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TMJ SECTION

EMBRACING CONSERVATIVE

APPROACHES: MANAGING

TEMPOROMANDIBULAR JOINT DISORDERS

Amelia Edmonds and Sidney Lisser

INTRODUCTION
Temporomandibular joint disorders (TMDs) are the second most
common musculoskeletal (MSK) condition resulting in pain and
disability (NIH, 2018). One of the most common causes of secondary
tooth pain is myofascial pain with referral (Bender, 2019). As dental
professionals you are often the first healthcare provider that will
identify these conditions. In 2020, unfortunately overlooked due to the
Covid-19 pandemic, the National Academies of Science, Engineering
and Medicine presented and published a consensus on the priorities
in care for TMDs. One of their major recommendations was that the
first line treatment for TMDs should be conservative and reversible
care. Implementing a stepped care approach highlights the utilization
of conservative care, proven to be effective for the majority of TMD
patients.
A stepped care model recommends the use of lower-risk, non-
surgical treatments when feasible, before considering invasive options
in MSK rehabilitation (Rhon et al, 2022) (Figure 1). Conservative care
should be considered for managing facial pain when red flags and Disorders (DC-TMD) as a dependable resource and standard to
odontogenic causes have been ruled out. The first step is a relevant follow for examination of the orofacial region for the general patient
clinical assessment and accurate diagnosis followed by appropriate (Schiffman 2014). Often, we need to look beyond the standard DC-
and best practices. Misdiagnosis or mismanagement in the initial TMD exam as patients may have adapted to their injury and present
stages often steers patients towards unnecessary, invasive procedures, abnormally. Physical examination should also reference the patients’
resulting in ineffective care and poor patient outcomes. activities of daily living and not just what is considered ‘normal’ within
In appropriate cases, there is a place for more invasive procedures the DC-TMD guidelines.
such as injectables, surgeries, or medications; however, it is the primary Historical findings in a patient that presents with the pain of an
treatment for a select few. This article will explore MSK diagnosis MSK origin may include pain with mastication, clicking, locking,
and examination, noninvasive approaches to treat TMDs, and the and headaches, to name a few. It is important to use your physical
challenges hindering accessible conservative care. As we discuss exam to then narrow down the MSK diagnosis. When observing
these topics, it will become evident that the understanding of these jaw movements, check for asymmetries, limited ranges of motion, or
components is crucial for advancing effective healthcare for TMDs. deviations during opening and closing.
If you observe limited opening, you must determine if it is the
MSK DIAGNOSIS & EXAM result of a physical and/or pain barrier, fear of opening, or abnormal
TMDs should be used as an umbrella term to encapsulate many opening due to pain (antalgia). After injury, patients are often afraid
orofacial pain conditions; however, it should not be considered as to move despite having full range of motion. If there is no acute
a diagnosis. TMD provides little specificity to the mechanism or trauma, encouraging movement despite associated pain is crucial in
pathology of the injury and would not be considered an accurate rehabilitating them back to normal function. Palpation of the joints
diagnosis in a stepped care model. Common MSK diagnoses like and associated muscles helps identify tenderness or pain, clicking,
tendinopathy, non-inflammatory arthropathies, or muscle-referred crepitus, or irregularities. Compressing joint surfaces passively can
pain are extendable to the orofacial area. also identify painful structures within the joint. Remember, your most
As a professional who will assess, treat, and triage facial pain, reliable tool when palpating structures is the patients report of pain
familiarizing yourself with the evaluation of the area is important. elicited on palpation.
Gaps exist in dental undergraduate education with regards to MSK Physical examination aids specific diagnosis and will help guide
diagnoses and how to assess them. In response to this, most dental management planning.
professionals can use the Diagnostic Criteria for Temporomandibular A study containing a cohort of 88,985 participants showed that less

44 Dental Practice I July-August 2024 I Vol 20 No 4