OPINION

The of temporomandibular disorders

J. Virdee1

In brief Recaps the key guidelines for the diagnosis and Discusses the role of the general dental practitioner Highlights the challenges presented by facial for management of temporomandibular disorders in facial pain disorders. patients and clinicians. (TMD).

This article endeavours to revise the key guidance and evidence on temporomandibular disorders (TMD), with a particular focus on myofascial pain. It highlights the important role that primary care dental practitioners play in providing holistic care during the patient’s journey to manage this painful condition. I hope to give an insight into my own personal experiences to highlight the challenges patients can face in seeking appropriate support.

Introduction was worse on hot or cold, but I had never met treatment. I had a personal insight into how a patient with non-odontogenic pain. frustrating a predicament this can be for patients Imagine pain in your face – a difficult concept It was unexpectedly that the pain in my face and felt determined to widen my own if you have never truly experienced it. From suddenly began. I visited a local dentist who knowledge on the subject of facial pain. During early in my dental career, I have realised that informed me that as this was out of his remit my undergraduate placements and now in my dentists and pain are a common patient asso- of care, he was unable to offer any advice. I dental foundation training year, temporoman- ciation. Individuals attending with had not revealed that I was in fact a final year dibular disorder (TMD) seems to be a prevalent can expect to leave with a relief of their dental student at the time and clearly recalled facial pain condition, which unlike sinusitis, symptoms, possibly with a pulp extirpation that pain of non-dental origin featured in my appears to have a greater tendency for chronic- or extraction. The challenge with facial lecture timetable. I felt a loss of faith in the ity of symptoms. This particular feature of the and of particular interest, myofascial pain, is dental profession, saddened to contemplate condition can pose great challenges to dental the difficulty in identifying a causative factor. that dentists only feel comfortable treating professionals and patients in managing the pain The pathophysiology of the condition, with teeth. Sat on the other side of the dental chair, symptoms and hence, formed the focus of my its potential for chronic disposition, further now as a patient, I was confused on whom to interest. An informative basis for management complicates the management strategy. There is turn to next. of these conditions can be found by The Royal no ‘quick fix’ for pain relief. Patients will likely I left the surgery disheartened and decided College of Surgeons (RCS), which suggests a return with pain. to contact my general medical practitioner, review paper providing guidance from the UK As dentists, we deliberate much over the dif- hoping that a clearer diagnosis would be Specialist Interest Group in Orofacial Pain and ferential diagnosis of pulpal pain, but beyond made. This soon seemed an unrealistic expec- Temporomandibular Disorders.1 This, alongside this, I question how confident a dentist would tation as, again, no definitive diagnosis was guidance published by the National Institute of feel assessing pain of non-dental origin. This made and I was sent home with an antibiotic Health and Care Excellence (NICE), forms the view is likely due to an experience more close to prescription. Unsurprisingly, the antibiot- basis of this recap on managing TMDs.2 home. My personal experience with facial pain ics proved unhelpful in improving my facial could be considered an unusual case. For the pain symptoms. I was genuinely worried Demographics majority of my time at dental school, facial pain and alarmed as to what could possibly be was a phenomenon I understood theoretically happening. After weeks of various medical TMD has been proposed as the third most in lectures and textbooks. I was well rehearsed consultations, a simple sinusitis was identi- common disorder but one should in investigating with patients if their toothache fied. Thankfully, this self-limiting condition consider that not all symptomatic patients may resolved spontaneously. present for treatment.3 Dental income protec- University of Liverpool Graduate and Foundation Dentist The experience, however, highlighted the tion provider Dentists Provident, claims that Correspondence to: Jaspreet Virdee worrying dilemma that my own patients may over a third of their claims paid to members in Email: [email protected] face in seeking help for facial pain, consulting 2013 were due to musculoskeletal disorders.4 Refereed Paper. Accepted 7 November 2017 different health professionals, with confusion It is also worth considering that The Health DOI: 10.1038/sj.bdj.2018.42 over the diagnosis and delays in appropriate and Safety Executive reported that in 2016, a

