|
Michael
C. Alpern, DDS, MS, and
M. Charlotte Wharton, Ph.D., and Port Charlotte.
MARQUETTE
UNIVERSITY SCHOOL OF DENTISTRY
The
role of arthroscopy in temporomandibular disorders (TMDs) has given
us an opportunity to glean new knowledge and thus develop new technology
and treatments. Arthroscopy of the temporomandibular joint (TMJ)
suggests that, contrary to existing thought, TMDs are not predominantly
caused by an anteriorly displaced disk. Instead we find a variety
of pathologic conditions, adhesions, degenerative changes, loose
bodies, bruxism dents, cartilage flaps, perforations, anterior tears,
and posterior tears. A posterior tear or anterior displaced disk
occurs 12% of the time. To treat every patient with TMD with an
anterior repositioning splint by manipulation would appear to be
using the wrong method of treatment for 88% of the pathologies found.
There are two types of cartilage in human joints: hyaline, which
is load-bearing, and fibrocartilage, which is the cartilage lining
the condylar fossa, the articular emimence, and the TMJ disk. Fibrocartilage
is histologically and chemically lacking, the percentage of proteoglycans
(present in hyaline cartilage) to withstand compressive loading.
Therefore, loading fibrocartilage causes degeneration. When fibrocartilage
receives compressive loading, matrix degeneration occurs, which
leads to fibrillation and cartilage death. Because the human body
heals by fibrin/clot formation and cartilage has no blood supply,
cartilage will not heal. Cartilage will only wear or degenerate.
Cartilage wearing is not remodeling. Loaded excessively, degeneration
will occur. A series of corrected tomographs and computed tomographic
scans clearly demonstrate the deleterious effects of loading (see
Alpern et al.1).
TREATMENT
OF TMDs BASED ON ARTHROSCOPY:
Initially,
the patient is educated about TMDs by both the orthodontist and
the psychologist and the importance of her role in correction. Forty
percent of the patients require no further treatment. Sixty percent
proceed with a team of diagnostic evaluation that consists of orthodontic/dental
records, clinical psychological diagnosis, neurologic or medical
diagnosis and clearance, and joint evaluation by the arthroscopic
surgeon. These patients are then reevaluated and 10% to 15% more
conclude that because they clearly know what is wrong, they can
treat it themselves.
The remaining patients undergo orthodontic splint therapy and simultaneous
psychological stress therapy. A few see the oral Surgeon, and less
than 3% of presenting patients require arthroscopic surgery. Our
clinical experience with this treatment approach demonstrates that
not every TMD patient requires a splint or any other type of definitive
treatment.
On this basis of 10 years' experience with this team approach to
arthroscopic surgery, we have developed several hypotheses regarding
TMJ function and the management of TMDs:
1.
The TMJ disk is the tendon of the superior head of the lateral pterygoid
muscle and attaches circumferentially to the condyle as a coronary
ligament.
2.
The human TMJ is a polycentric image joint that is partially loaded
on a slant and can be damaged when loaded by either macro- or micro-trauma
or any excessive compressive loading.
3.
Orthopedic treatment of the human TMJ can be safely performed only
before cessation of growth.
4.
Orthopedic treatment must have adequate vertical unloading and limited
anterior stimulation.
5.
After cessation of growth, the only safe splint therapy appears
to be vertically unloading on a flat plane splint with no guidance.
6.
Most important: TMJ condyles and disk must have freedom of unencumbered
motion. All encumbrances to freedom of motion cause pain, dysfunction,
and noise. The freeing of those encumbrances yields a patient without
symptoms.
7.
Stress-induced destructive habits appear to be a substantial contributor
to the problem. Treatment will likely fail without successful control
of stress or destructive habits. TMD destructive habits include
leaning on the jaw or face, sleeping on the jaw or face, chewing
ice, chewing objects, clenching teeth during the day or night, and
abnormal jaw popping. These habits are habitual or inadvertent responses
to stress.
A
retrospective observational study on more than 1000 patients suggests
that without destructive habit control, TMD treatment fails and
untreated patients get worse. We have found in our study that nearly
every patient with TMD has an inadvertent destructive habit of leaning
on his or her jaw or face. Therefore, we have found it exceptionally
helpful to teach every patient with TMD the following:
1.
