e t icimpa ir me n t a ssocia t e dwit h fa ile din t e r ve n t ion sa n d/ or pe r -
sist e n t pa in .Th e r e sult in gn e ga t ive se lf-ima ge ,disa ppoin t me n t ,a n d
fr ust r a t ion a ddt ot h e st r e ssa ssocia t e dwit h TMD.Psych ologica lst r a -
t e gie se st a blish e dfor ot h e r ch r on iccon dit ion sma ybe use fulin suppor t -
in gpa t ie n t sma n a gin gpe r sist e n t pa in ,socia lde bilit a t ion ,a n dt h e
e n suin glife st r e ssa ssocia t e dwit h TMD.Re la xa t ion a n dcogn it ive
be h a vior a lt h e r a pie sh a ve be e n sh own t obe e ffe ct ive in ma n a gin g
ch r on icpa in ,a lt h ough da t a fr omcon t r olle dst udie sa r e n ot a va ila ble
r egar dingt heir efficacyint hemanagement ofpainassociat edwit hTMD.
13
Ques t i on 5: What Are the Most Productive
Directions for Future Research, and What Types
of New Collaborations and Partnerships Should
Be Developed for Pursuing These Directions?
Th e followin gdir e ct ion sfor fut ur e r e se a r ch sh ouldbe con side r e d:
At pr e se n t ,TMDisbe st de scr ibe da n ddia gn ose din t h e con t e xt
ofde t a ile din for ma t ion a bout pr e se n t in gsympt omsa n dfulla sse ss-
me n t ofr e la t e dfa ct or sa n dcon dit ion s.Amor e con ve n t ion a ldise a se
cla ssifica t ion syst e mwouldbe difficult t ode ve lop,a n dcouldbe mis-
le a din g,give n t h a t ( a ) n e ce ssa r ye pide miologica lin for ma t ion is
la ckin ga n d( b) t h e e t iologie sun de r lyin gt h e con dit ion sca lle d
TMDh a ve n ot be e n a de qua t e lyde fin e da n dde scr ibe d.Ca r e fully
de sign e d,a n a lyt ica l,cr oss-se ct ion a l,popula t ion -ba se dst udie swit h
a ppr opr ia t e clin ica lme a sur e sa n dbiologica lma r ke r ssh ouldbe con -
duct e dt oide n t ifyt h e pr e va le n ce ofpr e se n t in gsign sa n dsympt oms
for TMD,e xcludin gwe ll-de fin e dsyst e miccon dit ion s.Th e se st udie s
sh ouldide n t ifya ssocia t ion swit h pot e n t ia llypr e disposin ga n dpr e -
cipit a t in gcon dit ion s.Fr e que n t lyr e por t e dge n de r diffe r e n ce s
wa r r a n t fur t h e r in ve st iga t ion .
Va lida t e ddia gn ost icme t h odsfor ide n t ifica t ion a n dcla ssifica t ion
ofTMDpa t ie n t sa r e n e e de d.Th e dia gn ost icva lue oft h e se a sse ss-
me n t t e ch n ique ssh ouldbe e st a blish e dwit h r e spe ct t ot h e cr it e r ia
ofse n sit ivit y,spe cificit y,r e lia bilit y,a n dcost -e ffe ct ive n e ss.
Wh e n sufficie n t da t a a r e a va ila ble ,a mult idisciplin a r ycla ssifica t ion
syst e mba se don me a sur a ble cr it e r ia sh ouldbe de ve lope da st h e
fir st st e pin a r a t ion a la ppr oa ch t ode ve lopin gdia gn ost icpr ot ocols
a n da ppr opr ia t e t r e a t me n t moda lit ie s.Th isa ppr oa ch sh ouldle a d
t oa la be lin gofsubt ype st h a t couldpe r mit t h e e limin a t ion oft h e
t e r mTMD,wh ich h a sbe come e mot ion a llyla de n a n dcon t e n t ious.
Ra n domize dcon t r olle dclin ica lt r ia lsa r e n e e de dt ode t e r min e
t h e e ffica cyofTMDt r e a t me n t s.Th e se st udie ssh ouldin clude
me a sur e sofbot h clin ica lout come a n dcost -e ffe ct ive n e ss.
Lon git udin a lst udie ssh ouldbe con duct e dt oide n t ifybot h t h e
n a t ur a lh ist or yoft h e n on spe cificsign sa n dsympt omsa ssocia t e d
wit h TMDa n dt h e pot e n t ia lr iskfa ct or susin gpr e dict ive a n d
e xpla n a t or yst a t ist ica lme t h odologie s.Th e se st udie ssh ouldbe
14
de sign e dt oe lucida t e t h e r e la t ion sh ipbe t we e n sign sa n dsympt oms,
a n de t iology.