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OPINION

staggering 8.8 million working days were taken to blame. A further theory suggests otalgia have much influence on treatment planning. off at the hands of musculoskeletal problems.5 occurs secondary to a ligamentous connection In any case, the use of ionising radiation as a Musculoskeletal conditions, such as TMD, between the temporomandibular joint and the special investigation in TMD must have a clear have a clear potential to significantly impede middle ear canal.8 justification.1 the ability to perform daily activities. A headache disorder or TMD mimicking a When forming a diagnosis, it should be headache is a challenging distinction to make. established whether a muscle, disc or joint Obtaining a history The two may also exist simultaneously. The disorder exists. Systemic conditions may be International Headache Society provides a of significance, including fibromyalgia and Even if you are referring onwards, obtaining comprehensive classification of primary and rheumatoid arthritis which may have a TMD a detailed history is valuable in aiding other secondary , cranial neuropathies and component.1 Once a diagnosis has been clinicians in reaching an appropriate diagnosis other headache disorders.9 The classification made, a treatment plan can be constructed as and helps track changes in symptoms which advises that disorders of the cervical spine and appropriate. could be clinically significant. It is important to other structures of the head and neck cannot appreciate that the RCS highlights the need to be excluded as potential causes of headache. Management in primary care make a psychosocial assessment of the patient.1 A headache may originate from the cervical, Making this assessment is vital to holistic care nuchal or occipital regions or may be localised Acute TMD of muscular origin may follow of the patient and could be approached by to these regions.9 Headaches are cervicogenic dental treatment such as a lower third molar investigating the social history and utilising in nature if causally associated with cervical extraction resulting in acute pain and limited pain scales to establish the effect TMD is myofascial pain sources, also known as myo- mouth opening. At this stage, the damage is having on life.6 It is easy to completely under- fascial trigger points. The headache is caused still within the biopsychosocial reparative estimate the impact of this facial pain disorder. by a disorder of the cervical spine and its bony, capacity. A soft diet, resting the jaw and anti- Normal daily activities such as eating well, can disc or soft tissue components and may also inflammatory such as ibuprofen, easily become adversely affected and have a be accompanied by . Evidence of should be advised.1 secondary impact on the overall wellbeing of causation may be demonstrated by a reduction The use of paracetamol in a stepwise manner our patients. in cervical range of motion and a worsening of alongside non-steroidal anti-inflammatory Extra-oral and intra-oral examinations are the headache on provocation of the myofascial drugs (NSAIDs) may be helpful.1 The full essential to any diagnosis being made. The trigger point. Accordingly, the headache is action of NSAIDs is obtainable face should be carefully assessed for asym- eliminated following a diagnostic block of the within a week, however, it may take as long as metries or swelling and any neurological signs cervical structure or its nerve supply.9 three weeks for the anti-inflammatory action or symptoms will necessitate the need for a Localised areas which cause exacerbation to take effect.11 All NSAIDs have the potential cranial nerve examination. Parafunctional of the patient’s pain on palpation may be con- to cause adverse gastrointestinal effects. Those habits must be noted and investigated. The sidered potential trigger points. Local anaes- with a low risk for these effects, for example TMJ should be palpated and assessed for thetic injections into these muscular trigger ibuprofen, should be preferentially selected, tenderness, range of movement, pain, mouth points may reduce or resolve the pain and can starting at the lowest recommended dose.11 opening and joint noises or crepitus. Likewise, be diagnostic in assessing whether a referral Topical ibuprofen over the muscle may limit the muscles of mastication should be palpated pattern truly exists. Longer acting anaesthet- systemic effects and provide direct relief.1 The to assess for tenderness, hypertrophy or the ics may induce inflammation and coagulation use of a short course of diazepam to assist presence of trigger points.1 This assessment necrosis of muscle tissue, a factor which must muscle relaxation may be considered in an should extend to other muscles of the head and be included in the consent process with the acute phase. Benzodiazepines are susceptible neck including scalene, sternocleidomastoid patient. Adrenaline containing solutions of to abuse with the potential to cause unpleasant and trapezius muscles, which may be involved local anaesthetic have a greater propensity to side effects and hence the minimum number of in referral patterns to other areas in the face.7 cause muscle damage. In light of this, it has tablets should be prescribed. A suitable five day been suggested that bupivacaine should be regime is one tablet of 2 mg diazepam, taken Pain referral pathways avoided due to the risk of myotoxicity. Despite up to three times daily.1,12 this risk, the diagnostic and therapeutic uses Preventing acute TMD pain from estab- As I looked into the presentation of facial may still be clinically justified in myofascial lishing chronicity is essential. Chronic TMD pains, I was surprised to learn that a headache pain conditions.10 A postural assessment of pain can be attributable to pain present for can in fact be due to dysfunction of the tem- the patient should be made to assess whether greater than a three month period. At this poromandibular joint. Additionally, facial forward posture exists and if this is a risk factor stage, the pain does not serve biological dysaesthesias may be the result of in generalised muscular pain of the head and reparative function with a potential role of pathways. Otalgia has previously been docu- neck region. central sensitisation.1 Discussing the chronic mented as the major presenting complaint in The RCS suggest that imaging should not be component of TMD is essential in educating over half of patients with TMDs.8 There is, essential for a definitive diagnosis to be made, patients that self-management of the condition however, ambiguity whether this is due to an but merely acts as an adjunct. It is highlighted is the ultimate goal with treatment strategies to actual referred pain phenomenon secondary that as most TMD cases are attributable to reduce pain and maintain function. Patients to impingement of the auriculotemporal functional rather than pathological changes, should be made aware that although TMD may nerve, or if spasm of the masseter muscle is the use of ionising radiation is unlikely to become chronic, acute exacerbations can occur

