Updates to TMD Recommendations

Disclaimer:

Any medical/health information in this course is provided for general informational and educational purposes only and does not substitute for professional advice. Accordingly, before taking any actions based on such information, I encourage you to consult with the appropriate professionals. The use or reliance of any information contained in this course is solely at your own risk.

What’s the best way to approach TMJ problems?

Well, just like with any health problem, our understanding of this changes over time.

As years go by, we learn more about the human body and how to help when things aren’t going well.

We usually learn more when researchers keep studying important questions, and providers listen to patients about what works and what doesn’t.

Often, after several years of studying and listening, groups of providers get together, sit around with coffee and ask, “Well, what are the big-picture things that we’ve learned over the past several years? Now that we know more, what should we change about our recommendations to patients and what we teach healthcare students?”

A group of researchers/providers recently did this for TMJ problems.

Thirty-eight researchers in dentistry and physical therapy gathered to talk about what’s new, what we’ve learned, and how we should approach TMJ problems differently compared to, say, 20 years ago.

It turns out, there’s a lot we’ve learned!

This group of 38 TMJ experts consolidated their updates into a “top 10 greatest hits” of advice and learnings. I’ll share each of them, and then translate each into what this means for you, if you’re a person who deals with TMJ problems.

Here are the top ten things that TMJ experts want you to know about managing your TMJ problem (I’ll quote each of their points, then give my own commentary):

1. “Patient-centered decision-making alongside patient engagement and perspective is critical to manage TMDs [temporomandibular disorders], with management being the process from history through examination into diagnosis and then treatment. Expectations should focus on learning to control and manage the symptoms and decrease their impact on the individual’s everyday life.” (1)

   
   

   What this means for you: Your treatment should not start with treatment. It should start with curiosity, lots of questions, and a thorough examination and diagnostic process before coming up with treatment recommendations. This may seem obvious, but it’s still common for people to never receive a proper examination before receiving TMJ treatment recommendations. Additionally, this process should be collaborative between you and your provider, rather than your provider making recommendations without your input. Your plan should focus on your goals and how your problem impacts your life - not on achieving a certain “textbook ideal."

   
   

2. “TMDs are a group of conditions that may cause signs and symptoms, such as orofacial pain and dysfunction of a musculoskeletal origin.”

   
   

   What this means for you: There are several different TMD conditions. There is not a “one-size-fits-all” diagnosis for jaw issues.

   
   

3. “The etiology of TMDs is biopsychosocial and multifactorial.”

   
   

   What this means for you: Etiology means “cause,” so this point talks about what causes TMJ problems. We used to think that TMJ problems were caused by issues with your anatomy - if you had pain, there must be something structurally wrong. Now, we know there’s more to it than that. Someone can experience pain yet have nothing structurally wrong. Or, they could have a structural abnormality, but this may not be the whole story, or even the majority of the story. “Biopsychosocial” means that that the causes could be related to “biology” (your anatomy and physiology), “psychology” (the brain and brain-body connection), or “social/environmental” (related to things outside of you) factors.

   
   

4. “Diagnosis of TMDs is based on standardized and validated history taking and clinical assessment performed by a trained examiner and led by the patient perspective.”

   
   

   What this means for you: TMJ problems are diagnosed through a standardized process. This means that if you’ve had a provider tell you you have “TMJ,” but haven’t gone through an extensive history and examination process, you are probably missing out on a more accurate and thorough perspective that can steer you towards better care.

   
   

5. “Imaging has been proven to have utility in selected cases but does not replace the need for careful execution of history taking and clinical examination. Magnetic Resonance Imaging is the current standard of care for soft tissues and Cone Beam Computerized Tomography for bone. Imaging should only be performed when it has the potential to impact the diagnosis or treatment. Timing of imaging is important and so is the cost:benefit:risk balance.”

   
   

   What this means for you: Hone in on these phrases: “Imaging has proven to have utility in selected cases,” and “Imaging should only be performed when it has the potential to impact the diagnosis or treatment.” This means that imaging is not helpful in all cases - only some. Additionally, imaging should only be used when it actually helps us rule in or rule out diagnoses. In most cases, imaging is not necessary to determine an evidence-based diagnosis and treatment plan.

   
   

6. “The evidence base for all interventions or devices should be carefully considered before their implementation over and above normal standard of care. Knowledge on developments in the field should be kept up to date. Currently, technological devices to measure electromyographic activity at chairside, to track jaw motion, or to assess body sway, amongst others, are not supported.”

   
   

   What this means for you: There are lots of fancy gadgets that providers might wheel around when diagnosing and treating TMD. Many are not helpful or worthwhile.