Tr e a t me n t pr ot ocolssh ouldbe de ve lope dfor a ppr oa ch e sa ime da t
fost e r in gt h e pa t ie n t scon t r ola n dsust a in in gor e n h a n cin gsocia l
fun ct ion in g.Re se a r ch sh oulda lsobe dir e ct e da t un de r st a n din g
se lf-ma n a ge me n t ofTMDsign sa n dsympt oms.
I n ce n t ive ssh ouldbe pr ovide dfor t h e pr iva t e pr a ct ice a n da ca -
de miccommun it ie st ocolla bor a t e in de sign in ga n dcon duct in g
we ll-con t r olle dclin ica lt r ia lsoft r e a t me n t sfor t h e se con dit ion s.
Th e r e isa n obviousn e e dfor ba sicr e se a r ch wit h r e spe ct t oTMD.
Th isr e se a r ch sh ouldin clude bot h h uma n a n da n ima lr e se a r ch in t o
t h e me ch a n ismsofpe r sist e n t pa in a ssocia t e dwit h t h e or ofa cia l
r e gion ,t h e r iskfa ct or sfor pe r sist e n t pa in a n d/ or dysfun ct ion ,t h e
r iskfa ct or sa n dcost -be n e fit con side r a t ion soflon g-t e r mopioiduse
in t h e t r e a t me n t ofTMD,t h e e t iologyofge n de r diffe r e n ce s,a n dt h e
biome ch a n icsoft h e TMJ a n dimpla n t s.
I n n ova t ive me t h odsdir e ct e da t t h e con st r uct ion ofpr ost h e se sfr om
livin gt issue sh ouldbe e n cour a ge d.Bioe n gin e e r sca n ma ke impor -
t a n t con t r ibut ionst oTMDr esear ch,includingst udiesont hemechan-
ica lpr ope r t ie s,biost a bilit y,a n dbiocompa t ibilit yofma t e r ia lsuse d
in impla n t s.
15
Conclusions
Evide n ce pr e se n t e da t t h e Te ch n ologyAsse ssme n t Con fe r e n ce le d
t ot h e followin gcon clusion s:
Th e r e a r e sign ifica n t pr oble mswit h pr e se n t dia gn ost iccla ssifica -
t ion sofTMD,be ca use t h e se cla ssifica t ion sa ppe a r t obe ba se don
sign sa n dsympt omsr a t h e r t h a n on e t iology.
Con se n sush a sn ot be e n de ve lope da cr osst h e pr a ct icin gcommun it y
r e ga r din gma n yissue s,in cludin gwh ich TMDpr oble mssh ouldbe
t r e a t e da n dwh e n a n dh owt h e ysh ouldbe t r e a t e d.
Th e pr e pon de r a n ce oft h e da t a doe sn ot suppor t t h e supe r ior it yof
a n yme t h odfor in it ia lma n a ge me n t ofmost TMDpr oble ms.Mor e -
ove r,t h e supe r ior it yofsuch me t h odst opla ce bocon t r olsor n ot r e a t -
me n t con t r olsr e ma in sun de t e r min e d.Be ca use most in dividua lswill
e xpe r ie n ce impr ove me n t or r e lie fofsympt omswit h con se r va t ive
t r e a t me n t ,t h e va st ma jor it yofTMDpa t ie n t ssh ouldr e ce ive in it ia l
ma n a ge me n t usin gn on in va sive a n dr e ve r sible t h e r a pie s.
Th e e ffica cyofmost t r e a t me n t a ppr oa ch e sfor TMDisun kn own ,
be ca use most h a ve n ot be e n a de qua t e lye va lua t e din lon g-t e r m
st udie sa n dvir t ua llyn on e in r a n domize dcon t r olle dgr oupt r ia ls.
Alt h ough clin ica lobse r va t ion ca n pr ovide dir e ct ion ,t h e se in sigh t s
must be followe dbyr igor ousscie n t ifice va lua t ion .
Th e r e a r e n oda t a t osuppor t some common lyh e ldbe lie fs.For e x-
a mple ,e vide n ce isin sufficie n t t owa r r a n t pr oph yla ct icmoda lit ie s
oft h e r a py.Addit ion a lly,a va ila ble da t a a r e n ot pe r sua sive t h a t
or t h odon t ict r e a t me n t pr e ve n t s,pr e dispose st o,or ca use sTMD.
Th e r a pie st h a t pe r ma n e n t lya lt e r t h e pa t ie n t socclusion ca n n ot
be r e comme n de don t h e ba sisofcur r e n t da t a .
