The Scope of TMD/Orofacial Pain (Head and Neck Pain Management) in Contemporary Dental Practice

Dental Practice Act Committee of the The Dental Practice Act Committee of the American Academy of American Academy of Orofacial Pain Orofacial Pain was convened in 1995 for the purpose of studying Committee Chairman: the scope of temporomandihular disorders (TMD)lorofacial pain Robert S, Rosenbaum, DMD and dental practice acts. The committee concluded that the scope Clinical Instructor of clinical practice of TMDiorofacial pain is expanding beyond the Department of Penodontology teeth and oral cavity to include the diagnosis and treatment of dis- Harvard School of Dental Medicrne orders affecting the entire head and neck. The expansion of clini- Boston. Massachusetts cal practice is consistent with historical precedent in dentistry and Committee Members: within the scope of current dental practice acts. The present report Sheldon G. Gross, DDS represents the position of the American Academy of Orofacial Chnical Assistant Professor Pain. Department of Prosthodontics

RichardA, Pertes, DDS Clinical Professor and Director TMD/Orofacial Pain Center Department of Prosthodontics

University of Medicine and Dentistry of New Jersey Mew Jersey Dental School Islevi/ark. New Jersey

Lawrence M, Ashman, DDS Clinical Associate Professor Department of Orthodontics University of Detroit Mercy School of Dentistry Detroit, Michigan he original disciplines of dentistry were oral .surgery, prosth- Michael K. Kreisberg, DDS odontics, restorative dentistry, orthodontics, and periodon- tics,' These disciplines were limited to the diagnosis and Atlanta, Georgia T treatment of diseases affecting the teeth and their supporting struc- Correspondence to: tures. Newer disciplines such as oral diagnosis/oral medicine, den- Dr Robert S, Rosenbaum tal anesrhesiology, and temporomandibular disorders (TMD)/oro- 396 Commonwealth Avenue facial pain are focused on the diagnosis and treatment of diseases Boston, Massachusetts 02215 affecting the entire head and neck. The evolution from disciplines that were primarily focused on teeth ro those that are concerned with the entire head and neck is an indication of the expanding scope of contemporary dental practice. The expansion of dental practice is not new. It represents a trend thar has been present throughout dental history.- Initially, the profession focused on teeth because there was a need to treat tooth pain caused by dental decay. With the advent of dental amalgam, the thinking in dentistry changed from an exrracc-and- replace mentality to one in which restoring and saving teeth was the primary goal. The new goal required that diseases in the sup- porting structures of teeth also be treated. Although it may seem unremarkable to contemporary dentists, periodontology first expanded dental practice by focusing on structures around teeth rarher than on the teeth themselves. In doing so, the profession took the first step toward expanding dental practice to include the diagnosis and treatment of tissues and structures other than teeth.

