Videos

Debunking Myths in the Diagnosis and Management of Temporomandibular Disorders

Video highlights

Evidence-based TMJ diagnostic approach using DC/TMD criteria
Advanced imaging: When cone beam CT is actually needed
Comprehensive pain history taking techniques for chronic orofacial pain
Oral behavior assessment using validated checklists
Conservative vs invasive treatment decision-making
Practical clinical examination techniques for TMJ disorders

This comprehensive webinar, presented by Dr. Roxanne Bavarian from Harvard School of Dental Medicine, represents a paradigm shift in how dental professionals approach temporomandibular joint disorders. Hosted by the Foundation for Oral Rehabilitation (FOR), this educational session systematically dismantles common misconceptions that have persisted in TMJ diagnosis and treatment, replacing them with evidence-based practices that improve patient outcomes.

Dr. Bavarian, a diplomate of both the American Board of Oral Medicine and the American Board of Orofacial Pain, brings her extensive clinical experience and academic expertise to address two critical myths that continue to influence clinical practice. Her unique background, combining oral medicine training at Brigham and Women's Hospital with specialized orofacial pain fellowship at Massachusetts General Hospital, provides the foundation for this authoritative presentation.

Myth #1: Advanced Diagnostic Tools Are Essential for TMJ Diagnosis

The webinar begins by challenging the widespread belief that sophisticated diagnostic equipment is necessary for accurate TMJ diagnosis. Dr. Bavarian systematically examines three commonly overused technologies: joint vibration analysis, cone beam computed tomography (CBCT), and arthroscopy. While acknowledging that each technology has its place in specific clinical scenarios, she emphasizes that these advanced tools are not prerequisites for effective TMJ diagnosis.

The presentation introduces the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD), a groundbreaking framework published in the Journal of Orofacial Pain and Headache in 2014. This 20-page, open-access publication represents the collaborative effort of an international consortium of dentists, oral surgeons, and physical therapists. The DC/TMD provides clinicians with validated, evidence-based diagnostic criteria that demonstrate superior sensitivity (≥0.86) and specificity (≥0.98) for common pain-related TMJ disorders.

Dr. Bavarian explains how the DC/TMD framework eliminates the guesswork from TMJ diagnosis by providing clear tables that outline specific symptoms patients present with and corresponding clinical examination findings. This systematic approach enables practitioners to differentiate between joint-based and muscle-based problems without relying on expensive imaging or invasive procedures.

Revolutionary Approach to Pain History Taking

A significant portion of the webinar focuses on the fundamental principle that "diagnosis is in the history," particularly relevant for chronic orofacial pain conditions. Dr. Bavarian details her comprehensive 45-minute patient consultation approach, which differs markedly from traditional acute pain assessments commonly encountered in general dentistry.

The presentation outlines a systematic methodology for gathering critical diagnostic information through targeted questioning. Key elements include determining pain onset and triggers, with particular attention to dental procedures, trauma, and stress-related factors. The temporal relationship between pain and daily activities provides crucial diagnostic clues, with morning pain suggesting nocturnal bruxism or sleep apnea, while end-of-day pain indicates postural or daytime clenching issues.

Dr. Bavarian introduces the innovative patient pointing technique, where individuals use a single finger to indicate their primary pain location. This simple yet powerful diagnostic tool helps differentiate between joint-based problems (preauricular pointing) and muscle-based conditions (diffuse hand placement over facial muscles). The anatomical precision of this technique, referencing structures like the condyle, glenoid fossa, masseter, and temporalis muscles, provides immediate diagnostic insights.

Advanced Pain Assessment and Quality Analysis

The webinar delves deep into pain quality assessment, emphasizing how descriptive language provides diagnostic clues about underlying pathophysiology. Dr. Bavarian explains how musculoskeletal TMJ pain typically presents as pressure, dull aching, or tension-type sensations, while nerve-based pain manifests as burning, itching, or numbness. The distinction between throbbing pain (suggesting neurovascular involvement or migraine) and electric shock-type pain (indicating possible trigeminal neuralgia) becomes crucial for appropriate treatment planning.

The presentation references the International Classification of Headache Disorders (ICHD-3) when discussing specific timing criteria for various headache conditions. This evidence-based approach to pain classification ensures accurate diagnosis and appropriate referral patterns when conditions extend beyond the scope of TMJ disorders.