Alt h ough n on in va sive t h e r a pie sa r e cle a r lypr e fe r r e dfor most TMD
pr oble ms,in t h e sma llpe r ce n t a ge ofpa t ie n t swit h pe r sist e n t a n d
sign ifica n t pa in a n ddysfun ct ion wh osh owe vide n ce ofpa t h ologyor
t h a t a n in t e r n a lde r a n ge me n t oft h e TMJ ist h e sour ce oft h e ir pa in
a n ddysfun ct ion ,a n dfor wh ommor e con se r va t ive t r e a t me n t h a s
fa ile d,sur gica lin t e r ve n t ion sh ouldbe con side r e d.
16
Th e most pr omisin ga ppr oa ch e st oma n a ge me n t a n dt r e a t me n t of
pa t ie n t swit h pe r sist e n t TMDpa in a n ddysfun ct ion ma yr e sult fr om
e vide n ce -ba se dpr a ct ice a n dpa t ie n t -ce n t e r e dca r e .Re la xa t ion a n d
cogn it ive be h a vior a lt h e r a pie sa r e e ffe ct ive a ppr oa ch e st oma n a gin g
ch r on icpa in .Ph ysica lt h e r a pya ppr oa ch e sn e e dt obe scie n t ifica lly
e va lua t e d,a sdoa lt e r n a t ive me dicin e moda lit ie s.
Fut ur e a dva n ce sin dia gn osisa n dt r e a t me n t ofTMDwilloccur a s
t h e r e sult ofmult idisciplin a r ycolla bor a t ion sa mon ga n umbe r of
fie ldsin volvin gba sica n da pplie dscie n ce a n dpr a ct ice .
Pr ofe ssion a le duca t ion isn e e de dt oe n sur e pr ope r a n dsa fe pr a ct ice
in t h e t r e a t me n t ofTMD,e spe cia llywit h r e ga r dt oph a r ma cologica l,
sur gica l,a n dbe h a vior a la ppr oa ch e s.Mor e ove r,ifpa t ie n t sa r e t o
kn owwh e r e t ose e kh e lp,a n difin sur a n ce compa n ie sa r e t ofully
a ckn owle dge t h e n e e dfor t r e a t me n t ofTMD,a con se n susmust be
de ve lope dr e ga r din gt h e pr ofe ssion a le xpe r t ise n e e de dt odia gn ose
a n dt r e a t t h e se se r ioush e a lt h pr oble ms.
17
Technology Assessment Panel
J udi t h E. N. Al bi no, Ph. D.
PanelChairperson
PresidentEmeritaandProfessor
ofPsychiatry
UniversityofColoradoHealth
SciencesCenter
Denver,Colorado
J a me s D. Be c k, Ph. D.
KenanProfessorandChair
DepartmentofDentalEcology
SchoolofDentistry
UniversityofNorthCarolina
atChapelHill
ChapelHill,NorthCarolina
Ka re n J . Be rkl e y, Ph. D.
McKenzieProfessor
PrograminNeuroscience
DepartmentofPsychology
FloridaStateUniversity
Tallahassee,Florida
J a me s N. Ca mpbe l l , M. D.
ProfessorofNeurosurgery
SchoolofMedicine
J ohnsHopkinsHospital
Baltimore,Maryland
J oe l Ede l ma n, J . D.
ExecutiveVicePresident
andFounder
FrontierCommunityHealth
Plans,Inc.
Englewood,Colorado
Edga r Ha be r, M. D.
ElkanR.BloutProfessor
ofBiologicalSciences
Director,DivisionofBiological
Sciences
HarvardSchoolofPublicHealth
Boston,Massachusetts
Donna L. Ha mmond, Ph. D.
AssociateProfessorofAnesthesia
andCriticalCareandthe
CommitteeonNeurobiology
DepartmentofAnesthesia
andCriticalCare
UniversityofChicago
Chicago,Illinois
Ma rjori e J e f f c oa t , D. M. D.
RosenProfessorandChair
DepartmentofPeriodontics
SchoolofDentistry
UniversityofAlabama
atBirmingham
Birmingham,Alabama
Thoma s S. J e t e r, D. D. S. , M. D.
OralandMaxillofacialSurgeon
PrivatePractice
SanAngelo,Texas
Sonja M. Mc Ki nl a y, Ph. D.
President
NewEnglandResearchInstitutes
Watertown,Massachusetts
El i za be t h J . Na rc e s s i a n, M. D.
ClinicalChief
PainManagementProgram
KesslerInstitutefor
Rehabilitation,Inc.
EastOrange,NewJ ersey
AssistantProfessorofPhysical
MedicineandRehabilitation
NewJ erseyMedicalSchool
Newark,NewJ ersey
Buddy D. Ra t ne r, Ph. D.
