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2 Definitions and Scope: What Are TMDs?
Pages 31-80

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From page 31...
... Also, while much more needs to be learned about the impact of TMDs and orofacial pain on people's lives, the evidence is clear that cultural, geographic, socioeconomic, and gender factors contribute to the impact of altered masticatory function on an individual's 31
From page 32...
... It is important to note that neither "TMD" nor "TMDs" is a diagnostic term. Each condition, as based on the most current full taxonomy, has established diagnostic criteria, and the validity of the criteria range from untested, to tested and poor, to tested and excellent.
From page 33...
... The first known published observation, in 1887, of a masticatory system disorder identified internal derangements -- an altered position of the disc in the temporomandibular joint (TMJ) -- in an anatomically descriptive manner consistent with current knowledge (Annandale, 1887)
From page 34...
... . In response to the confusion regarding the nature of the masticatory system disorders as well as increasing contentiousness within the practicing dental pro fession, in 1983 the American Dental Association (ADA)
From page 35...
... . While progress was being made in understanding the TMD pain disorders, particularly highlighted by the publication of the Research Diagnostic Criteria for Temporomandibular Disorders in 1992 (Dworkin and LeResche, 1992)
From page 36...
... Additionally, attention has been given to exploring how the types of TMDs that are painful fit into broader categorizations of orofacial pain disorders. The following section provides a brief overview of the history of the categorization systems; more details are available (Ohrbach and Dworkin, 2016)
From page 37...
... Research Diagnostic Criteria for Temporomandibular Disorders and Initial Guidelines from the American Academy of Orofacial Pain In 1992 the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) was released (Dworkin and LeResche, 1992)
From page 38...
... , along with individuals representing a range of specialty areas. The working groups expanded and refined the TMD taxonomy, and their work led to the eventual publication in 2014 of the Diagnostic Criteria for Temporomandibular Disorders ­­­ (DC/TMD)
From page 39...
... ; and • ACTTION-APS1 pain taxonomy, which has a specific focus on the chronic painful TMDs (Ohrbach and Dworkin, 2019)
From page 40...
... * Disc disorders are categorized as • Disc displacement with reduction • Disc displacement with reduction with intermittent locking • Disc displacement without reduction with limited opening • Disc displacement without reduction without limited opening SOURCES: Peck et al., 2014; Schiffman and Ohrbach, 2016.
From page 41...
... The third part of the recommendations focused on the projected research by which the recommendations could be empirically evaluated. Of particular relevance to this report, the task force on chronic low back pain also identified a number of key principles underlying the structure of the recommendations: • Guidelines should be evidence-based and incorporate a biopsycho social model of chronic pain.
From page 42...
... Next Steps for TMD Diagnostic Criteria The diagnostic validity of the DC/TMD is excellent for painful TMDs, excellent for subluxation, good for disc displacement without reduction in the acute phase of limited jaw movement, and poor for other disc displacements and degenerative joint disease, with the stated recommendation within the DC/TMD to use appropriate imaging for the disorders that have poor diagnostic validity when a definitive diagnosis is clinically required. Further efforts to build on and improve the DC/TMD include: • Better understanding of the orofacial pain disorders and how painful TMDs (a type of musculoskeletal pain)
From page 43...
... . Additionally, the central role of pain in persistent disorders of the TMJ may also be reconsidered in light of the primary findings from the Orofacial Pain Prospective Evaluation and Risk Assessment (OPPERA)
From page 44...
... has provided etiological information on the painful TMDs (Slade et al., 2013a, 2016; Meloto et al., 2019; Sharma et al., 2019b; Ohrbach et al., in press)
From page 45...
... , with substantial overlap in history and impact. It is not unusual for the multiple diagnoses of myofascial pain, arthralgia, disc displacement with reduction, and headache attributed to a TMD to be present in the same individual.
From page 46...
... . Chronic primary pain includes the subtype of high-impact chronic pain, which is associated with higher usage of health care for pain, lower quality of life, more pain-related interference with activi­ ies, and more frequently reported pain at multiple anatomic locations t (Von Korff et al., 2016)
From page 47...
... However, arthralgia may also accompany TMJ disc disorders or degenerative joint disease (see sections below)
From page 48...
... . None of the disc displacements can be diagnosed based on a clinical assessment of clicking sounds or jaw deviation during opening; while diagnosis has been attempted with various instruments, MRI remains the standard method for diagnosis (Li et al., 2012; Sharma et al., 2013; Schiffman et al., 2014b)
From page 49...
... Such degeneration may require surgical treatment to improve pain and function, such as arthrocentesis, arthroscopy, ­ open joint arthroplasty, or total joint replacement. Due to its chronicity, ­ however, osteoarthritis is frequently associated with pain comorbidities, ­ and evidence from other load-bearing joints such as the knee clearly indi­ cates that pain and disability associated with degenerative joint disease are not predicted by the extent of bony destruction but rather by the same full range of biopsychosocial factors applicable to TMDs as a whole (Summers et al., 1988; Salaffi et al., 1991; Dekker et al., 1993; McAlindon et al., 1993)
From page 50...
... Relationship of TMDs to Orofacial Pain Disorders The common painful TMDs (myalgia, myofascial pain, and arthralgia) are similar to pain disorders found elsewhere in the body, and the same diagnostic principles and treatment principles are applicable.
From page 51...
... Orthopedic techniques are suggested to reposi tion the mandible in order to decompress nerves around the temporomandibular joint (TMJ) and improve symptoms such as clicking, popping, locking, or bruxism (teeth gritting or grinding)
From page 52...
