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Dental hygienists: first line of defense for TMD patients?

Approximately 10 million Americans, the majority women, suffer from a temporomandibular disorder (TMD). (1-6) As dental hygienists, we typically spend a significant amount of time with our patients; therefore, we may be the first health care provider to identify undetected TMD-related symptoms. Could dental hygienists be an even greater advocate for their patients in recognizing early signs of TMD?

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TMD Diagnosis

The term TMD encompasses dysfunctions of the masticatory musculature, the temporomandibular joint (TMJ) and surrounding structures. (1) TMD may manifest as muscle pain with or without mandibular limitations; jaw fatigue or stiffness; disc displacement with or without reduction; joint pain, osteoarthritis; and popping, clicking or grating sounds of the TMJ. (3), (7-12) TMD is comparable to strain or injury in other joints of the body after undue stress or excessive repetitive motion. (13-16) Although TMD is multifactorial, stress is a known major risk factor. (2), (17-20) Some patients exhibiting hypermobility in other joints may exhibit greater mobility in their TMJ, possibly predisposing them to a TMD, (21) Even certain pre-existing occlusal discrepancies may be potential factors in the development of future TMJ disease. (7) TMD may be detected during a clinical examination; however, the definitive diagnosis is most often determined collectively using the health history, clinical examination and radiographic imaging. (22), (23)

Understanding the TMJ

The TMJs are located in the preauricular region on both sides of the skull. (14), (15) They are ginglymoarthrodial joints, moving in both a rotational and transitional manner. (1) The structural components of the TMJ are the mandibular condyle, the mandibular fossa and eminence of the temporal bone, and disc. (1) The condyle and fossa correspond in a hinge fashion, cushioned by an articular fibrous disc. (1) The disc is held in place by ligaments. Synovial fluid contained within the joint decreases friction and nourishes the nonvascular and noninnervated areas of the joint. Despite the natural lubrication provided by the synovial fluid, overexertion and strain may still lead to joint injury and muscle fatigue. (1) Once initiated, muscle fatigue and soreness occurring in the jaw joint are often aggravated by grinding, clenching and bruxing. (24-27) Certain habits such as poor posture, stress, prolonged computer use, chewing gum, and eating hard foods may exacerbate an existing TMD condition. (2), (7), (17), (28), (29) Trauma to the joint, head or neck and even playing certain musical instruments may cause or worsen an existing temporomandibular disorder. (30)

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Effects of the TMD

The harmful effects of TMD may manifest via physical, mental or dental symptoms. Physical effects may include joint pain radiating to the head and neck, stiffness of the jaw, limited opening, inability to close the mouth, chronic headaches and difficulty chewing and speaking. (31), (32) Some TMD patients report depression and difficulty sleeping. (2) Mental and physical effects may be associated with additional stress and anxiety. (33) Dental effects may include attrition, mobility, sensitivity, craze line damage and gingival recession. (31), (32) Depending on the complexity of the disorder, TMD patients may suffer one or many of these symptoms.

Failure to diagnose early may lead to irreversible damage to the condyles, eminence, ligaments and dentition. Early changes may be detected by palpating the muscles of mastication and the TMJ. (13) Patients may report popping, clicking or grating noises during a dental appointment, prompting their dental care provider to investigate further. (34) A perceptive practitioner may inquire about a patient's limited opening, uneven occlusion, crossbite or inverted teeth to investigate the possibility of pain or of a TMD. Early identification of TMD symptoms may allow the dentist to determine if TMD management is needed. TMD treatments may include physical therapy, use of a bite splint or stress management. (34)

Independent Studies

As someone with TMD, I have been fascinated by the topic for many years. During my senior year in dental hygiene school, I had an opportunity to complete an independent study relating to TMD. I was anxious to expand my knowledge of the subject and accepted without hesitation. My mentor, Janet Kinney, RDH, MS, MS, arranged for me to intern with two of the school's leading experts in the area of TMJ and TMD. During my initial meeting with Geoffrey E. Gerstner, DDS, MS, PhD, and Lawrence Ashman, DDS, we outlined two semesters of independent study during which my skills as a dental hygienist would support their current TMD work.