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As the dental profession matured, diagnosis and ated with tempotomandibular and related muscu- treatment expanded to include treatments for tis- loskeletal disorders as well as otber orofacial pain sues and structures that were once thought to be disorders."Conditions such as inttaoral, muscu- outside the scope of dental practice. Conremporary loskeletal, neutovascular, and neuropathic pain, as periodontists and oral surgeons grafr bone in the well as cancer pain affecting the head and neck, maxillary sinus in preparation for placing dental are within rhe scope of contemporary TMD/orofa- nnplants. Before implant dentistry, operating in the cial pain practice. maxillary sinus was primarily in the province of The expansion of dental practice is consisrent otolaryngologic surgery. Oral surgeons perform with recommendations made hy the Institute of orthognathic surgety; temporomandibuiar joint Medicine in a document" published in 1995 pet- (TMJ) surgery; head and neck tumor surgery; hone taining to dental education m the United States. grafts using donor sires from rbe calvaria, ribs, This document" contains analyses of past and pre- hips, and knees; nerve grafts using donor sites ftom sent trends as well as recommendations for the the sura! nerve in the foot; and plastic surgety, such futute. The Institute concluded that dental educa- as rhinoplasty and blepharoplasry. In the past, tion in tbe United States should he patterned after these procedures were performed primarily hy oto- medical education, and rhat denristty should be lar>'ngologic surgeons, orthopedic surgeons, neuro- practiced more like medicine is practiced. surgeons, and plastic surgeons. Maxillofacial Incorporating oral diagnosis/otal medicine, dental prosthodontists make ptosthetic eyes, ears, and anesthesiology, and TMD/orofacial pain into den- other facial strucrures. Orthodontists influence tistry is consistent with these recommendations. grovrth and development of the entire facial skele- The present report traces the evolution of ton, and they have renamed their discipline TMD/orofacial pain from a rime when TMD was ortbodontics and dentofacial orthopedics. These rhe primary extraoral pain treared hy dentists to examples illusrrate the trend in dental histoty in the contemporary era, in which a broad range of which each discipline has grown to include tech- musculoskeleral, neurovasculat, and neuropathic niques that increased the scope of dental practice. pains are wirhin the scope of dental practice. A significant conrribution tnade by oral diagnosis/ oral medicine, dental anesthesiology, and TMD/ orofacial pam rowatd the gtowth and maturation The Evolution of TMD/Orofacial Pain of dental practice is the expansion beyond tbe teeth and oral caviry to include diagnosis and tteat- Initially, TMD was thought to he a dental disorder ment of disorders affecting the entire head and caused by occiusai factors best treated hy occlusal neck. Practitioners of oral diagnosis/oral medicine adjustment, ptosthetic rehabilitation, and ortho- diagnose and treat local and systemic disorders in dontic rrearment.'' However, occlusion has since the head and neck. Curriculum guidelines for oral heen shown to play a secondary role as an etio- diagnosis/oral medicine recommend thar diagnosis logic factor.^-^'' In addition, stress was consideted and treatment of all diseases {both primary and an important cause of TMD,"''- but recently the secondary) affecring the head and neck he taught relationship between tbe stress-prone personality in postgraduate programs.^ Based on these recom- and TMD has been questioned.''•'•* Tempotoman- mendations, medical conditions affecting the head dibular disorders is now thought ro he a medical and neck, such as Lyme disease,'' acquired im- disorder in which diagnosis and treatment is hased munodeficiency syndrome (AIDS), and cancer, are on principles used to diagnose and treat other in the scope of oral diagnosis/oral medicine. joints and muscles in the body.^^ Dental anesthesiologists provide general anesthesia Reclassifying TiVID as a medical disorder led to and sedation fot patients undergoing medical or tnerhods of diagnosis and treatment similar ro rhose dental surgery. In addition, curriculum guidelines ttsed for comparable medical conditions. Diagnostic for anesrhesia and pain conrrol in dentistry recom- methods expanded from evaluaring the occlusion to mend that postgraduate programs educate dental include a thorough medical history, a pain history, anesthesiology residents about acute and chronic and a head and neck evaluarion. Cuidehnes'^'"^'*' pain affecring the head and neck.' Practitioners of puhlished by the American Academy of Orofacial TMD/orofacial pain diagnose and treat inttaoral Pain state that a head and neck evaluation includes and extraoral bead and neck pain. The curriculum inspection of the head and neck; screening exami- guidelines for TMD and orofacial pain^ stare that nation of the cranial nerves; musculoskeletal assess- ment of the masticatory and cervical systems; an educational programs should teach tbe "diagnosis ear, nose, and throat evaluation; an intraoral evalu- and management of pain and dysfunction associ-