Never touch or lean on the jaw or face except for hygiene purposes
or when applying make-up.
2. One must sleep on one's back.
3. One must focus on stopping all daytime clenching.
4. One must eliminate all chewing of objects, such as ice, pencils,
or chewing gum.
The
importance of bruxism and destructive habits in the development
of TMD has historically been controversial. For example, workers
such as Butterworth and Deardorff2 and Eversole et al.3 have suggested
that two groups of patients present for treatment: those who have
true internal derangements arid those who have myogenic pain. When
we began examining the temporomandibular joint (see Alpern et al.4),
we were able to test this hypothesis with direct observation of
the joint. We hypothesized that patients who were rated high in
stress would be less likely to have abnormal findings upon arthroscopic
examination than patients rated low in stress. Our findings, however,
failed to support this hypothesis. We related this to the work of
Rugh and Harlan,5 who found that chronic bruxism, especially during
rapid-eye-movement sleep, is destructive to the joint. We later
understood that the fibrocartilage that lines the condylar fossa,
the articular eminence and makes up the TMJ disk is degenerated
by compression loading. This increased our resolve to treat bruxism
and all destructive habits in all patients.
To assess the work of our interdisciplinary team previously described,
we questioned 28 consecutive patients regarding their symptoms before
treatment and after team treatment and had them rate their joint
noise, difficulty in function, and joint facial pain on a five-point
scale. For example, patients told us whether their joint pain was
none, slight pain, some pain, moderate pain, severe pain, or unbearable
pain. Joint noise was described as no noise, infrequent noise, occasional
noises, frequent noises, and noises with every movement. Chewing
difficulties were described as no difficulty, infrequent difficulty,
occasional difficulty, frequent difficulty, arid difficulty every
time I chew." Major findings were as follows:
Mean pretreatment noise decreased by two units of the category scale
from 2.9 (approximately equivalent to noise with every movement)
to 0.9, equivalent to occasional joint noise (Table 1). Mean pretreatment
chewing difficulty was 3.93 (approximately equivalent to frequent
difficulty), which was reduced to a mean of 1.0, equivalent to infrequent
difficulty chewing. Pain was reduced from 2.6 (equivalent to half
of the patients reporting, moderate pain and approximately half
reporting some pain) to 0.5, a mean of less than slight pain. These
patients were questioned from 1 to 6 years after completing treatment.
Because of ethical restrictions in a private-practice setting, we
were not able to assign patients randomly to team treatment and
other more traditional treatment and compare results from the two
groups. We attempted to minimize bias by having the psychologist
team member contact the patients and conduct the research. She was
unaware of the details or course of their dental treatment and knew
only their names and their stress scale ratings.
A second follow-up study has just been concluded using 27 consecutively
treated patients. This second study was undertaken to meet criticism
of retrospective ratings by patients. In other words, patients in
the first study had to remember how they felt before treatment;
in the second study they described their symptoms before treatment
arid after treatment was completed. In addition, we believed it
was important to continually sample our patients to assess our success
in designing a treatment program.
At the first visit to the psychologist, before any treatment was
started, each patient rated her right and left joint pain, headache
frequency, and joint noise frequency on five-point scales. These
five-point scales were similar to those described above in our first
study of 28 patients who had finished treatment. Headache was assessed
in this study, rather than chewing difficulty. Points on this scale
included no headaches, infrequent headaches, occasional headaches,
frequent headaches, and daily headaches. At subsequent visits to
the orthodontist's office, each patient described the percentage
of improvement or lack of improvement in these symptoms as treatment
progressed.
Major findings were as follows: a decrease from a mean pain rating
of 2.9 before treatment to a mean rating of 0.6 at the completion
of treatment for a reduction of 2.1 points. Initial mean rating
for headache frequency was 2.3 ending with a mean rating of 0.7
for an improvement of 1.6 points. Noise frequency changed from a
mean of 2.2 to a final mean rating of 0.7 for an improvement of
1.5 points (Table II).