Comprehensive Behavioral Assessment Using Validated Tools

Dr. Bavarian introduces the Oral Behaviors Checklist (OBC), a validated assessment tool developed by the same researchers who created the DC/TMD criteria. This comprehensive checklist evaluates both sleep-related and waking-state parafunctional activities that contribute to TMJ disorders. The presentation details how this tool goes beyond simple questions about grinding and clenching to identify subtle behaviors like jaw tensing, forward positioning, and tongue placement between teeth.

The webinar explains how the OBC categorizes behaviors into functional activities (normal physiological functions) and non-functional activities (parafunctional habits). This distinction helps clinicians understand which behaviors require modification and guides targeted behavioral interventions. Professional activities such as singing, sustained talking, and playing wind instruments are addressed as potential contributing factors that require specialized management approaches.

Myth #2: TMJ Disorders Are Untreatable

The second major myth addressed in the webinar concerns the perceived difficulty in treating TMJ disorders. Dr. Bavarian systematically presents the spectrum of available treatments, from conservative approaches to invasive interventions, emphasizing the importance of evidence-based treatment selection.

The presentation advocates for a conservative, multimodal treatment approach that prioritizes reversible interventions before considering irreversible occlusal or surgical procedures. Flat-plane stabilization appliances receive particular attention as having the strongest evidence base among occlusal therapies, with treatment customization based on specific pain subtypes and contributing factors.

Dr. Bavarian emphasizes the importance of addressing both physical and psychosocial factors in TMJ treatment, referencing the DC/TMD Axis II assessment tools that evaluate psychological distress, jaw functional limitations, and pain-related disability. This comprehensive approach ensures that treatment addresses all contributing factors rather than focusing solely on mechanical aspects of the disorder.

Clinical Examination Techniques and Diagnostic Protocols

The webinar provides detailed guidance on systematic clinical examination techniques for TMJ assessment. Dr. Bavarian outlines both extraoral and intraoral examination components, including assessment of gait, cervical range of motion, cranial nerve screening, and facial asymmetry evaluation.

Specific attention is given to mandibular range of motion assessment, including opening, lateral, and protrusive movements, with distinction between pain-free and maximal ranges. Joint sounds (clicking, popping, crepitus) and opening path deviations provide additional diagnostic information that guides treatment planning.

The presentation covers palpation techniques for both muscle and joint structures, emphasizing the importance of systematic assessment of all masticatory muscles, cervical muscles, and temporomandibular joint structures. Intraoral examination includes evaluation of dental attrition patterns, exclusion of odontogenic pain sources, and assessment of occlusal relationships.

Evidence-Based Imaging and Laboratory Assessment

While emphasizing that advanced imaging is not always necessary, Dr. Bavarian provides clear guidelines for when diagnostic studies are appropriate. Cone beam CT imaging is discussed in the context of suspected osseous pathology, while MRI is reserved for soft tissue assessment when conservative treatment fails.

Laboratory testing protocols are outlined for cases where inflammatory or autoimmune conditions are suspected, including rheumatoid factor, antinuclear antibodies, anti-CCP antibodies, vitamin D levels, and specific markers for conditions like Sjögren's syndrome.

Future Directions and Clinical Implementation

The webinar concludes with practical guidance for implementing these evidence-based approaches in clinical practice. Dr. Bavarian emphasizes the importance of thorough documentation, systematic assessment protocols, and patient education in achieving successful treatment outcomes.

The presentation advocates for a paradigm shift away from technology-dependent diagnosis toward comprehensive clinical assessment based on validated criteria. This approach not only improves diagnostic accuracy but also reduces healthcare costs while maintaining superior patient outcomes.

Scientific References and Continuing Education

Throughout the webinar, Dr. Bavarian provides specific references to peer-reviewed literature, ensuring that practitioners can access the primary sources for continued learning. The DC/TMD criteria, ICHD-3 classification system, and Oral Behaviors Checklist are presented as freely available resources that support evidence-based practice.

This comprehensive educational session represents essential continuing education for dental professionals seeking to improve their TMJ diagnostic and treatment capabilities while staying current with the latest evidence-based approaches in orofacial pain management.

Q&A

During the webinar, Dr. Bavarian responded to multiple questions from the audience. Due to limitations in time, Dr. Bavarian was kind enough to provide answers to some of the questions after the conclusion of the webinar. Please see these answered questions from Dr. Bavarian, below:

Q1: Thank you Dr. Bavarian for the insightful lecture! May I know your thoughts on shock wave therapy for managing TMD?