Journai ot Orofacial Pain 79 Dental Practice Act Committee

ation; and a psychosocial evaluation. Diagnostic nervous systems. Examples of neuropathic pains are anesthesia of the masticatory muscles, cervical mus- paroxysmal neuralgias (trigeminal neuralgia, glos- cles, TMJ, upper cervical region, and autonomie sopharyngeal neuralgia, nervus intermedius neural- ganglia is indispensable in assisting the diagnostic gia, superior laryngeal neuralgia) and continuous process."' Reclassifying TMD as a medical disorder neuralgias (deafferentation pain syndromes, periph- also caused a shift from occlusally oriented treat- eral neuritis, postherpetic neuralgias, posttraumatic ment to reversible multidisciplinary treatment and postsurgical neuralgia, sympathetically main- including dental orthopedic appliances, physical tained pain). Cancer pain resulting in noxious stim- therapy, stress reduction, and medications.""'^"'*''" ulation of various tissues and structures in the head In rare instances, surgical treatment of the TMJ is and neck is also within the scope of TMD/orofacial indicated, and in patients who are completely re- pain. Diagnosis and treatment of all orofacial pains fractory to treatment, long-term management may are consistent with current standards of care as include narcotic and/or nonnarcotic medications. defined in the medical and denral literature. Multidisciplinary treatment typically calls for a Disorders within the scope of TMD/orofacial team approach consisting of a dentist, a psycholo- pain may be expressed extraorally as headaches, gist or a psychiatrist, and a physical therapist, but it neckaches, and facial pain, or intraorally as tooth- may involve any medical or dental discipline. aches of nondental origin.'' It is well known that a The evolution of TMD as a medically oriented healthy tooth can experience pain that has been discipline also led to the recognition that practi- referred to it from a diseased tooth^^ or from car- tioners needed to be familiar with other types of diac pain.'^ It is not well known that toothaches paiti affecting the head and neck. Initially, the sig- can occur secondary to neuromuscular, neurovas- nificance of other head and neck pains was appre- cular, and neuropathic pain. Toothaches can be ciated because some patients did not respond to caused by myofascial trigger points,-" neurovascu- TMD treatment. Réévaluation of patients refrac- lar disorders such as migraine with and without tory to treatment led to the conclusion that pa- aura,^' cluster headache," chronic paroxysmal tients with symptoms of TMD may present with hemicrania,^^ cough headache,-** and carotidynia.'' comorbid neurovascular and/or neuropathic pain. Toothaches can also arise from neuropathic disor- In these cases, combinations of treatments proved ders such as pretrigeminal neuralgia,^^ trigeminal to he more effective than TMD treatment alone. neuralgia,^^'-^ atypical odontalgia,^^•^'' phantom Sometimes réévaluation led to the conclusion that tooth pain,^' neuritis, posttraumatic neuralgia, neu- patients did not have TMD at all. Patients who are romas, and psychogenic causes.'^ Because so many refractory to treatment may have other types of conditions manifest as toothaches of nondental ori- musculoskeleta!, neurovascular, or neuropathic gin, dentists need to be aware of orofacial pains pain that cause symptoms similar to, but are not, when diagnosing dental pain. Once a toothache of those of TMD. Because there are multiple types of nondental origin has been identified and a specific pain that affect the head and neck, TMD ex- diagnosis is made, dentists may provide treatment panded into a comprehensive discipline known as consistent with current standards of care as defined TMD/orofacial pain. in the medical and dental literature. The discipline of TMD/orofacial pain consists of disorders that are classified as intracramal pam dis- orders, primary headache disorders (neurovascular Discussion disorders), neurogenic pain disorders, inrraoral pain disorders, temporomandibular disorders, and Axis Dentistry began as a profession because skilled II, mental disorders.''"^^""'''*' Temporomandibular practitioners were needed to treat orofacial pain disorders encompasses disorders of the TMJ, the caused by diseased teeth.^ The first dentists were masticatory muscles, and associated structures (eg, exodontists whose sole objective was to eliminate cervical spine and cervical muscles). Neurovascular dental pain. These dentists did not have the oppor- paki encompasses disorders caused by complex in- tunity to study orofacial pain with the sophistica- teractions between the central and peripheral ner- tion that is availahle today. However, when they vous systems with cranial and cervical blood vessels. extracted a tooth because of pulpal pain, the ex- Examples of neurovascular pain are migraine traction was as much a treatment for deep somatic headaches, migraine variants, cluster headache, par- pain of the visceral type as it is today. Similarly, oxysmal hemicrania, cranial arteritis, and carotidy- when they extracted a tooth because of a perio- nia. Neuropathic pain encompasses disorders result- dontal abscess, the extraction was as much a treat- ing from pathology in the central and/or peripheral ment for deep somatic pain of the mu.sculoskeletal