Eighty-nine percent of our patients ended treatment with a pain
rating of 0 or 1 (none or slight pain). Sixty-one percent ended
treatment with no pain. These figures are very similar to those
obtained in the initial sample of patients with TMD. In that study,
92% of out patients ended with no pain or slight pain; 71% reported
no pain. We believe that this indicates a stable and successful
treatment program that is 90% successful in relieving pain.
Psychological stress management procedures have been discussed elsewhere
(see Wlarton6). The treatment can briefly be described as a two-pronged
plan: basic issues such as perfectionism, chronic feelings of resentment,
and overconscientiousness are dealt with in short-term psychotherapy.
Stress management exercises learned by the patient and practiced
by him or her to relax the musculature and to reduce the body's
automatic response to events perceived by him or her as challenging
or threatening. Tooth clenching and destructive habits are understood
to be part of this automatic response. Special techniques are used
to deal with nighttime clenching and other destructive habits. We
believe it is necessary to reduce tooth clenching and other destructive
habits and to also help the patient to modify overconscientiousness,
perfectionism, and chronic resentment.
Psychological
testing is partially described in Alpern et al.7 Since then we have
added a second test, The State-Trait Anger Expression Inventory,
to explore our earlier findings that patients with TMD have chronic
feelings of anger or resentment. The pattern of mean scores for
24 males and 135 females shows high chronic anger that is suppressed
rather than expressed outward.
For 10 years we have classified all patients on the "Wharton
TMD Scale," (see Wharton).6 Information based on psychological
interview and testing yields a 1 to 5 rating. In brief, patients
having a rating of 1 or 2 have no significant stress. Patients with
a rating of 3 have significant stress. Patients having a rating
of 4 or 5 have serious attention before any other occlusal therapy
is commenced.
Of the first 200 patients, 28.5% were rated as 1 or 2; 51% were
rated as 3; and 20.5 % were rated as 4 or 5. We found that it was
safe to treat patients from categories 1 to 3 only with a splint
or surgery. We had a near 100% failure rate in patients who were
rated as category 4 or 5. Stress is the primary problem of these
patients, and they should receive psychological or psychiatric treatment
before receiving any splint therapy.
Objective research performed and published in 1988 showed that approximately
72% of our study sample of 200 patients with TMD had significant
stress and needed help in ending tooth clenching, leaning on their
jaw, and other destructive habits. Certain psychological characteristics
were found to describe these patients: chronic resentment toward
important persons in their lives, either current or continuing from
the past; overconscientious and perfectionism; and tooth-clenching
habits, day and night.
Our conclusions are that the total team approach produces a satisfactory
outcome. Psychological intervention alone is 42% as effective in
reducing pain as was the total treatment program. The only other
long term study published, that of Williamson and Sliefficid,8 reported
that 24% of their finished patients had no pain, whereas 63% to
71% of our study reported no pain. Out- data do not support the
contention that TMD is either structural or functional. Rather,
these uncontrolled clinical observations support the view that careful
diagnosis, attention to stress and destructive habit control, vertically
unloading flat plane splint therapy, skilled orthodontic and dental
treatment, and conservative surgical intervention, when appropriate,
produce significant improvements in pain and dysfunction in patients
with TMD.
Without complete diagnosis, we have found that some patients who
came to us for diagnosis who had previously been treated with bite
splints, manipulation, and physical therapy actually had a life-threatening
diagnosis of carotid artery aneurysm, sarcoma of the soft palate,
left temporal lobe epilepsy, temporal arteritis / blindness, or
terminal brain tumors.
RECOMMENDATIONS
FOR CLINICAL MANAGEMENT OF TMD:
1.
A complete diagnosis must be performed before any treatment.
2. The patient must be informed of three potential outcomes to splint
therapy: improvement, stay the same or a crisis may develop, requiring
immediate surgery.
3. Splint therapy is not innocuous. The patient must be informed
of the possible resultant changes. The occlusion may change, requiring
one or any of the following: equilibration, orthodontic splint therapy,
full mouth rehabilitation, or permanent splinting.
4.
Results depend completely oil stress control cooperation and the
extent of the intracapsular pathology. The patient should expect
the same results as with any other joint problem: The best that
we cut hope for is more good days than bad days; there is no cure;
and the major responsibility is with the patient with stress/destructive
habit control. Splint therapy fails without stress/destructive habit
control.
|