Professor
CenterforBioengineering
UniversityofWashington
Seattle,Washington
18
E. Di a nne Re kow, D. D. S. , Ph. D.
ProfessorandChair
DepartmentofOrthodontics
NewJ erseyDentalSchool
UniversityofMedicineand
DentistryofNewJ ersey
Newark,NewJ ersey
Li s a A. Te de s c o, Ph. D.
ProfessorandAssociateDeanfor
AcademicAffairs
SchoolofDentistry
UniversityofMichigan
AnnArbor,Michigan
St e phe n B. Towns , D. D. S.
President
NationalDentalAssociation
Chicago,Illinois
19
Speakers
Mi c ha e l C. Al pe rn, D. D. S. , M. S.
Th e Rol e ofAr t h r oscopy
i n t h e Tr e a t me n t of
Te mpor oma n di bul a r Di sor de r s
AdjunctProfessorofOrthodontics
SchoolofDentistry
MarquetteUniversity
PortCharlotte,Florida
Gl e nn T. Cl a rk, D. D. S.
Mode r n Con ce pt sofOccl usa l
Di se a se a n dt h e Effi ca cyof
Occl usa l Th e r a py
ProfessorandChair
DepartmentofDiagnostic
ScienceandOrofacialPain
SchoolofDentistry
UniversityofCalifornia,
LosAngeles
LosAngeles,California
Ba rry C. Coope r, D. D. S.
Th e Rol e ofBi oe l e ct r on i c
I n st r ume n t a t i on i n t h e
Docume n t a t i on a n d
Ma n a ge me n t of
InternationalPresident
InternationalCollegeof
Cranio-MandibularOrthopedics
Lawrence,NewYork
Lambert G. M. de Bont , D. D. S. , Ph. D.
Epi de mi ol ogya n dNa t ur a l Pr o-
gr e ssi on ofTe mpor oma n di bul a r
J oi n t I n t r a ca psul a r a n d
Ar t h r i t i cCon di t i on s
ProfessorandChairman
DepartmentofOraland
MaxillofacialSurgery
GroningenUniversityHospital
Groningen,TheNetherlands
Ra ymond A. Di onne , D. D. S. , Ph. D.
Ph a r ma col ogi cModa l i t i e s
Chief,ClinicalPharmacologyUnit
NeurobiologyandAnesthesiology
Branch
DivisionofIntramuralResearch
NationalInstituteofDentalResearch
NationalInstitutesofHealth
Bethesda,Maryland
M. Fra nkl i n Dol wi ck, D. M. D. , Ph. D.
Te mpor oma n di bul a r J oi n t Sur ge r y
for I n t e r n a l De r a n ge me n t
ProfessorandDirectorof
ResidencyPrograms
DepartmentofOral
CollegeofDentistry
UniversityofFlorida
Gainesville,Florida
Sa mue l F. Dworki n, D. D. S. , Ph. D.
Be h a vi or a l a n dEduca t i on a l
Moda l i t i e s
Professor
DepartmentsofOralMedicine,
Psychiatry,andBehavioral
Sciences
OrofacialPainResearchGroup
SchoolsofDentistryandMedicine
Seattle,Washington
J oc e l yne S. Fe i ne , D. D. S. , M. S. ,
H. D. R.
Ph ysi ca l Th e r a py:ACr i t i que
AssociateProfessor
FacultyofDentistry
McGillUniversity
Montreal,Quebec
Canada
20
Ke nne t h M. Ha rgre a ve s , D. D. S. ,
Ph. D.
Ne ur oe n docr i n e a n dI mmun e
Con si de r a t i on s
AssociateProfessor
DivisionofEndodontics
DepartmentofRestorativeSciences
SchoolofDentistry
UniversityofMinnesota
Minneapolis,Minnesota
Pe nt t i Ki rve s ka ri , D. D. S. , Ph. D.
Occl usa l Adjust me n t
AssociateProfessor
InstituteofDentistry
UniversityofTurku
Turku,Finland
Li nda Le Re s c he , Sc . D.
Asse ssi n gPh ysi ca l a n dBe h a vi or a l
Out come sofTr e a t me n t
ResearchAssociateProfessor
DepartmentofOralMedicine
OrofacialPainResearchGroup
SchoolofDentistry
Seattle,Washington
Fra nk P. Luyt e n, M. D. , Ph. D.
ASci e n t i fi cBa si sfor t h e Bi ol ogi ca l
Re ge n e r a t i on ofSyn ovi a l J oi n t s
ProjectLeader
DevelopmentalBiologyProgram
BoneResearchBranch
Bethesda,Maryland
J os e ph J . Ma rba c h, D. D. S.
