Transitioning to chronic temporomandibular disorder pain: A combination of patient vulnerabilities and iatrogenesis.

BACKGROUND: Based on a variety of studies conducted in recent years, some of the factors that might contribute to the negative treatment responses of some TMD patients have been elucidated. METHODS: This paper describes known vulnerability factors that make individuals susceptible to developing temporomandibular disorders (TMDs), as well as those that contribute to the perpetuation of such problems. In addition, the topic of iatrogenesis is discussed as a major contributor to the negative outcomes that can be seen in this field. RESULTS: At the patient level, anatomical, psychosocial and genetic factors may contribute to individual vulnerability. The anatomy and pathophysiology of muscles, joints, disc and nerves may all be involved in predisposing to TMD symptoms, especially when the patients have pain elsewhere in the body. Among the psychosocial factors, some features may be elucidated by the DC/TMD axis II, while others (eg illness behaviour, Munchausen syndrome, lack of acceptance of non-mechanical approaches) require careful evaluation by trained clinicians. Genetic predisposition to first onset TMDs and to chronification of symptoms has been identified for individuals with certain psychological traits, presence of comorbid conditions and certain abnormal clinical manifestations. Regarding iatrogenesis, sins of omission may influence the clinical picture, with the main ones being misdiagnosis and undertreatment. Joint repositioning strategies, occlusal modifications, abuse of oral appliances, use of diagnostic technologies, nocebo effect and complications with intracapsular treatments are the most frequent sins of commission that may contribute to chronification of TMDs. The patients who present with massive occlusal and jaw repositioning changes combined with persistent severe orofacial pain are not a rarity within TMD and orofacial pain canters; these patients are the most difficult ones to manage because of this horrific combination of negative factors. CONCLUSIONS: The information presented in this paper will help clinicians to understand better why some individuals develop temporomandibular disorders, why some of them will progress to becoming chronic patients, and what the appropriate responses may be.

Centric relation critically revisited-What are the clinical implications?

PURPOSE OF THE ARTICLE: Centric relation is a dental term that has undergone many alterations over the years, which in turn have led to significant clinical controversies. These continuing changes in the meaning of the term CR have not only led to confusion, but they also have resulted in a variety of unnecessary diagnostic and therapeutic procedures. Analysis of the dental literature reveals ongoing misunderstanding and disagreement regarding that term among both clinicians and academic dentists. MATERIALS AND METHODS: A search of the PubMed database was performed with the following search terms: "centric relation", "masticatory muscles", "maxillomandibular relationship" and "condylar position." Relevant literature from the past 70 years until the present day was meticulously scrutinised. RESULTS: As expected, the literature review on the topic of CR revealed a problematic pattern of changing definitions and clinical disagreements, all of which have had a significant impact on the practice of dentistry. CONCLUSION: There are semantic, conceptual and practical reasons for concluding that the term 'centric relation' is flawed. Those flaws have a significant impact on dental practice. Based on our analysis, argumentation is provided to conclude that the term 'centric relation' should be abandoned. Instead, it appears that every individual has a unique temporomandibular joint relationship which cannot be described by any singular term. In healthy dentate patients, this relationship is determined by the maximum intercuspation of the teeth and should therefore be considered as biologically acceptable.

The evolution of temporomandibular disorders: A shift from experience to evidence.

After over 80 years of much obsession as well as avoidance of the subject of temporomandibular disorders (TMDs), the dental profession is still divided over what they are and how to deal with them. Over this period, nearly every discipline in dentistry has played some role in the development of this field. Unfortunately, a significant amount of this information has been based on personal opinion, experience-based philosophies, or poorly conducted research. Furthermore, each dental specialty has been responsible for contributing to the concepts of the etiology and management of TMDs with their own professional bias; for example, orthodontists describe these problems in orthodontic terms and offer orthodontic treatments or solutions for their patients. As various treatment approaches were found to be effective at least some of the time, this has further led to misinformation and confusion within the profession. Advances in research from diverse fields, including neurophysiology, pain pathophysiology, genetics, endocrinology, behavioral sciences, and psychology, have significantly altered our understanding of TMDs and how they should be managed. The rigid mechanical and dental-based model of the past has been gradually replaced by a biopsychosocial medical model for the diagnosis and treatment of TMDs as well as other acute and chronic pain disorders. This paper discusses the evolution of our understanding of TMDs since they were first described 85 years ago. Contemporary scientific findings and their implications are presented in some detail for clinicians who wish to provide the appropriate management for their orofacial pain patients.