During the first semester, I worked with Dr. Gerstner. Our goal was to convert the TMD diagnostic form being used in the patient care clinics into one that would elicit early detection, prompt referral and treatment for patients with TMD. At the time, the diagnostic form was extremely lengthy, consisting of 10 pages that could be overwhelming to students who were not well versed in TMD verbiage. Therefore, the new form needed to be user-friendly yet collect all of the pertinent information. Revised questions had to navigate dental students through a diagnostic tree by using preliminary data from the patient's record along with data gathered during the appointment. If appropriate, it would also lead the student to make the appropriate referral.

During the next few weeks, Dr. Gerstner and I collaborated to create a new form that comprised tables, diagnostic trees, diagnostic heads showing palpation areas and check boxes (Figure 2). We scrutinized and rejected several versions before we agreed on a condensed, straightforward form that was user-friendly yet comprehensive.

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As in any professional environment, there is often resistance to change. The true challenge would be incorporating the new format into existing practice. By the end of the semester, we were prepared to submit our form for approval. To our elation, it received positive reviews and was quickly adapted for integration into the school's internal computer system for use in the patient care clinics. I was extremely pleased and encouraged that I played an integral role in developing the new form that would be easily accessed and utilized by students and faculty in identifying patients with TMD.

The second half of my independent study proved to be just as exciting as the first. For the next 14 weeks, I shadowed Dr. Ashman as he treated TMD patients at the University of Michigan TMD and Orofacial Pain Clinic located in Ann Arbor, Mich. I gained irreplaceable knowledge concerning the diagnosis and treatment of TMD. I observed Dr. Ashman in a vast array of patient care activities, including new patient examinations, diagnosis and treatment planning, and follow-up appointments to gauge the patient's degree of progress. I learned that in many cases the site and source of pain are not always the same. Dr. Ashman's initial evaluation was very thorough, including a comprehensive history, a clinical examination that included range of motions of the cervical area and the mandible, palpation of the muscles of mastication and the cervical muscles, functional movements of the jaw, listening for TMJ and cervical sounds, and additional measurements and tests. On many occasions, patients with TMD also presented with pain in their ears, sinus and neck region, depression and accounts of recent stressful life events. While observing Dr. Ashman, I learned that to treat the patient comprehensively, every issue must be addressed separately. The thorough, in-depth evaluation ensured that each patient received an individualized diagnosis, treatment and any necessary referrals.

I assisted Dr. Ashman by documenting patients' medical history and chronicling the history of their TMD. I also contributed to patient care by recording measurements and taking notes during the initial evaluation and assisting with the taking of radiographs and impressions.

During the course of my independent study at The University of Michigan TMD and Orofacial Pain Clinic, I identified many patient care tasks a dental hygienist could assume within this specialized setting. These included conducting an initial interview with new patients; recording a patient's medical, dental, family and TMD disorder histories; taking impressions and radiographs for use in treatment planning; administering local anesthetic when required; providing oral hygiene instruction and patient education; calling patients and communicating with referring providers. Although the parameters of my independent study with Dr. Ashman had been determined in advance, I quickly concluded that the dental hygienist could assume a vital role in this setting, freeing the TMD specialist for quality time with patients, ultimately providing better patient care.

Following my internship, I quickly identified my next career goal--to relay knowledge gained from my independent study to enhance the care I provide for my TMD patients. For example, I learned the importance of detecting TMD as early as possible so that treatment can begin. For my patients with TMD, dental appointments can be torturous. Correct patient management is crucial for their comfort and care in my dental chair. Modifications such as shorter appointments, offering breaks for patients to rest their jaws, and utilizing bite blocks during an appointment to prevent jaw fatigue may make a significant difference. (34) It is also imperative that I personalize oral hygiene instruction for patients who have limited opening or soreness with opening. Recommending oral hygiene aids that will help patients access hard-to-reach areas could make a significant difference in their oral hygiene and ultimately, their dental health.

