Quality Resource Guide
l
Temporomandibular Disorders 3rd Edition
6
www.metdental.com
Diagnostic Considerations
In order to deliver accurate and reliable
diagnosis(es) it is important to have a validated
and
reliable
classification
system
to
be
used as a guide. The first dual axis criteria,
incorporating both physical and psychosocial
findings, was the Research Diagnostic Criteria
for
Temporomandibular
Disorders
(RDC/
TMD), originally published in 1992.
94
This has
since evolved into the Diagnostic Criteria for
Temporomandibular Disorders (DC/TMD)
95
which
is a more validated clinically oriented classification
system for the most common joint and muscle
conditions. To date, it is the only classification
system that incorporates standardized and reliable
self-report questionnaires, clinical examination
procedures, scoring systems, and decision
trees. Furthermore, no other system integrates
biophysical diagnosis to a disability index that
measures the impact that pain has on the patient’s
behavior. A supplementation and extension of the
DC/TMD, to include less common masticatory
muscle and temporomandibular joint conditions, is
the expanded DC/TMD.
96
This system incorporates
37 conditions that have operationalized diagnostic
criteria. Recently, a collaborative group of
international individuals representing multiple
organizations and associations developed the
International Classification of Orofacial Pain.
97
This
classification
system
emphasizes
the
characteristics of the pain disorders rather than
the anatomic location of pain. Included in ICOP are
TMD diagnostic criteria which have been adopted
from the DC/TMD by including only painful TMD
conditions. Additionally, ICOP incorporates a time
component to diagnosis as well as distinguishing
primary from secondary pain.
To assist the clinician in the diagnostic process,
a validated TMD screener has been developed
which may be administered in either a short
(three-item) or long (six-item) version. This
psychometric instrument has excellent levels
of reliability, sensitivity, and specificity thus
supporting its usefulness in any clinical office
setting.
98
Management Considerations
Management of TMD/orofacial pain must be
viewed on a case-specific basis. To achieve
optimum
outcomes,
the
practitioner(s)
must address the specific pathophysiology.
The
traditional
model
of
monodisciplinary
management has proven to be effective in cases
where definitive cause and effect relationships
may be established. However, the multifaceted
nature of these conditions, in combination with
the associated features and comorbidities of
recurrent and/or chronic pain, add a significant
degree of complexity to management decisions
and interventions. Utilization of a multidisciplinary
model of diagnosis and management encourages
the integration of a management plan with input
from a cadre of health practitioners (
Table 1
). This
approach will enhance outcomes by addressing
physical, somatic, psychological, environmental,
and behavioral factors in a well-orchestrated
fashion. The goals of management include: 1)
reduce or eliminate pain; 2) halt the disease
process when possible; 3) normalize function; 4)
improve quality of life; and, 5) reduce the need for
long-term care.
99
Implementation of this multidisciplinary strategy
requires adherence to a biopsychosocial model
that allows the therapy team to develop a complete
and
definitive
diagnosis
encompassing
all
physical and psychosocial factors. Goals must be
established with regard to treatment duration, pain
management approaches, patient involvement,
and a plan for the patient to return to activities
of daily living. Success is dependent on regular
communication between the team members.
Table 1
- Team members and their respective roles in the diagnosis and management of
TMD/orofacial pain
Dentist
Physical Therapist
Clinical and Health
Psychologist
Other
Healthcare
Consultants
(if required)
Perform evaluation/diagnosis
Perform evaluation/
diagnosis
Perform evaluation/
diagnosis
Pharmacy
Provide patient education/
reassurance
Provide patient
education/reassurance
Identification of
underlying and
resultant psychological
issues
Neurology
Provide coordinated
pharmacologic management
Deliver modalities/
techniques
Provide cognitive-
behavioral therapy
training
Otolaryngology/
ENT
Provide dental care (when
necessary for specific dental
issues)
Encourage and enhance
rehabilitation
Provide pain and stress
management education
and skills
Rheumatology
Occlusal orthosis (intraoral
appliance) therapy
Facilitate team interaction
Entrainment of
enhanced coping skills
Internal
Medicine
Coordinate appropriate
consults
Facilitate team
interaction
Neurosurgery
Facilitate team interaction
Anesthesia Pain
Disciplines
Participate in the
normalization of sleep
quantity and quality
Sleep Medicine