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Posted by: The Probe 3rd March 2020
Temporomandibular Joint (TMJ) disorders have long presented somewhat of a challenge to the dental profession. Treatments and even the disorders themselves have been surrounded in uncertainty. Indeed, there was a time when the topic was discounted entirely by professors and educational providers. However, with improved knowledge, science and technologies in the modern profession, TMJ management can now be highly effective.
Traditionally, treatment for a TMJ problem would have included a dental splint and occlusal adjustment. This remains a valid solution, or part of the solution for patients today, it’s just that our techniques and materials have improved.
Where a patient faced greater complications, surgery would have been indicated. As in all surgical fields, the minimally invasive, microscopic procedures of the modern world were preceded by open surgeries with much greater risks. Open joint surgery was often the order of the day for TMJ patients, but it was very destructive. In addition, the materials being used to replace and reconstruct the TMJ were poor and therefore regularly rejected by the hosts. All in all, dental professionals came to think of TMJ treatments as disasters waiting to happen.
Today, we have many more tools at our disposal that have enhanced management of TMJ problems no end. For example, MRI scans produce more detailed images of the soft tissues and joint. With more accurate visualisation of the anatomy, maxillofacial surgeons can better isolate and treat the problem.
Another potential and minimally invasive solution available is botulinum toxin injections. These can provide pain relief in certain cases, relaxing the TMJ muscles and counteracting the effects of excessive grinding and clenching. These are commonly used as an effective adjunctive treatment alongside a dental splint.
Furthermore, the surgical methods used in more complex TMJ cases have improved significantly. Arthroscopic surgeries have been refined and digital technologies make the procedure much less invasive than it once was. We can now operate within the joint with a 1.9mm microscope, enhancing patient comfort, improving healing and reducing surgery time.
Finally, the materials used in modern TMJ replacements have changed drastically. They are now manufactured in orthopaedic laboratories, adhering to the same standards and qualities as any other orthopaedic component. After all, the TMJ is a joint just like any other in the body. It should therefore be treated in the same way. In many cases, what works in the knee will work in the TMJ. Continued and closer collaboration between dental, maxillofacial and orthopaedic experts will likely be integral to the future progression of TMJ management techniques.
Take on or refer
With several treatment options at dentists’ disposal, there is opportunity to provide pain relief and solutions for patients with TMJ problems in-house. However, as in any other area of dentistry, it’s crucial for GDPs to understand their professional remit and know when to refer to an expert in the field – in this case, a maxillofacial surgeon.
Most patients with TMJ disorders fit into the following three categories:
- Those that primarily have a joint problem, such as arthritis or any other rheumatological diseases. This is the most common reason for TMJ issues. Patients usually present with pain specifically in the TMJ region, noises in the joint upon movement and restricted function. These patients require referral to a maxillofacial surgeon who deals with TMJ disorders. The sooner treatment begins, the less damage will be caused to the joint and surrounding muscles.
- Patients principally with a muscle problem are the next most common group. This may result from a TMJ disorder alone, myofascial pain syndrome, constant grinding and/or clenching, and malocclusion. In these cases, the patient doesn’t always need a referral. Their condition can be managed with dental splint therapy, occlusal adjustment, botulinum toxin injections and physiotherapy. It may prove helpful for GDPs to have literature that the patient can take away about exercises to do at home.
- Those whose problem started in the muscle, but has progressed into joint damage too. A combination of therapies is best for these patients in order to treat the cause of the problem, as well as the consequences. Collaboration between the GDP and maxillofacial surgeon is essential.
A word about the referral pathway is necessary when it comes to TMJ disorder management. Not all maxillofacial surgeons will offer appropriate treatments for these patients, so it’s important to check this. The European Society of TMJ Surgeons offers a list of registered experts and their fields, which may be useful to GDPs. Further still, it is just as important to work with a maxillofacial surgeon that can provide all the treatment options in between dental splints and open joint surgery. This ensures that the most conservative solution can be found for the patient.
Improving patient care
Patients can suffer much pain and discomfort as a result of undiagnosed and untreated TMJ disorders. It can affect every part of their lives. Consequently, management of minor TMJ problems within the dental practice can be a huge business builder. Patients will be so grateful for the reprieve and for the level of care provided. Where more serious issues are present, referral to an appropriate specialist is crucial, but collaboration is key. Ultimately, treatments for TMJ disorders are no longer the horrors they once were. They have been developed and refined significantly and today provide an opportunity to change lives.
Dr Luke Cascarini is a Consultant Oral and Maxillofacial Surgeon and a Head and Neck Surgeon. He has completed extensive training and has grown his expertise to include trans-oral robotic surgery (TORS), Temporomandibular joint surgery and electrochemotherapy. After ten years as a Consultant in Head and Neck Surgery, he is now taking a break from NHS cancer wok to concentrate on private surgery, but retains an honorary post at Guy’s and St Thomas’. Luke holds a Fellowship in Dental Surgery, Royal College of Surgeons (England), as well as in Maxillofacial Surgery, and is a member of the European Society of TMJ Surgeons. He has published over 50 papers, presented nationally and internationally, has written three leading surgical textbooks and contributed numerous chapters to other books.