... Occlusion Because this has been an area of ongoing discussion, particularly within the field of dentistry, the committee focuses this section on occlusion before discussing its adoption of the biopsychosocial model for etiology and treatment. The field of dentistry has historically focused to a great extent on dental occlusion -- how teeth fit together -- as an assumed cause of TMDs and a basis for diagnosis of a TMD, and consequently emphasized treatments for TMDs designed to alter the occlusion.
From page 53...
... One example of knowledge that has been discovered but not applied to clinical practice concerns the interactions between the cervical and masticatory systems; of relevance here, the status of the cervical system affects the dental occlusion (Mohl, 1984) , yet clinical management of the occlusion typically ignores head posture and health of the cervical structures.
From page 54...
... , the understanding of the etiologies of types of TMDs will continue to evolve and will provide more of the insights that are necessary to improve treatments. Conclusion 2-3: The biopsychosocial model is most closely aligned with and has the best evidence for addressing the range of temporo mandibular disorders (TMDs)
From page 55...
... . These issues -- acute versus chronic disorders, high-impact chronic pain, multi-system disorders, and pain as a disease -- are not independent but instead overlap with differing emphases.
From page 56...
... When the pain and the signs of heat, redness, and swelling have resolved and when active tissue damage is no longer apparent, then the acute condition is considered to be coming to an end. If pain is still present but the signs of tissue damage have resolved, then the condition becomes an acute pain disorder, which may then transition to a chronic pain disorder (Wall, 1979)
From page 57...
... Persistent pain refers to pain that never goes away. How a patient copes with pain can heavily influence the reporting of episodes and whether a chronic pain is persistent or is not persistent but chronic (i.e., with clear pain-free periods)
From page 58...
... Another example is that a painful TMD such as myofascial pain in the masticatory muscles can be the primary disorder, which results in headache as a secondary disorder (­ chiffman et al., 2012)
From page 59...
... Moreover, the presence of a comorbid condition increases the probability that a localized condition at onset is more likely to act like a chronic pain disorder. In contrast, a TMD with multi-system components is characterized by an identifiable TMD (meeting the diagnostic criteria for a localized d ­ isorder)
From page 60...
... . As noted in the preface to the 2011 IOM report, "While pain can serve as a warning to protect us from further harm, it can also FIGURE 2-2  Structure of the International Association for the Study of Pain classification of chronic pain.
From page 61...
... is not certain about a better diagnosis. It should be noted, however, that the diagnostic criteria for the most common painful TMDs are substantially better in terms of rigorous validation procedures than most of the other conditions subsumed within the chronic primary pain rubric.
From page 62...
... For example, the four issues regarding disease course discussed in the prior section indicate that a recent ­ onset TMD in the presence of other already established pain disorders might be considered chronic pain from the beginning simply because multiple risk factors for chronicity are already active. When pain persists there are many opportunities for it to influence and be influenced by psychological and social factors (Fordyce, 1976)
From page 63...
... All of the major chronic pain conditions are quite heterogeneous with respect to the severity of the symptoms, the quality of life, and the psychosocial impacts, and a substantial proportion of individuals with these conditions experience marked impairment in physical or psychosocial function, as is the case with other conditions (Dworkin and Massoth, 1994; Manfredini et al., 2010)
From page 64...
... Finally, among chronic pain conditions, TMDs are unique in their management being carried out largely within the dental rather than medical ­ setting. This can create considerable challenges with access to care, and the dental–­ edical divide can impose substantial negative impacts on the m effective management of people with TMDs (see Chapter 6)
From page 65...
... These anatomical and functional distinctions of the TMJ, in contrast to other joints, underlie part of the complexity of TMD when it is a local condition, and these distinctions are further compounded when TMD becomes a multi-system disorder because of overlapping comorbidity. Consequently, there is great potential for unique interactions between the complex subsystems making up the masticatory system and comorbid disorders, and knowledge obtained from other pain conditions may well not help in the development of a better understanding of the masticatory system and of the TMJ in particular.
From page 66...
... TMDs can be usefully separated into two groups: the common TMDs with validated diagnostic criteria and the uncommon TMDs that do not yet have validated diagnostic criteria due to the challenges of conducting research on rare conditions. When possible, a patient's diagnosis needs to be focused on the specific TMD or TMDs.
From page 67...
... . Research methodologies that capture the interplay and reciprocal relationships between pain and biological, psychological, and social processes are especially needed; •  xploration of a broader perspective to the painful TMDs, beyond the cur E rent dominant two-axis approach; a recent five-axis approach (diagnostic criteria, common features, common comorbidities, consequences, and putative mechanisms)
From page 68...
... 2010. The Research Diagnostic Criteria for Temporomandibular D ­ isorders.
From page 69...
... 2019. The IASP classification of chronic pain for ICD-11: Chronic secondary headache or orofacial pain.
From page 70...
... : An evidence-based and multidimensional approach to classifying chronic pain conditions. Journal of Pain 15:241–249.
From page 71...
... 2015. TMD and chronic pain: A current view.
From page 72...
... 2012. Ultrasonography for detection of disc displacement of temporomandibular joint: A systematic review and meta-analysis.
From page 73...
... 2016. Overlapping chronic pain conditions: Implications for diagnosis and classification.
From page 74...
... 2019. AAPT Diagnostic Criteria for Chronic Painful Temporo­mandibular Disorders.
From page 75...
... 1988. Differential utility of medical procedures in the assessment of chronic pain patients.
From page 76...
... 1990. Quantification of biomedical findings of chronic pain patients: Development of an index of pathology.
From page 77...
... 2019b. Challenges in the clinical implementation of a biopsychosocial model for assessment and management of orofacial pain.
From page 78...
... 1990. The robustness of an empirically derived taxonomy of chronic pain patients.
From page 79...
... 2005. Towards a new taxonomy of idiopathic orofacial pain.


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