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TMD: Diagnostics, treatment and scientific advances

3D image exams and advances in the study of articular prosthesis are the greatest differential for the treatment of TMD.

In spite of being one of the most common orofacial pains in the population in general, there is still lack of enough specific knowledge for the dentist in relation to the diagnostics and treatment of the temporomandibular joint dysfunction.

Among the causes for the orofacial pains recognized by Odontology, the dysfunction of the temporomandibular joint dysfunction (TMD) is among the most frequent in the world population. According to a term of the First Consensus in Temporomandibular Dysfunction and Orofacial Pain, approved in 2010, it is estimated that, in Brazil, around 37% of the population show at least one symptom of that problem.

There have been many advances in the studies referring to TMD. From anamnesis for identifying the problem to the most complex cases, specialists have identified new methods for precise diagnostics and more efficient treatments, which improve patients’ quality of life. It is necessary that all professionals working in Odontology are aware of the issue, not only the specialists.

The ideal would be that all dentists, independent from their specialty, are able to identify a TMD. For that, it is necessary to know the signals and symptoms (see box). Usually, it is recommended that the patient with that dysfunction is directed to a specialist for the adequate treatment.

Diagnostics – Presently, dentists count on systems that allow for the complete and detailed analysis of the temporomandibular articulations through 3D images generated through tomography. The use of specific software allows to visualize several cross-sections of the image captured, besides allowing for the view from different angles.

“The advent of the 3D image has brought to us the intra-articular view, which allows for a better understanding (of the problems of the temporomandibular articulations) and, therefore, more possibilities to stabilize the dysfunctional process.

Odontological treatments can be compromised if the temporomandibular joint dysfunction is not diagnosed.
Complementary tests can be allied to the diagnostics and those, together with tomography allow for a more assertive treatment with faster results. For muscular analysis, professionals can use electromyography, which consists of identifying how facial muscles are working and if there are inflammations by means of electrodes strategically positioned.

Other systems like JMA (Joint Movement Analysis) and JVA (Joint Vibration Analisys), will also do a computerized evaluation of the mandible by means of the analysis of movement and vibration. Those exams can be carried out by third parties but there are temporomandibular joint dysfunction treatment clinics that already count on those procedures for the treatment.

Clinical treatments – The priority of the treatment of the TMD is to end pain. Even if a later surgical procedure is recommended, the clinical treatment is the first step. The objective is to eliminate muscular and articular inflammations and stretch the limitations of the movements of the mandible. In some cases, it is even possible to reposition it.

That procedure is based on the use of the interocclusal plate. According to Dr. Guiovaldo Paiva, specialist in Orofacial Pain and Temporomandibular Dysfunction and founding partner of Centro de Diagnostico e Tratamento da ATM, the thickness of the plate and the adequateness to the patient are defined by the professional according to the established diagnostics. “For a more effective result of that first phase, we recommend TMJ physiotherapy which consists of low-intensity laser applications, ultra-sound and muscular exercises,” he explains.

After rehabilitating the articulation functional system, the patient will be recommended to the second phase. In most cases, that process will be guided by the orthodontist, and, when necessary, also implantodontics. However, it is necessary to guarantee that the first phase is concluded with success. “We cannot ignore TMJs before beginning any odontological treatment, because, if there is a dysfunction, all that is done by the other specialties may be damaged,” explains Dr. Guiovaldo Paiva.

Presently, besides the interocclusal plate, some professionals use the botulinum toxin A as a minimally invasive therapy, applied to some specific points in the muscles. According to Dr. Tarley Pessoa de Barros, doctor in Odontology at Universidade de São Paulo and specialist in maxillofacial Surgery and Traumatology, the toxin acts together with the neuromuscular junction avoiding the liberation of acetylcholine as a consequence of muscular contraction.

The specialist explains that he considers this one of the most efficient alternatives because the substance is a potent muscle relaxant. According to him, the inconvenience is the necessity to re-apply. “The therapy shows fast action and minimum side effects or almost none, provided the patient is not allergic to the components of the formula, is not pregnant or breast-feeding or if he/she does not have a neuromuscular disease,” says Dr. Barros.
A study carried out by the Allergan group, which produces Botox™ in Brazil, showed that the toxin applied to patients diagnosed with bruxism, have shown a 50% reduction in the cases of pain and obtained even more improvement in the quality of their sleep.

In spite of the therapeutic use of the toxin in odontological procedures having been authorized by the Federal Odontology Council in 2014, the theme still generates diverging opinions, demanding additional studies with evidence.

Surgical intervention – For more severe dysfunctions, the use of articular prosthesis has been pointed out. Presently, Brazil is one of the most advanced countries in the field. The prosthesis allow for repairing the TMJ´s with the conservation of the articular movement. “That option is recommended in severe cases of arthrosis and allows for better control of the quality of the movement, which would not be possible in other procedures”, explains Dr. Luiz Fernando Lobo. However, the specialist alerts for the fact that all temporomandibular articulation treatments have to undergo previous clinical processes.
“It is not possible to define previously the cases that have to be recommended to surgery, but there are proposed classifications that help the clinical evaluations”, says Dr. Lobo. Among them, is the articular disk dislocation with reduction of persistent reduction with signals of pops and noise, dislocation without reduction and severe arthrosis with low mobility.
Lack of diagnostics – Besides compromising other odontological treatments, TMDs can trigger even cases of depression, if not treated adequately. “Many patients are part of the group with irritability, hyperactivity or repetitive movements that can be diagnosed as anxiety”, explains Dr. Luiz Fernando Lobo.

Besides psychologists and psychiatrists, other specialists may be added to the treatment of TMD’s like physiotherapists, when there is elongation of the muscle and speech therapists to improve the articular movement.
“Today we know about the importance of involving other fields of the health in this process as well as other dental specialties such as orthodontics and prosthesis” concludes Dr Tarley Pessoa de Bassors, PhD in Odontology by the Universidade de Sao Paulo (Sao Paulo University) and specialist in Maxillofacial Surgery and Traumatology.

On the way to the diagnostics
TMD is originated from a number of factors. According to the term of the 1st Consensus in TMD and Orofacial pain, these factors can be from trauma, psychosocial (anxiety and depression) and physiopathology (systemic diseases, altered intra-articular pressure and genetics). What will define the diagnostics will be the patients symptoms and the signs identified in the clinical exams.

TMD Symptoms– Patients
• Pain in the face, on the TMJ and on the masticatory muscles.
• Pain on the head and on the ears, and
• Otologic manifestations – tinnitus, vertigo and muffled sound

TMD signals – Clinical exam
• TMJ and muscular sensitiveness
• Limitation or non-coordination of mandibular movements
• Articulation noises, and
• Wrong location of the teeth
According to the specialist in TMJ and Orofacial pain and founding partner of the Centro de Diagnóstico e Tratamento da ATM (Center for the Diagnosis and Treatment of the ATM), Dr. Guiovaldo Paiva, additionaly of the most usual symptoms check, the dentist should also question about recent or not accidents, previous dental treatment (mainly orthodontics) and also regarding sleeping conditions. ”It is very important to know if the patient sleeps well, since we know that the obstructive sleep apnea may be related to ATM and the image exams will allow for evaluating also the superior airway, where the oropharynges is located, likely the responsible of the air intake”, says.

In order to analyze with more precision all the information and generate a comprehensive diagnosis, it is important that the patient be directed to a specialized professional. “It is very rare people to look for a specialist when they perceive the signals and symptoms, this way the dentists need to further exam, identify the problem and know whom the patients must be referred to”, states Mr. Paiva.

Published by Pablo Henrique Asenjo de Macedo

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