Fut ur e Di r e ct i on sfor Adva n ci n g
Tr e a t me n t ofCh r on i cMuscul o-
ske l e t a l Fa ci a l Pa i n
RobertandSusanCarmelProfessor
inAlgesiology
DepartmentofOralPathology,
Biology,andDiagnosticSciences
andDepartmentofPsychiatry
UniversityofMedicineand
DentistryofNewJ ersey
Newark,NewJ ersey
J a me s A. Mc Na ma ra , D. D. S. , Ph. D.
Or t h odon t i cTr e a t me n t a n d
ProfessorandResearchScientist
DepartmentofOrthodonticsand
PediatricDentistryandCenterfor
HumanGrowthandDevelopment
AnnArbor,Michigan
Cha rl e s Mc Ne i l l , D. D. S.
Hi st or ya n dEvol ut i on ofTe mpor o-
ma n di bul a r Di sor de r Con ce pt s
ClinicalProfessor
Director,CenterforTMDand
OrofacialPain
DepartmentofRestorativeDentistry
SchoolofDentistry
UniversityofCalifornia,
SanFrancisco
SanFrancisco,California
21
St e phe n B. Mi l a m, D. D. S. , Ph. D.
Fa i l e dI mpl a n t sa n dMul t i pl e
Ope r a t i on s
AssociateProfessor
DivisionofOralandMaxillofacial
Surgery
DepartmentofSurgery
MedicalSchool
UniversityofTexasHealthScience
CenteratSanAntonio
SanAntonio,Texas
Ge ra l d J . Murphy, D. D. S.
Ph ysi ca l Me di ci n e Moda l i t i e s
a n dTr i gge r Poi n t I n je ct i on s
i n t h e Ma n a ge me n t of
President
AmericanAcademyofHead,Neck,
andFacialPain
GrandIsland,Nebraska
J e f f re y P. Oke s on, D. M. D.
Cur r e n t Te r mi n ol ogya n dDi a gn ost i c
Cl a ssi fi ca t i on Sch e ma
Professor,DepartmentofOral
HealthPractice
Director,OrofacialPainCenter
CollegeofDentistry
UniversityofKentucky
Lexington,Kentucky
Chri s t i a n S. St ohl e r, D. D. S. , Ph. D. ,
D. M. D.
Epi de mi ol ogya n dNa t ur a l
Pr ogr e ssi on ofMuscul a r
Te mpor oma n di bul a r Di sor de r
Con di t i on s
ProfessorandChair
DepartmentofBiologicand
MaterialsSciencesandCenter
forHumanGrowthand
Development
SchoolofDentistry
AnnArbor,Michigan
De nni s C. Turk, Ph. D.
Psych osoci a l a n dBe h a vi or a l
Asse ssme n t ofTe mpor oma n -di bul a r
Di sor de r Pa t i e n t s
Director,PainEvaluationand
TreatmentInstitute
UniversityofPittsburgh
MedicalCenter
ProfessorofPsychiatry,
Anesthesiology,andBehavioral
Science
UniversityofPittsburgh
SchoolofMedicine
Pittsburgh,Pennsylvania
22
J os e ph P. Va c a nt i , M. D.
Ti ssue En gi n e e r i n g
AssociateProfessorofSurgery
DirectorofOrganTransplantation
DepartmentofSurgery
HarvardMedicalSchool
ChildrensHospital
Boston,Massachusetts
Mi c ha e l R. Von Korf f , Sc . D.
He a l t h Ca r e Se r vi ce s
I ssue sCon ce r n i n g
ScientificInvestigator
CenterforHealthStudies
GroupHealthCooperativeof
PugetSound
Seattle,Washington
La rry M. Wol f ord, D. D. S.
Te mpor oma n di bul a r J oi n t De vi ce s:
Tr e a t me n t Fa ct or sa n dOut come s
ClinicalProfessor
DepartmentofOraland
BaylorCollegeofDentistry
BaylorUniversityMedicalCenter
Dallas,Texas
23
Planning Committee
J udi t h E. N. Al bi no, Ph. D.
PanelChairperson
PresidentEmeritaandProfessor
ofPsychiatry
UniversityofColoradoHealth
SciencesCenter
Denver,Colorado
Pa t ri c i a S. Brya nt , Ph. D.
Director
Behavior,Pain,OralFunction,and
EpidemiologyProgram
DivisionofExtramuralResearch
Bethesda,Maryland
El a i ne Col l i e r, M. D.
Chief,AutoimmunitySection
DivisionofAllergy,Immunology
andTransplantation
NationalInstituteofAllergyand
InfectiousDiseases
Bethesda,Maryland
Ra ymond A. Di onne , D. D. S. , Ph. D.