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OPINION

and self-care strategies should be in place to conservative measures in primary care. Of urgent referral for appropriate management:2 limit these. course, certain cases require specialist input • Previous history of malignancy Physiotherapy is regarded as particularly and should be referred to secondary care. • Persistent or unexplained neck lump or useful for patients with concurrent cervical Patients with persistent symptoms despite cervical lymphadenopathy muscular pain and demonstrates short-term primary care, an uncertain diagnosis, unex- • Neurological symptoms, including cranial benefits in the acute phase. The evidence for plained persistent or widespread chronic pain nerve abnormalities with changes in the use of acupuncture in the treatment of and patients with chronic temporomandibular sensory or motor function muscular trigger points suggests that it may symptoms lasting for longer than three months • Facial asymmetry, facial swelling or help break cycles of continuous symptoms. should be considered for onward referral. This profound trismus These options can be accessed by liaising with also includes patients experiencing psychologi- • Recurrent epistaxis, purulent nasal the patient’s general medical practitioner.1 cal distress associated with their symptoms or discharge, persistent anosmia or reduced Occlusal splint therapy aims to provide patients a persistent hypervigilance of their occlusion. hearing on the ipsilateral side with biofeedback and to protect the dentition Further imaging, such as the use of MRI, may • Unexplained fever or weight loss from parafunctional habits. It should be noted, be considered.2 • New-onset unilateral headache or however, that these appliances can increase Patients with signs of a headache disorder, scalp tenderness, jaw claudication and awareness of the mouth and could result in an primary or secondary in nature, may be referred general malaise increase in symptoms, especially if a soft splint to a neurologist for further investigation • Occlusal changes. is used. The patient should hence be warned of and pharmacological intervention. Tricyclic the potential for this to occur.1 Hard occlusal have an unlicensed indication Conclusion splints can be time-consuming and complex to for facial pain, usually taken at night to limit side construct, and should not be used in isolation effects.11 These are of course not on the dental The complex neurophysiology of the trigemi- as the sole treatment option for TMD. practitioners’ formulary. Potential candidates nal nerve plays a central role in dental and The psychosocial component to TMD must for this treatment require specialist referral facial pain. Its propensity to cause debilitating not be taken lightly. Patients with significant and psychological support to accompany drug pain symptoms, from irreversible pulpitis and chronic pain should be considered candidates treatment. The progress of patients and man- masticatory myofascial pain or even trigeminal for psychological support such as cognitive agement of side-effects must be monitored. Of , should not be underestimated. TMD behavioural therapy.2 The patient should dental relevance, amitriptyline may cause a dry is arguably one of the most difficult conditions be advised to consult their general medical mouth which could impact on patient compli- for dentists to manage. There is no real cure practitioner to access NHS talking therapies ance.11 The use of gabapentin for myofascial available and a single management strategy and psychological support. In the case of TMD has also been suggested.1 may not work for every patient. There are dif- some NHS services, it may be possible for the Botulinum injections may be considered an ficulties posed to clinicians and patients alike patient to self-refer for this. A recent concept alternative option for masticatory myofascial in managing pain with a chronic disposition. in the management of stress and anxiety is pain if conservative methods have failed. In a A sound knowledge of the relevant guidance mindfulness meditation, which may play a prospective study analysing botulinum injec- to manage TMD will enable patients to access role in the treatment of physical, cognitive tions in patients who did not recover after the care they need, including psychological and behavioural components of chronic pain.13 conservative measures to manage myofascial support and specialist input if indicated. More During an undergraduate placement at Aintree pain, a significant reduction in pain scores importantly, we can empower patients with University Hospital, many patients discussed were reported following treatment.15 The use management strategies for their pain and assist that regular yoga and pilates classes were of botulinum injections cannot be offered as a them in reaching a satisfactory outcome. followed by a reduction in their chronic TMD guaranteed solution to resolve myofascial pain Acknowledgements symptoms. While this may have been purely but may improve severity of symptoms. This Thank you to Dr F. O’Neill and Mr M. Shorafa for their coincidental, it does draw thought upon the must of course be balanced against adverse insight into the subject. use of exercise and relaxation in the manage- effects associated with this treatment, in par- 15 1. Durham J, Aggarwal V, Davies S et al. Temporoman- ment of the condition. Any form of managing ticular facial muscle weakness. dibular Disorders (TMDs): an update and management stress, such as regular exercise, will support All reversible therapies should have been guidance for primary care from the UK Specialist Interest Group in Orofacial Pain and TMDs. The Royal College of the patient’s general well-being, psychologi- attempted, with irreversible treatments only Surgeons, 2013. cal health and could be a simple solution to considered in a small minority of patients. 2. Temporomandibular Disorders, NICE Clinical Knowledge decrease muscle tension.14 Surgery is not routinely offered to manage Summaries. Available at https://cks.nice.org.uk/temporo- mandibular-disorders-tmds (accessed October 2017). TMD and only occasionally considered. 3. Prasad S R, Kumar N R, Shruthi H, Kalavathi S. Tempo- Patients with chronic pain without a functional romandibular pain. J Oral Maxillofac Pathol 2016; 20: Referring to secondary care 272–275. problem should not be offered surgery as their 4. Dentists’ Provident 2013 Claim Statistics. Available at Having consulted a number of maxillofacial pain symptoms are actually at risk of increasing http://dentistsprovident.co.uk/news/dentists-provi- 1. dent-2013-claims-statistics/ (accessed October 2017) surgeons in Merseyside and Surrey, as a patient following surgical intervention. 5. HSE. Work-related musculoskeletal disorder(WRMSDs) and a dental professional, I have been informed Certain facial pain symptoms mimic TMDs statistics, Great Britain. Health and Safety Executive, 2016. 6. Suvinen T. I, Reade P. C, Kemppainen, P, Könönen, M, that many TMD referrals do not meet the NHS but may in fact indicate a more serious underly- Dworkin S F. Review of aetiological concepts of tempo- selection criteria. In the majority of presenting ing condition. The following ‘red flags’ indicate romandibular pain disorders: towards a biopsychosocial cases, TMD can be adequately managed with potentially serious conditions which need model for integration of physical disorder factors with