A: I do not have experience with this personally, but I know there is growing research for shockwave therapy in the orthopedic literature for other types of musculoskeletal pain. There is limited research for TMD, but the results are promising. Because there is not much literature on it, I would not recommend it as first-line treatment for my patients at this time, but as a non-invasive treatment with minimal side effects, I would be happy to incorporate it to my clinical practice as an adjunctive or second-line treatment for TMD, should the patient not respond to an occlusal appliance, traditional manual physical therapy, behavioral therapy/habits to reduce daytime clenching, and/or muscle relaxants QHS PRN

Q2: Would you treat acute muscle pain (TMD) with Botox first and then follow with longer term splint therapy?

A: I think that is reasonable! I always try to start with more conservative treatment with an occlusal appliance and physical therapy and perhaps muscle relaxants nightly as needed for more moderate – severe pain, but I have some cases where either (1) the patient cannot afford an occlusal appliance, (2) having time and the means of easy transportation to physical therapy is difficult for the patient, and (3) muscle relaxants carry side effects and/or drug interactions. Other times, as you say, the patient is in significant distress with their jaw pain and headaches inhibiting their ability to function, in which case I may opt to treat with Botox sooner.

Q3: It seems that Gabapentin is being discussed as a pain medication in general. Can you see any issue in Dentists prescribing this for Myofascial pain if necessary?

A: My apologies if I mis-spoke. My opinion is that if a patient has chronic and complex myofascial pain, meaning that it has not responded to conservative measures like an occlusal appliance, physical therapy, home care, and muscle relaxants QHS PRN, I would recommend referral to an orofacial pain specialist for consideration of prescribing medications for chronic pain (e.g. gabapentin, nortriptyline). I am not opposed to a dentist prescribing gabapentin if they feel comfortable doing so, but I acknowledge that it is a controlled substance, can be difficult to gradually titrate, carries side effects of sedation and dizziness, and has potential for drug interactions, so I think it is best that the prescribing clinician has experience in prescribing this medication.

Q4: Do you have experience or opinions with use of lasers for photo biomodulation or low level laser therapy for TMD?

A: I do not have personal experience with use of LLLT/photobiomodulation for TMD. I do not perform it in my office and have not yet encountered any physical therapists in my area who offer this. There is research to support it as helping reduce pain and improve range of motion for patients with TMD of both myogenous and arthrogenous etiologies, as well as musculoskeletal pain in general. I would not rely on it as a stand-alone treatment, but in addition to other conservative and evidence based treatment, I support it as an adjunctive treatment that is non-invasive and safe with little to no side effects.

References

[1]- Schiffman E, Ohrbach R, Truelove E, Look J, Anderson G, Goulet JP, List T, Svensson P, Gonzalez Y, Lobbezoo F, Michelotti A, Brooks SL, Ceusters W, Drangsholt M, Ettlin D, Gaul C, Goldberg LJ, Haythornthwaite JA, Hollender L, Jensen R, John MT, De Laat A, de Leeuw R, Maixner W, van der Meulen M, Murray GM, Nixdorf DR, Palla S, Petersson A, Pionchon P, Smith B, Visscher CM, Zakrzewska J, Dworkin SF. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: Recommendations of the International RDC/TMD Consortium Network and Orofacial Pain Special Interest Group. J Oral Facial Pain Headache. 2014;28(1):6-27.

[2]- Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211.

[3]- Donnarumma V, Ohrbach R, Simeon V, Lobbezoo F, Piscicelli N, Michelotti A. Association between waking‐state oral behaviours, according to the oral behaviors checklist, and TMD subgroups. J Oral Rehabil. 2021;48(9):996-1003.

[4]- Ohrbach R, Gonzalez Y, List T, Michelotti A, Schiffman E. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) Clinical Examination Protocol: Version 02June2013.

[5]- Slade GD, Ohrbach R, Greenspan JD, Fillingim RB, Bair E, Sanders AE, Dubner R, Diatchenko L, Meloto CB, Smith S, Maixner W. Painful Temporomandibular Disorder: Decade of Discovery from OPPERA Studies. J Dent Res. 2016;95(10):1084-92.

Clinical topics

Questions

Ask a question