Chief,ClinicalPharmacologyUnit
NeurobiologyandAnesthesiology
Branch
DivisionofIntramuralResearch
Bethesda,Maryland
J e rry M. El l i ot t
ProgramAnalyst
OfficeofMedicalApplications
ofResearch
Bethesda,Maryland
J ohn H. Fe rgus on, M. D.
Director
ofResearch
Bethesda,Maryland
Wi l l i a m H. Ha l l
DirectorofCommunications
ofResearch
Bethesda,Maryland
St e phe n P. He ys e , M. D. , M. P. H.
Director
OfficeofPrevention,Epidemiology
andClinicalApplications
NationalInstituteofArthritisand
MusculoskeletalandSkinDiseases
Bethesda,Maryland
Che ryl A. Ki t t , Ph. D.
HealthScientistAdministrator
DivisionofDemyelinating,Atrophic,
andDementingDisorders
NationalInstituteofNeurological
DisordersandStroke
Bethesda,Maryland
J ames A. Lipton, D.D.S., Ph.D.
SpecialAssistantforTraining
andCareerDevelopment
Bethesda,Maryland
24
Ma ry D. Luc a s Le ve c k, Ph. D. , R. N.
ScientificProgramAdministrator
DivisionofExtramuralPrograms
NationalInstituteofNursing
Research
Bethesda,Maryland
Wi l l i a m Ma a s , D. D. S.
ChiefDentalOfficer
AgencyforHealthCarePolicy
andResearch
Rockville,Maryland
St e phe n B. Mi l a m, D. D. S. , Ph. D.
AssociateProfessor
DivisionofOraland
DepartmentofSurgery
MedicalSchool
UniversityofTexasHealthScience
CenteratSanAntonio
SanAntonio,Texas
J e f f re y P. Oke s on, D. M. D.
Professor,DepartmentofOral
HealthPractice
Director,OrofacialPainCenter
CollegeofDentistry
UniversityofKentucky
Lexington,Kentucky
J oyc e Rudi c k
SeniorProgramAnalyst
OfficeofResearchonWomensHealth
OfficeoftheDirector
Bethesda,Maryland
Pa t ri c i a G. She ri da n
TechnicalWriter/Editor
PublicInformationand
ReportsBranch
Bethesda,Maryland
Chri s t i a n S. St ohl e r, D. D. S. , Ph. D. ,
D. M. D.
ProfessorandChair
DepartmentofBiologicand
MaterialsSciencesandCenter
forHumanGrowthand
Development
SchoolofDentistry
AnnArbor,Michigan
Ca rol yn A. Tyl e nda , D. M. D, Ph. D.
DentalOfficer
DentalDevicesBranch
CenterforDevicesand
RadiologicalHealth
FoodandDrugAdministration
Rockville,Maryland
J ohn T. Wa t s on, Ph. D.
Head
BioengineeringResearchGroup
DivisionofHeartand
VascularDiseases
NationalHeart,Lung,and
BloodInstitute
Bethesda,Maryland
Sus a n S. Wi s e
ProgramAnalyst
OfficeofPlanning,Evaluation,
andCommunications
Bethesda,Maryland
25
Conference Sponsors Conference Cosponsors
Na t i ona l Ins t i t ut e of
De nt a l Re s e a rc h
HaroldC.Slavkin,D.D.S.
Director
Of f i c e of Me di c a l Appl i c a t i ons
of Re s e a rc h, NIH
J ohnH.Ferguson,M.D.
Director
Na t i ona l Ins t i t ut e of Art hri t i s
a nd Mus c ul os ke l e t a l a nd
Ski n Di s e a s e s
StephenI.Katz,M.D.,Ph.D.
Director
Ne urol ogi ca l Di s orde rs
a nd St roke
ZachW.Hall,Ph.D.
Director
Nurs i ng Re s e a rc h
PatriciaA.Grady,R.N.,Ph.D.
Director
Of f i c e of Re s e a rc h on Wome ns
He a l t h, NIH
VivianW.Pinn,M.D.
Director
26
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27
Di bbe t sJ HM,va n de r We e l e LT.Lon g-t e r me ffe ct sofor t h odon t i ct r e a t me n t ,
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28
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29
30
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31
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33

Management of
Temporomandibular Disorders
A Continuing Education Activity Sponsored by the
National Institutes of Health
OBJECTIVE
The objective of this NIH Technology Assessment Statement is to inform the biomedical
research and clinical practice communities of the results of the NIH Technology Assess-
ment Conference on Management of Temporomandibular Disorders. The statement
provides state-of-the-art information regarding the diagnosis, treatment, and management
of temporomandibular disorders, and presents the conclusions and recommendations of
the technology assessment panel regarding these issues. In addition, the statement
identifies those areas of study that deserve further investigation. Upon completing this
educational activity, the reader should possess a clear working clinical knowledge of the
state-of-the-art regarding this topic.
