Temporomandibular Disorders

Diagnosis/Definition

These disorders include multiple diagnoses encompassing a variety of hard and soft tissue disorders including masticatory muscle dysfunction and internal derangements of the temporomandibular joint.

Initial Diagnosis and Management

Acute presentations should be evaluated by a thorough focused history and physical examination which should include a screening panoramic radiograph and measurement of the patient’s range of mandibular motion and interincisal distance at maximal opening. Patients may describe a wide variety of symptoms from headache to earache to masticatory or facial myalgias with restricted masticatory function and range of motion. Other causes of subjective symptoms should be sought.
Initial treatment for TMD should include soft diet, moist heat to painful areas, NSAIDs, and skeletal muscle relaxants. All patients should be warned that gum chewing, yawning widely, and hard chewy foods may antagonize the condition.
Patients may see slow improvement of their symptoms over few weeks to several months.

Ongoing Management and Objectives

Patients with ongoing TMD complaints after several weeks of treatment should be referred to their general dentist for fabrication of a hard acrylic splint.
Active duty personnel should be referred to their assigned dental clinic for evaluation and treatment.
Dental care for other than active duty personnel (active duty family members, retirees or family members of retirees) is not available at military dental facilities. These patients should be referred to their civilian dentist.
Fabrication of TMD splints is covered by TRICARE with preapproval.

Indications for Specialty Care Referral

Most TMD patients can be managed in the primary care setting. This can be accomplished by the primary care physician or dentist.

Surgery is seldom indicated for TMD patients. Most patients can be managed nonsurgically with medications, physical therapy, stress reduction therapy, and dental splints. Hard acrylic splints fabricated by a skilled dentist are the mainstay of non surgical treatment and a prerequisite for surgical referral for the chronic TMD patient. The exceptions to this are the acute (less than 1 week duration) closed lock (unable to open) patient or the open lock (subluxated- unable to close) patient that cannot be reduced. These patients should be referred to the Oral and Maxillofacial Surgery resident on call.

Patients who fail a trial of nonsurgical treatment including splint therapy should be given an oral surgery consult.

Criteria for Return to Primary Care

Resolution of anatomic malformations through surgery.