Patients with temporomandibular disorder strike fear into the hearts of many dentists. The image of crazed, stressed-out clenchers and grinders come to mind, and the typical response is, “I don't treat TMD patients.”
The reality is, we all treat TMD patients. The prevalence of structurally altered temporomandibular joints is far greater than our profession assumes, and these patients are in our offices whether we realize it or not. TMJ problems arise earlier in life than previously thought and are involved in many common restorative cases.
A high percentage of Class II occlusions, anterior open bites, deep bites, worn teeth, facial asymmetries, retrognathic maxillas, retrognathic mandible and airway disordered patients we see will have a joint component that is either responsible for the problem or integral to its solution.
For dentists who strive to implement comprehensive treatment planning on a regular basis, the ability to recognize, diagnose and treat TMD is critical to serving their patients. The patients who need comprehensive treatment planning will many times present with the problems mentioned above.
In order to treat patients predictably, both the general practitioner and specialist must be able to offer patients treatment options based on direct visualization of TMJ soft tissue anatomy with MRI and hard tissue anatomy with CBCT.
For years, we have tried to guess joint anatomy through indirect visualization techniques like load testing, muscle palpation, measuring a range of motions and listening to TMJs with a stethoscope, doppler or joint vibration analysis. While these techniques are effective screening tools, they cannot give the dentist or patient a realistic analysis of the risk factors for successful treatment.
The inability of dentists to understand risk factors is the exact reason many dentists are fearful of treating TMD patients. As a result, dentists refer patients for TMD treatment and any necessary occlusal, orthodontic, restorative, orthognathic, esthetic and airway treatment to another office.
The irony is that many of these dentists who are referring patients out of their practice are spending money with marketing consultants to try to attract new patients. If the dentist was confident is treating TMD, they may not need to attract new patients to the practice.
It is more likely the number of new patients will rise, sometimes dramatically, in practices where dentists are confident in treating TMD, since they understand the anatomic risk factors through direct visualization with MRI and CBCT.
The likelihood of effective treatment outcomes is higher when the risk factors are clearly understood. Successful treatment outcomes will lead to an increase of patients seeking TMJ treatment and any associated treatments.
TMD can be treated successfully today. Patients with structurally intact TMJs (Figure 1) can usually be treated at the tooth level with very low-risk levels for the patient and the dentist.
TMJ patients who have structurally altered joints with the injury contained at the lateral pole (Figure 2) can be treated successfully at the tooth level and have low to moderate risk levels for patients and dentists.
The increase in the risk, in this case, is due to the partial herniation of the disk and the inability of the disk to protect the condyle at the lateral pole.
TMJ patients that have structurally altered joints with the injury at both the lateral pole and the medial pole (Figure 3) can be treated successfully at the tooth level. The problem is that not all patients with structurally altered TMJs with injury at both the lateral and medial pole can be treated successfully at the tooth level.
These patients present with a moderate to high level of risk, which is responsible for the fear many dentists have regarding TMD patients.
If the anatomic deficit is great enough, treating the occlusion at the tooth level may not be able to overcome the effects of a large herniated disk, eroded bone, small bone or edematous bone.
If these risk factors are recognized before treatment through MRI and CBCT imaging, the patient and the dentist can make an informed decision about what treatment options are appropriate.
TMD patients can be wonderful to treat if they are not too minimally diagnosed.
Jim McKee, D.D.S., is a member of Spear Resident Faculty.