ACCREDITATION
For Physicians
The National Institutes of Health is accredited by the Accreditation Council for Continu-
ing Medical Education to sponsor continuing medical education for physicians. The
National Institutes of Health designates this continuing medical education activity for 1
credit hour in Category I of the Physicians Recognition Award of the American Medical
Association. Each physician should claim only those hours of credit that he/she actually
spent in the educational activity.
For Dentists
The National Institute of Dental Research is an ADA CERP-recognized provider
#09896006. This continuing dental education activity has been certified for 1 credit hour.
EXPIRATION
This form must be completed and postmarked by April 30, 1998, for eligibility to
receive continuing education credit for this continuing education activity. The expiration
date for this test may be extended beyond April 30, 1998. Beginning May 1, 1998, please
check the NIH Consensus Development Program web site (http://consensus.nih.gov) or
call the NIH Office of Medical Applications of Research at 301-496-1144 for information
regarding an extended expiration date for this continuing medical education activity.
INSTRUCTIONS: The Technology Assessment Statement contains the correct answers
to the following 15 questions. Select your answer(s) to each question and write the
corresponding letter(s) in the answer space provided. Mail the completed test by the
expiration date shown above to CME Program, Office of Medical Applications of
Research, National Institutes of Health, Federal Building, Room 618, 7550 Wisconsin
Avenue MSC 9120, Bethesda, MD 20892-9120. You will receive notification of your test
results within 2 to 3 weeks. If you have successfully completed the test (11 or more
correct answers), you will receive a certificate for 1 hour of continuing education credit
along with your test results. Photocopies of this form are acceptable. There is no fee for
participating in this continuing education activity.
National Institutes Of Health
Co n t i n u i n g Med i ca l Ed u ca t i o n
1. TheclinicalconditionsusuallyclassifiedasTMDincludethosewith:(You must indicate all

that are true.)
a) painordysfunctioninthetemporomandibularjoint(TMJ)
b) painordysfunctioninthestructurescontiguoustotheTMJ
c) drynessofthemouth
d) alloftheabove
ANSWER: _________________________________________________________
2. WhichoneofthefollowingstatementsisFALSE:
a)Generallyaccepted,scientificallybasedguidelinesforthediagnosisandmanagementof
TMDareavailable.
b)Asagroup,TMDconditionshavenocommonetiologyorbiologicalexplanation,although
specificetiologiessuchasdegenerativearthritisandtraumaunderliesometypesofTMD.
c)TMDconditionscompriseaheterogeneousgroupofhealthproblemswhosesignsand
symptomsareoverlapping,butnotnecessarilyidentical.
d)CurrentdiagnosticclassificationsofmosttypesofTMDarebasedonsignsandsymptoms
ratherthanetiology.
ANSWER: _________________________________________________________
3. Availablepopulation-basedepidemiologicdataindicatethattheprevalenceofself-reported
TMDsignsandsymptomsis:
a) lessthan5percent c) between15and25percent
b) between5and15percent d) between25and30percent
ANSWER: _________________________________________________________
4. PeakprevalenceofTMDoccursinindividuals
a)lessthan20yearsofage c)40to50yearsofage
b)20to40yearsofage d)roughlyequalprevalenceinallagegroups
ANSWER: _________________________________________________________
5. InclinicalcaseseriesstudiesofTMDpatientswithnodetectableorganicetiology,inwhich
conservative,reversible,noninvasivetherapywasemphasized,thepresentingsignsand
symptomsappearedto:
a)improveinthevastmajorityofpatients c)worseninthemajorityofpatients
b)persistorrecurinmostpatients d)remainthesameinmostpatients
ANSWER: _________________________________________________________
6. Whichofthefollowingstatementsclearlyissupportedbydatafromcontrolled,randomized
studies:
a)OrthodontictreatmentpreventsTMD d)Alloftheabove
b)OrthodontictreatmentpredisposestoTMD e)Noneoftheabove
c)OrthodontictreatmentcausesTMD
ANSWER: _________________________________________________________
7. InitialmanagementofTMDpatientsshouldbebasedoninformationthatincludesallof
thefollowingEXCEPT:
a)presenceoftendernessinthejawjointorcontiguousmuscles
b)existenceofparafunctionalconditions,suchasclenchingorgrindingtheteeth
c)thepatientsperceptionofpainanddysfunctionandtheimpactoftheseonthepatients
qualityoflife
d)analysisofperiodontalpathologyorsalivaryflow
ANSWER: _________________________________________________________
D
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a
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h

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o
c
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8. InitialmanagementofTMDpatientswithoutunderlyingsystemicorovertTMJ
pathologycouldincludeallofthefollowingEXCEPT:
a)patienteducationonwhatisknownaboutTMD
b)proceduresdirectedateliminatingcertainbehaviorsperceivedtobeharmful,
suchasclenchingandgrindingtheteeth
c)extensiverestorativedentalprocedures
d)medicationssimilartothoseusefulforotherpainfulmusculoskeletalconditions
ANSWER: _________________________________________________
9. Whichofthefollowingareconsideredconservative,noninvasive,andreversible
approachesthatgenerallyareusefulfortheinitialmanagementofTMDpatients:
(You must indicate all that are true.)
