Temporomandibular Disorders (TMD)
TMDs are usually transient and self-limiting; therefore, there is no need for complicated and irreversible procedures. The main objectives in TMD treatment are pain reduction or elimination and resumption of normal mandibular activity. By addressing the physical disorder and perpetuating factors through a structured and time limited program, these goals could be simply met. The five basic general principles of TMD managements include a) patient education and self-care b) cognitive-behavioral interventions c) pharmacologic management d) physical therapy e) surgery.
A) Patient Education And Self-Care
The primary objective for satisfactory management of TMD is explanation and reassurance for the patient. Most often persistent noise in the TMJ is interpreted as a sign of disease and it may be difficult for the patient to accept that joint noise is very prevalent and may occur in otherwise healthy joints. The home care program should include instructions like avoiding chewy foods, performing jaw stretching exercises, applying moist heat or ice, and not clenching teeth during the day. These simple modifications may be sufficient to alter symptom intensity.
B) Cognitive-Behavioral Interventions
Changing persistent maladaptive habits may be accomplished with simple exercises or a structured approach requiring a well-trained behavioral therapist. Behavioral modification may include life style counseling, progressive relaxation, biofeedback, and hypnosis. The best outcome is achieved by individualizing the treatment considering each patient’s preferences, problems and life style.
C) Pharmacologic Management
Medications are employed to control the TMD symptoms by promoting patient comfort and healing. These include analgesics, no steroidal anti-inflammatories, corticosteroids (often injected), muscle relaxants, tricyclic antidepressants, selective serotonin/epinephrine reuptake inhibitors, sedatives, and anticonvulsants.
D) Physical Therapy
Physical therapy includes posture, stretching and strengthening exercises, joint mobilization and the use of modalities like vapocoolant spray and stretch, trigger point injections, hot packs, ice, ultrasound or other stimulating techniques. Treatment goal is to decrease pain and improve joint movement by altering nociceptive sensory input, reducing inflammation, coordinating and strengthening muscle activity and promoting tissue regeneration. Occlusal appliance therapy has been the mainstay of TMD therapy. The type of appliance used in TMD is controversial but the use of stabilization appliances are reported to be the most effective with the least adverse effects. Stabilization appliances are made out of hard cured acrylic and should cover the entire maxillary or mandibular teeth. The potential benefits of the appliance use are protecting teeth, providing joint stabilization, redistributing forces on the joint surface, relaxation of masticatory muscles and reducing par functional habits. A second appliance is an anterior repositioning device that holds the lower jaw in a forward position. When compared to stabilization appliances, they are equally or effective in managing TMJ clicking and locking. The long term use (more than 3 months) of these appliances may lead to occlusal changes; therefore, they are to be used with caution. Nociceptive Trigeminal Inhibition Reflex (NTI) device is another appliance that is popular. Potential side effects like swallowing, possible aspiration, tooth movement, and bite changes make this appliance unattractive.
Since TMD is self-limiting, invasive surgical interventions are rarely warranted. Most patients respond to a simple joint injection with corticosteroid. However, with repeated corticosteroid injections condylar damage is reported. Intraarticular irrigation (arthrocentesis) of the joint with lactated Ringer’s solution or normal saline is very helpful in reducing TMJ pain and improving range of motion. Arthroscopy is another method which allows direct viewing of the TMJ surfaces but it is more invasive than arthrocentesis. The open joint surgery is performed less frequently and is indicated for more complex disease or traumatic conditions.