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psychological and psychosocial illness impact factors. of Headache Disorders, 3rd edition. Cephalalgia 2013; 13. Curtin K, Norris D. The relationship between chronic Euro J Pain 2005; 9: 613–633. 33: 629–808. musculoskeletal pain, anxiety and mindfulness: Adjust- 7. Fernández-de-Las-Peñas C, Ge H-Y, Alonso-Blanco C, 10. Okeson J P. Management of Temporomandibular Disorders ments to the Fear-Avoidance Model of Chronic Pain. González-Iglesias J, Arendt-Nielsen L. Referred pain and Occlusion. 7th Edition. Elsevier, 2012. Scand J Pain 2017; 17: 156–166. areas of active myofascial trigger points in head, neck, 11. National Institute for Clinical Excellence. British National 14. Geneen L J, Moore R, Clarke C, Martin D, Colvin L A, and shoulder muscles, in chronic tension type headache. Formulary. Available at https://bnf.nice.org.uk/ (accessed Smith B H. Physical activity and exercise for chronic pain J Bodyw Mov Ther 2010; 14: 391–396. October 2017). in adults: an overview of Cochrane Reviews. Cochrane 8. Chen R C, Khorsandi A S, Shatzkes D R, Holliday R A. 12. Scottish Dental Clinical Effectiveness Programme. Man- Database Syst Rev 2017; 1: CD011279. The Radiology of Referred Otalgia. AJNR Am J Neurora- agement of Acute Dental Problems. 2013. Available at 15. Sidebottom A, Patel A, Amin J. Botulinum injection for diol 2009; 30: 1817–1823. http://www.sdcep.org.uk/wp-content/uploads/2013/03/ the management of myofascial pain in the masticatory 9. Headache Classification Committee of the International SDCEP+MADP+Guidance+March+2013.pdf (accessed muscles. A prospective outcome study. Br J Oral Maxil- Headache Society (HIS). The International Classification January 2018). lofac Surg 2013; 51: 199–205.

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