a)physicaltherapy c)occlusaltherapies
b)stabilizationsplints
ANSWER: _________________________________________________
10. Thepreferredpharmacologicagentsforinitialsymptommanagementof
mostTMDpatients,atadosagecommensuratewiththelevelofpain,include:
a)nonsteroidalanti-inflammatorydrugs(NSAIDs)
b)musclerelaxantmedicationsandsedatinglow-doseantidepressants
c)opiates
ANSWER: _________________________________________________
11. Occlusaltherapy,whichpermanentlyaltersanextensiveamountofapatients
toothstructureandtheindividualsocclusion,isirreversible.Sincethesuperiority
ofthistreatmentoverreversibletherapieshasnotbeendemonstratedinrandom-
izedcontrolledprospectivetrials,thisformofocclusaladjustmentprobablywill
notrepresentbestpracticeforinitialmanagementofTMD.
a)True b)False
ANSWER: _________________________________________________
12. Giventhelackofevidenceaboutthedemonstratedeffectivenessinrandomized
controlledclinicaltrialsofanysingletreatmentorcombinationofproceduresfor
themanagementofpatientswithpersistent TMDpainanddysfunction,thereis
noconsensusaboutspecifictreatmentrecommendationsthatcanbemadeat
thistime.
a)True b)False
ANSWER: _________________________________________________
13. Datafromrandomizedcontrolledstudiesareavailablethatshowtheconsistent
effectivenessofrelaxationandcognitivebehavioraltherapiesinthemanagement
ofpainassociatedwithTMD.
a)True b)False
ANSWER: _________________________________________________
14. WhichgroupsofdrugscanbeconsideredforpatientswithpersistentTMDpain
anddysfunctionwhorespondpoorlytoorareunabletotolerateNSAIDsand
opiates?
a)tricyclicantidepressants c)sympatholyticagents
b)anticonvulsants d)alloftheabove
ANSWER: _________________________________________________
15. AllofthefollowingstatementsaretrueEXCEPT:
a)Themostpromisingapproachestomanagementandtreatmentofpatientswith
persistentTMDpainanddysfunctionmayresultfromevidence-basedpracticeand
patient-centeredcare.
b)SurgicalinterventionmaybeappropriateinasmallpercentageofTMDpatientswho
havepersistentandsignificantpainanddysfunction,whoshowevidenceofcorrect-
ableorganicTMJpathology,andforwhommoreconservativetreatmenthasfailed.
c)TheefficacyofmosttreatmentapproachesforTMDisunknownbecausemosthave
notbeenadequatelyevaluatedinlong-termstudiesandvirtuallynoneinrandomized
controlledgrouptrials.
d)ThereisconsensusacrossthedentalandmedicalcommunitiesregardingwhichTMD
problemsshouldbetreatedandhowtheyshouldbemanaged.
ANSWER: _____________________________________________________
Youranswertothefollowingtwoquestionsisoptionalandwillhavenoeffectonthe
gradingresultsofthistest.
Wastheobjectiveofthiscontinuingeducationactivityclearlystated?
a)notatall d)considerably
b)verylittle e)completely
c)somewhat
ANSWER: _____________________________________________________
Didtheactivityplannersprovidethenecessaryinformationtomeetthestatedgoalsand
objectives?
a)notatall d)considerably
b)verylittle e)completely
c)somewhat
ANSWER: _____________________________________________________
Pleasechoosethetypeofaccreditationyouwishtoreceive(checkonlyonebox):
AmericanMedicalAssociation(ForPhysicians)
AmericanDentalAssociation(ForDentists)
NAME(Please type or print clearly)
TITLE
ADDRESS
CITY STATE ZIP
PHONE FAX
Please mail test to: CME Program
Office of Medical Applications of Research
National Institutes of Health
Federal Building, Room 618
7550 Wisconsin Avenue MSC9120
Bethesda, MD 20892-9120
36
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Management of Temporomandibular Disorders

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Management of Temporomandibular Disorders

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37

Th e use ofce r t a in a llopla st icimpla n t sin sur ge r yfor TMDh a sr e -

1. TheclinicalconditionsusuallyclassifiedasTMDincludethosewith:(You must indicate all

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