In wrapping up my TMD research materials, I realized I may not be afforded as much time to research every topic once I am employed in private practice; however, this independent study has revealed the importance of remaining current on not only the area of TMD, but a vast array of other dental topics.

Conclusion

In the future, new technologies may advance the diagnosis and treatment of TMD patients. Utilizing TMJ diagnostic methods such as microarrays on tissue, synovial fluid or serum samples may become the standard of care someday. (1) Until that time, dental hygienists, should recognize that we are in a position to advocate for our TMD patients by detecting signs or symptoms of the disorders that may assist in reaching a definitive diagnosis.

References

(1.) Wadhwa S, Kapila S. TMJ disorders: future innovations in diagnostics and therapeutics. J Dent Educ. 2008; 72(8): 930-44.

(2.) Slade GD, Diatchenko L, Bhalang K, Sigurdsson A, et al. Influence of psychological factors on risk of temporomandibular disorders. J Dent Res. 2007; 86(11): 1120-5.

(3.) Dworkin SF, LeResche L, DeRouen T, Von Korff M. Assessing clinical signs of temporomandibular disorders: reliability of clinical examiners. J Prosthet Dent. 1990; 63: 574-9.

(4.) Von Korff M, Dworkin SF, Le Resche L, Kruger A. An epidemiologic comparison of pain complaints. Pain. 1988; 32:173-83.

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(16.) Okeson JP. Management of temporomandibular disorders and occlusion, 6th ed. St. Louis, Mo.: CV Mosby; 2008.

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(21.) Kavuncu V, Sahin S, Kamanli A, et al. The role of systemic hypermobility and condylar hypermobility in temporomandibular joint dysfunction syndrome. Rheumatol Int. 2006; 26: 257-60.

(22.) Petersson A. What you can and cannot see in TMJ imaging--an overview related to the RDC/TMD diagnostic system. J Oral Rehab. 2010 April. Epub ahead of print.

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(27.) Zarb GA, Carlsson GE. Temporomandibular disorders: osteoarthritis. J OrofacPain. 1999; 13: 295-306.

(28.) Perri R, Huta V, Pinchuk L, et al. Initial investigation of the relation between extended computer use and temporomandibular joint disorders. J Can Dent Assoc. 2008; 74(7): 643. Available online at www.cda-adc.ca/jcda/vol-74/ issue-7/643.html.

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(30.) Yeo DKL, Pham TP, Baker J, Porter SAT. Specific orofacial problems experienced by musicians. Aust Dent J. 2002; 47:(1): 2-11.

(31.) Pollmann L. Sounds produced by the mandibular joint in a sample of healthy workers. J Orofac Pain. 1993; 7: 359-61.

(32.) Kafas P, Chiotaki N, Stavrianos Ch, Stavrianou I. Temporomandibular joint pain: diagnostic characteristics of chronicity. J Med Sci. 2007; 7: 1088-92.

(33.) Laskin DM. Etiology of the pain-dysfunction syndrome. J Am Dent Assoc. 1969; 79: 147-53.

(34.) Jerjes W, Upile T, Abbas S, et al. Muscle disorders and dentition-related aspects in temporomandibular disorders: controversies in the most commonly used treatment modalities. Int Arch Med. 2008; 1:23.

Brittany Forga, RDH, BSDH, is a 2010 graduate from the University of Michigan (UM) Dental Hygiene Program. She served as secretary and class representative for the student chapter of ADHA. She plans to divide her career between private practice and community-based clinics.

The faculty mentor for this edition of Strive was Janet Kinney, RDH, MS, MS.
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Title Annotation:strive; temporomandibular disorder
Author:Forga, Brittany
Publication:Access
Geographic Code:1USA
Date:Nov 1, 2010
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