80 Volume 1 1, Number 1, 1997 Denial Ptactice Act Committee

type as it is today. Although the ability of practi- a federation to propagate topics of interest to clini- tioners to classif}', diagnose, and treat pain intrao- cians and academicians, not the least of which is rally and extraorally is more sophisticated today achievmg specialty status for head and neck pain than in the past, the treatment of orofacial pain is management. not new. Dentists are uniquely qualified to evaluate and As pain management in dentistry expanded, the treat intraoral and cxtraoral pains, including those name of the discipline changed to reflect the nature emanating from associated structures in the head of clinical practice. Initially, extraoral pain man- and neck. Patients with complex head and neck agement in dentistry was limited to musculoskele- pain may present wirh headaches, neckaches, and tal disorders of the masticatory system. Names facial pain, including jaw pain and toothaches. used to describe the discipline reflected the puta- Comprehensive evaluation of all patients, and tive etiology and pathology of masticatory disor- especially complex patients, includes locating the ders. Thus Costen's syndrome,^- temporomandi- primary source of pain, distinguishing it from het- bular joint pain dysfunction syndrome {TMJ erotopic pain, and classifying the pain as muscu- syndrome),^^ and myofascial pain dysfunction loskeletal, neurovascular, or neuropathic in origin. (AÎPD) syndrome'- were popular at various times. The cvaluator of complex pain needs to be knowl- Then it was recognized that symptoms of mastica- edgeable about all causes of head and neck pain, tory disorders do not constitute a syndrome. To including dental causes. Dentists are trained about reflect this fact, the name temporomandibular dis- dental disorders and about head and neck ana- orders became widely used because it implies a cat- tomy, physiology, and pathology. In addition, they egor>' of disorders rather than a single diagnosis.^^ are experienced in performing various diagnostic When management of neurovascular and neuro- and therapeutic injections for the purpose of local- pathic pain was incorporated into clinical practice, izing and classifying pain. These injections include, the term TMD and orofacial pain became useful to but are not limited to, trigger-point injections into reflect the expanded scope of practice. Some clini- masticatory and cervical muscles for evaluation cians use the term orofacial pain exclusively, with and/or treatment of pain referred from musculo- the understanding that it is a broad term that skeletal structures; intramuscular or subcutaneous encompasses TMD. Currently there is an emphasis injection of serotonin agonists for evaluation and/ on the fact that dentists treat musculoskeletal, neu- or treatment of neurovascular pain; and anesthetic rovascular, and neuropathic pain in the entire head blocks of trigeminal and upper cervical nerves, and and neck rather than in the oral and facial regions automatic ganglia, for evaluation and/or treatment exclusively. The name orofacial pain implies of neuropathic pain. As a result of the comprehen- anatomic limitations that are not consistent with sive nature of dental education and the experience the scope of clinical practice. A name that is con- of clinical practice, only the dentist is able to assess sistent with contemporary practice is head and whether intraoral pain, jaw pain, and facial pain neck pain management. originate from local causes or as a result of referred Head and neck pain management evolved into a pain from cervical musculoskeletal structures, neu- discipline consisting of elements referred co as the rovascular pain, or neuropathic pain. Since the triumvirate of dental history—journal literature, pathophysiology and treatment of pain is the same, education, and organizational components.' The regardless of whether it is expressed as a toothache 5ame components catapulted dentistry itself mto of nondental origin, as facial pain, or in associated professional status. Through research, dentists structures in the head and neck, it is within the have become leaders in clinical investigations of province of dental practice ro employ accepted head and neck pain and basic science investiga- medical and dental techniques to treat head and tions of all pam. Head and neck pain is the suhject neck pain. of dental journals, textbooks, and articles in well- Although dentists may be knowledgeable about regarded medical journals. Dental schools incorpo- al! head and neck pain, there are some disorders rate head and neck pain management into under- that dentists do not treat. For example, dentists do graduate and graduate curriculums, and master of not treat diseases that are intrinsic to the eyes and science and PhD programs are available. In clinical ears, or pains caused hy some vascular disorders practice, dentists increasingly limit their practices such as carotid dissection and cerebral aneurysm. to head and neck pain management. Appropri- Similarly, dentists do not treat brain tumors that ately, some professional organizations dedicated to cause head and neck pain. In these cases, and oth- the field of head and neck pain management have ers, there are medical specialties that educate been created. Recently, these organizations formed physicians to a standard of care that cannot be

Journal of Orofaciai Pain 81 Dental Practice Act Committee

attained by dentists who do not have access to References sitiiilar speciahy training. However, pain manage- ment, and specifically head and neck pain manage- 1. Hook SA. The eiyht dental specialties; Their origm and ment, is not a specialty of medicine. Therefore, the rise. Alumni Bulletin, Indiana University School of Den- same information is accessible to physicians and tistry, Spring 1985. dentists ahcut musculoskeletal, neurovascular, and 2. Asbell MB, Dentistry: A Histiirital Perspecrive. Bryn neuropathic pains affecting the head and neck. Mawr, PA: Dorrantc, 1988. This conclusion is also true for cancer pain affect- 3. CiirricLilum guidelines for postdoctoral orai diagnosis/oral medicine, J Dent Educ 1 W2;56:704-709. ing die head and neck. A guide to assist dentists in 4. Heir GM, Fein MD. Lyme disease: Considerations for choosing which pains to treat may be valuable. dentistry. J Orofacial Pain 1996;10:73-86. The most appropriate currently used guide for 5. 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