A Protocol for the Treatment of Temporomandibular Disorder
James E Metz, DDS, Diplomate ABDSM
Mickey C Harrison, DDS
The Metz Center for Sleep Apnea
1271 East Broad Street
Columbus, Ohio 43205
©2015, The Metz Center; Unauthorized reproduction or distribution will be prosecuted. Requests for reproduction should be directed to Dr. James Metz at email@example.com.
Primary Site Stimulation (Stress Test)
The answer to differentiating temporomandibular dysfunction (TMD) from other head pain
, even with the complexities of cranial nerve V, may be a simple technique utilized by medical practitioners. Primary Site Stimulation
is a pressure technique that can be useful in the diagnosis of TM issues1 2
. If the clinician puts pressure on a specific structure and it creates the chief complaint, then one has usually found the problem. The complexities and anatomic deviations of the system are not an issue here; the goal is to find and reproduce the pain.
A simple example is that of a patient with “arm pain.” If they cannot tell the origin of the pain
, the practitioner must test. If the arm is examined by the use of primary site stimulation, then pressure is applied by the clinician to various structures located in the arm. If the patient’s chief complaint is “stimulated” while applying pressure to a specific structure, the diagnosis is complete, and whatever was stimulated to hurt is the source of the pain. Realize that this test cannot predictably be accomplished with palpation3
or jaw manipulation to diagnosis a TMD problem. The inaccessibility of some muscles to palpation and the complexity of the system create the need for a different type of testing.
The protocol is similar to the medical standard of care for distinguishing between local, projected
, referred and central pain and tenderness1
. The stress test should become the standard of care for dentistry, as it is in medicine. The test should always be a part of the complete TMD examination.
Two methods can be employed:
Anterior Deprogrammer (Figures 6, 7, 8)
Anterior Appliance (Figure 9)
Fig. 6 Anterior Deprogrammer, Retruded position Fig. 7 Anterior Deprogrammer, Protruding mandible
Fig. 8 Ant. Deprogrammer, Checking posterior contact Fig. 9 Anterior Appliance, Note: Excellent esthetics
The reliability of the stress test by either method has a high degree of confidence. Each of the tests will give a yes or no to the diagnosis of TMD, but with a different urgency. Stress testing by either means will minimize inconvenience, pain, misery or cost to the patient. However, if the practitioner wants a true understanding of this TMD protocol with all of its ramifications, a complete knowledge of the anterior deprogrammer must be gained prior to the use of the anterior appliance as a stress test method. At least twenty-five patients should be diagnosed with the anterior deprogrammer stress test before the anterior appliance is substituted.
It must be realized that sometimes there is no substitute for the expediency of the anterior deprogrammer. This is especially true with a doubtful patient, or if a yes/no answer is urgently required. The anterior deprogrammer stress test shows
, vividly, the character and distribution of the pain related to TMD4
Once the anterior deprogrammer is understood, the anterior appliance is the most reliable diagnostic tool available. However, the cost to the patient is greater. The anterior deprogrammer gives a quicker diagnosis but does not separate TM joint patients from muscle patients as accurately as does the anterior appliance. Testing with the anterior deprogrammer is completed during one office visit. If the anterior appliance is used, a period of two weeks will be required for diagnosis.
The patient is asked to keep a record of their symptoms until they are pain free and the diary is reviewed at each check appointment. The joint will sometimes remain somewhat painful (anti-inflammatory medications can be utilized as needed) for a period of one week with the anterior appliance. Approximately 60% of the time this pain will disappear during the first week. However, TMJ pain should never be allowed to continue beyond the two week check. If the joint is still painful after the initial two weeks, a pivotal appliance is indicated, and will be discussed in subsequent sections.
The stress testing with the anterior deprogrammer causes
, among other things, an eccentric (lengthening) contraction of the lateral pterygoid muscle5 6
; an isometric contraction of the masseter, medial pterygoid, and temporalis muscles; and pressure on the temporomandibular joint. Centric relation occlusion and habitual occlusion will not normally be coincidental7
. The doctor will usually be able to demonstrate a “slide in occlusion” very conclusively after the test.
There are variations on the anterior deprogrammer.
Huffman numbered leaf gauge (originally proposed by Hart Long8): mylar film 10 mm wide and .1 mm in thickness attached together in book form, total thickness with all “leaves” 5.5 mm. (Huffman Leaf Gauges, 853 Sylvan Shores Drive, South Vienna, OH, 45369-9517, phone 937.624.6101)9.
Woelfel sliding guide: made from hard plastic, which is calibrated, and varies in thickness from .5 mm to 16 mm. The Woelfel sliding guide is the simplest to use and most sterilizable of the anterior deprogrammers. (Girrbach Dental GmbH, Durrenweg 40, D-75177 Pforzheim, Germany, phone 0049.723.1957000; see website at www.girrbach.de)10 11.
Lucia jig: custom molded plastic which can be modified with an acrylic bur to any thickness desired. The jig is generally molded over maxillary centrals for retention and has point contact on a mandibular central10 12.