Evidence-based dentistry or meta-analysis illness? A commentary on current publishing trends in the field of temporomandibular disorders and bruxism.

The field of temporomandibular disorders (TMDs) and bruxism research has recently witnessed a publishing trend leaning towards an overuse of systematic reviews (SRs) that contribute little or nothing to current knowledge. The majority of these seem to be more methodological exercises than manuscripts prepared to provide clinicians and researchers with up-to-date information to advance knowledge. In addition, given the increasing number of researchers who have been reviewing the dental literature on various topics without seemingly having any specific clinical or scientific background in the topic under review, the ultimate value of some SRs is questionable. Some of them end up producing meta-analyses (MAs) to give "numbers" (eg, risk measures and strength of association) that do not have a biological basis, due to the clinical heterogeneity of the articles being reviewed. Based on the above, the present commentary discusses this ongoing publishing trend that is affecting the TMD and bruxism field, which does not align well with the core principles of evidence-based dentistry (EBD). Ideally, EBD should be derived from a combination of literary, clinical and patient-centred information, but relying only on the bibliographic aspects could potentially expose less expert clinicians and other readers who merely browse the literature to incomplete, misdirected or even incorrect conclusions.

Scoping review of systematic review abstracts about temporomandibular disorders: Comparison of search years 2004 and 2017.

INTRODUCTION: The purposes of this study were to determine how many systematic reviews and meta-analyses relating to temporomandibular disorders (TMDs) had been published as of 2017 compared with those published as of 2004 and then to summarize the findings, based on an analysis of the abstracts from those studies. METHODS: A PubMed search was initiated on May 1, 2017. There were 2 separate searches. The first search was for the topic, "temporomandibular disorders." The second search was for "temporomandibular disorders and published in the Cochrane database." The number and the topic category of reviews for 2017 were compared with those published as of 2004. RESULTS: There were 120 relevant TMD systematic reviews found in search year 2017: 110 from the PubMed and 10 from the Cochrane searches. By comparison, there were only 8 TMD systematic reviews published in 2004. The abstracts for all 120 reviews indicated increased roles of genetics and psychosocial factors in the etiology of TMD. The future of TMD diagnoses appears to be toward various psychosocial and cellular tests, along with brain neuroimaging. The reviews on the topic of "treatment" supported conservative, noninvasive, reversible therapies, with a trend toward more targeted individual strategies. CONCLUSIONS: There were only 8 TMD systematic reviews published in 2004 compared with 110 in 2017. Overall, the trend has been in the direction of better diagnostic procedures, more scientific concepts of etiology, and more conservative treatments for TMD.

Nonpainful phantom sensations in dentistry: an update of etiologic concepts.

Various phantom disorders have been discussed extensively in the medical literature, the most common being phantom limb pain. However, phantom conditions have not received much attention in the dental literature. This article provides a topical review of relevant literature to update current thinking on the etiology of various nonpainful phantom phenomena involving the oral cavity, traces the evolution of these concepts, and offers practical patient management recommendations for dentists. Educating dentists about these phenomena will enable them to avoid extensive, time-consuming procedures that seldom resolve their patients' chief complaints.

Overtreatment "Successes"--What Are the Negative Consequences for Patients, Dentists, and the Profession?