   
   

7. “TMD treatment should aim to reduce the impact of pain and decrease functional limitation. Outcomes should be evaluated also in relation with the reduction of exacerbations, education in how to manage exacerbations, and improvement in quality of life.”

   
   

   What this means for you: Treatment should focus on helping you get back to the activities of life, rather than on changing something found in imaging.

   
   

8. “TMD treatment should primarily be based on encouraging supported self-management and conservative approaches, such as cognitive-behavioral treatments and physiotherapy. Second-line treatment to support self-management includes provisional, interim, and time-limited use of oral appliances. Only very infrequently, and in very selected cases, are surgical interventions indicated.”

   
   

   What this means for you: Surgery is very rarely the answer. In the vast majority of cases, you can get better on your own, or with some guidance from professional help. The best, most frequently successful form of help? Low-risk treatments that put you in the driver’s seat and teach you how to take steps forward, like physical therapy and other therapies.

   
   

9. “Irreversible restorative treatment or adjustments to the occlusion or condylar position are not indicated in management of the majority of TMDs. The exception to this may be an acute change in the occlusion, such as in the instance of a high filling or crown with TMD-like symptoms developing immediately following these procedures or a slowly progressing change in dental occlusion due to condylar diseases.”

   
   

   What this means for you: The majority of the time, TMJ problems are not caused by your bite or joint being off or out of place. Sure, it’s possible, but usually not the case.

   
   

10. “The presence of complex clinical presentations with uncertain prognosis, such as in the case of concurrent widespread pain or comorbidities, elements of central sensitization, long-lasting pain, or history of previous failed interventions, should lead to the suspicion of chronification of TMDs or non-TMD pain. Referral to an appropriate specialist is thus recommended; the specialty will be geographic-specific as not all countries have a specialty of orofacial pain.”

    
    

    What this means for you: If you aren’t getting better, you should see a specialist who is up to date on the latest evidence for TMJ diagnoses and treatments.

    
    

It actually takes a long time for new research to make it’s way into your doctor’s office. This means that you might still get mixed advice or care that doesn’t match what this research suggests.

This doesn’t mean your provider isn’t doing their best; it just means that there is no way for every provider to keep up to date on every piece of research that comes out, so it takes a lot of time for the “old ways” to shift into the “new ways.”

So, you might still get some “old ways” suggested to you. And, some of those old ways might still work for some folks. But, this is how we’re learning to treat people, as a whole, better, and not waste time, money, and resources on things that aren't likely to help.

In summary, here are some things you should look for as you pursue TMJ care:

• Your provider should listen to you

• Your provider should ask questions, and do a physical exam

• Imaging, surgery, or restorative dental treatments are most likely not necessary to help you reach your goals.

• The cause of your problem is likely multifactoral, not reduced to only that which is found on imaging.

• Your treatment plan should be a collaborative effort between you and your provider. Your input, values, and preferences should influence how you both move forward.

• Your treatment should focus on getting you back to daily function with less pain, rather than on correcting a structurally abnormal imaging finding.

• Most individuals can reach their goals with low-risk, minimally-invasive methods such as physical therapy and other conservative therapies. In some cases, an oral appliance might be helpful. In very rare cases is surgery necessary and should only be explored in specific circumstances and after conservative options have been exhausted.

  
  

That’s our latest update!

If you have a TMJ problem and would like an evaluation informed by the latest research like I described above, reach out on the “Contact Us” page to set up a free phone consult.

Cheers,

Dr. Rebecca Salstrand, PT

References:

1. Manfredini D, Häggman-Henrikson B, Al Jaghsi A, Baad-Hansen L, Beecroft E, Bijelic T, Bracci A, Brinkmann L, Bucci R, Colonna A, Ernberg M, Giannakopoulos NN, Gillborg S, Greene CS, Heir G, Koutris M, Kutschke A, Lobbezoo F, Lövgren A, Michelotti A, Nixdorf DR, Nykänen L, Oyarzo JF, Pigg M, Pollis M, Restrepo CC, Rongo R, Rossit M, Saracutu OI, Schierz O, Stanisic N, Val M, Verhoeff MC, Visscher CM, Voog-Oras U, Wrangstål L, Bender SD, Durham J; International Network for Orofacial Pain and Related Disorders Methodology. Temporomandibular disorders: INfORM/IADR key points for good clinical practice based on standard of care. Cranio. 2025 Jan;43(1):1-5. doi: 10.1080/08869634.2024.2405298. Epub 2024 Oct 3. PMID: 39360749.