NTI-tss (NTI-TSS Inc.) appliance: A modified Lucia jig, which can be used for a short time as an appliance. The deficiency is the small number of teeth contacted in the lower arch. The increased pressure on such few teeth is problematic, especially as compared to the anterior appliance described in this paper13.
The claims of NTI-tss for the treatment of migraine are based on a 19 person study conducted in 1996 by Lamey, Steele, and Aitchison at Queen’s University of Belfast and reported in the British Dental Journal14
. The Lamey study was conducted with full centric relation splints and not the NTI. The FDA granted the acceptance for migraine because of the similarity of the NTI to the centric relation splint, and the CR splints decreased migraine by 40%. Therefore, by this logic the NTI would also have this effect. As stated previously
, there is great confusion as to the diagnosis of migraine or TMD. Splints are for TMD and may benefit some true migraine patients because TMD can be a secondary symptom. Controlling a secondary symptom may decrease the frequency of the migraine, but true migraine will not be controlled with an anterior splint. This leaves the claims of others subject to judgment.
The test with the anterior deprogrammer begins by:
Placing it between the patient’s maxillary and mandibular central incisors.
The patient must first protrude and then retrude the mandible to its most posterior position.
They then bite with “substantial” pressure on the deprogrammer.
The doctor or auxiliary must sit with the patient, making sure that they stay retruded and continue to bite with substantial pressure. It is necessary that the test be conducted for at least 7 minutes; muscles sometimes take that long to spasm. Many times the patient will feel nothing prior to the onset of the painful spasm.
No posterior teeth can touch (see figure 8).
It is also important that the patient be comforted if the test produces a painful result, and duplication of the symptoms is successful. The patient is never asked to continue beyond their endurance. Place warm moist towels on affected area for comfort.
The Key: Once the patient reproduces the chief complaint
, the test does not need to continue. The diagnosis of TMD has been made, and an appliance (anterior or pivotal) is appropriate. The following steps are physical therapy (refer to page 19 for more information). If the pain is minor or the patient does not desire an appliance the following technique may be used to control symptoms.
Once the pain begins, the patient should alternately bite for six seconds and relax for six seconds.
Test continues for 7 but no longer than 10 minutes, measured from the beginning of testing. The test is stopped prior to the 10 minutes if pain subsides. This is referred to as cycling the muscle, which is a stretching of the muscle until the myospasm subsides.
A true joint patient will be in pain from the onset of the test, and seven minutes is long enough for them to tolerate the discomfort.
The Key: If stressing a structure reproduces the chief complaint, then the source of the pain has been diagnosed with the stress test.
A phenomenon occurs when a patient first complains of joint symptoms at the onset of the test. The joint pain will sometimes go away after 2 to 3 minutes and is then replaced by the typical muscle spasm related to TMD. It is hypothesized that a muscle spasm of the lateral pterygoid repositions the disc (through the stretched TMJ capsule) in a more forward position than normal; once the disc is in this forward position, it is sensitive to the initial testing15
(see figure 10). However, it will then reposition to a more normal posture when the muscle starts to release. If the test is stopped prior to the 7 minutes the clinician may incorrectly conclude that the patient has a joint problem, which is a more involved treatment than that for a muscle spasm.
Figure 10: Left side, disc out of position; Right side, normal disc position.
The test is simple, but very telling because of the neurologic principle of primary site stimulation1 16. Primary site simulation, as previously discussed, is the premise that if one presses on a structure that is truly causing the pain, the pain will change. If the practitioner presses on a structure that is aching because of referred pain, the pain will not change. If the stress test causes or changes the chief complaint, the diagnosis of TMD is appropriate. It is important that the clinician asks the patient, “Is this the same pain as your headache or just part of the headache?” The question can also be asked, “Is this the pain for which you are seeking treatment?”
Patients can be both a TMD and
headache sufferer. One of the conditions will be more significant. If they are mainly a headache patient with a lesser amount of TMD
, treating the TMD successfully will not
get rid of the headache. However, if the dentist is able to eliminate the TMD component, the headache may decrease in either intensity and/or frequency17
. Remember, the trigeminal nerve is the major sensory nerve of the head and neck. Beware of referred pain18
Another condition that may be associated with TMD deals with patients having otologic complaints, such as otalgia
, tinnitus, vertigo, and hearing loss. These individuals have a higher incidence of otologic complaint than do control subjects without TMD signs or symptoms19
. The overlap of symptoms is most likely due to convergence. It is probable that other muscles can also be affected by the phenomenon. Possibly, the tensor tympani, which dampens and stabilizes the inner ear to vibration, could also be affected. Taking one more step
, the tensor veli palatine may also be affected by convergence. Loughner hypothesizes that the closing of the Eustachian tube, the responsibility of this muscle, creates a sensation similar to a sea shell over the ear20
. The sensation created may be the otologic symptom for which the patient has a complaint.
TMD Splints – When, Why, and How21
Potential Sources of Headache and Orofacial Pain:
Vascular, Myofascial, Neurologic, and Intracapsular / Joint Pain