AIMS: To describe how some management practices in the field of orofacial musculoskeletal disorders (also described as temporomandibular disorders [TMDs]) are based on concepts about occlusal relationships, condyle positions, or functional guidance; for some patients, these procedures may be producing successful outcomes in terms of symptom reduction, but in many cases, they can be examples of unnecessary overtreatment. METHODS: The authors discuss the negative consequences of this type of overtreatment for both doctors and patients, as well as the impact on the dental profession itself. Special focus is given to trying to move the dental profession away from the old mechanical paradigms for treating TMDs and forward to the more modern (and generally more conservative) medically based approaches, with emphasis on the biopsychosocial model. RESULTS: The clinical implications of such a discussion are apparent. For example, it can be argued that the routine use of Phase II dental or surgical treatments for managing most orofacial pain cases represents overtreatment, which cannot be defended on the grounds of symptom improvement (ie, "successful" outcomes) alone. Similarly, there is enough clinical evidence to conclude that complex biomechanical approaches focusing on the search for an ideal specific condylar or neuromuscular position for the management of orofacial musculoskeletal disorders are not needed to produce a positive clinical result that is stable over time. CONCLUSION: Typically, overtreatment successes cannot be easily perceived by the patients or the treating dentists because the patients are satisfied and the dentists feel good about those outcomes. However, neither party knows whether an excessive amount of treatment has been provided. Therefore, both the practical and ethical aspects of this discussion about proper treatment vs overtreatment deserve attention.

Temporomandibular disorders: current status of research, education, policies, and its impact on clinicians in the United States of America.

Temporomandibular disorders (TMDs) encompass a number of different musculoskeletal disorders often accompanied by pain and dysfunction. Most TMDs are acute, but can become chronic leading to disability and quality of life issues. There is wide variation in treatment of TMDs, including both conservative/reversible therapies as well as invasive/irreversible treatments, which present difficulties for clinicians, patients, and third-party payers as to what constitutes appropriate care. Data sources: A recent report by the National Academies of Sciences, Engineering, and Medicine highlighted a number of deficiencies, most notably in the education of TMDs within United States of America dental schools at both the predoctoral and postdoctoral (dental) levels as well as addressing the historic inconsistencies in both diagnosis and treatment. New areas for research and interprofessional collaboration should assist in the understanding of TMDs, and updated clinical practice guidelines should help reduce variation in the delivery of evidence-based care. Recently, the American Dental Association recognized orofacial pain as a specialty, which should increase the level and availability of expertise in treating these issues. Summary: Based on the current best evidence, this report is an attempt to alert the profession to discontinue irreversible and invasive therapies for the vast majority of TMDs and recognize that the majority of these disorders are amenable to conservative, reversible interventions.

Orthodontics and temporomandibular disorders: a curriculum proposal for postgraduate programs.

In a previous article, we reported the results of a survey of American and Canadian orthodontic postgraduate programs to determine how the topics of occlusion, temporomandibular joint, and temporomandibular disorders were currently being taught. Based on the finding of considerable diversity among those programs, we decided to write a curriculum proposal for temporomandibular disorders that would be compatible with and satisfy the current curriculum guidelines for postgraduate orthodontic programs. These guidelines arose from a combination of the requirements published by the American Dental Association's Commission on Dental Accreditation and the written guide (July 2010) of the American Board of Orthodontics for the its clinical examination. The proposed curriculum, based on the latest scientific evidence in the temporomandibular disorder field, gives program directors a template for covering these subjects thoroughly. At the same time, they can focus on related orthodontic issues, so that their future graduates will be prepared to deal with patients who either have or later develop temporomandibular disorder problems.

Survey of orthodontic residency programs: teaching about occlusion, temporomandibular joints, and temporomandibular disorders in postgraduate curricula.

INTRODUCTION: Teaching orthodontic postgraduate students about occlusion and the temporomandibular joint is a fundamental component of their education, but faculty members are confronted with disputes and controversies about these topics. The purpose of this study was to ascertain where the orthodontic teaching community currently stands on the topics of occlusion, temporomandibular joint, and temporomandibular disorder. METHODS: A 46-question survey was sent to every orthodontic program director in the United States and Canada (n = 69). Responses were submitted by 46, and the results were tabulated. RESULTS: Three interrelated topics (normal or ideal temporomandibular joint, normal or ideal occlusion, and management of temporomandibular disorder) are being taught in diverse ways in these postgraduate orthodontic programs. CONCLUSIONS: The results of this survey will help us to understand and improve how these topics are being taught at accredited orthodontic programs in the United States and Canada. Perhaps a standardized curriculum can be developed.