I want to welcome Dr. Peck. My name is Dr. Farshid Areez. I'm a moderator this evening webinar on paradigm traps of TMD. I'm joined with our speaker Dr. Conor Peck. The AADSM does not endorse any services, products, devices, or appliances they use, mention, or descriptive by any services, product, devices, or appliances during this webinar should not be interpreted as an endorsement, recommendation, or preference by the AADSM. Any opinion, express, or communication regarding any product, devices, or appliances during the webinar is solely the opinion of the individual expressing or communicating that opinion and not that of the AADSM. Whenever possible, presentation should be supported by evidence. In the instance where evidence is lacking, speakers have been asked to verbally disclose their presentation in case-based or based on clinical experience so that you can use independent clinical judgment to make a decision for your practice and your patients. Now I'll turn it over to Dr. Peck. Thank you for the background, the introduction, and thank you to everybody in webinar land who's joining tonight for this talk. The title, as Dr. Areez mentioned, is the Paradigm Traps of TMD, a whole person approach. A little bit of background about myself. This is me and my gang here. We live in Milwaukee, Wisconsin. I went to Marquette University School of Dentistry and then around my third year we had a series of lectures from a local group practice or facial pain specialty practice and kind of caught my attention, caught my interest, started doing some shadowing and decided that that was kind of my calling. I decided at that point that I wanted to jump right into that specialty so I ended up going to the University of Minnesota where I completed my orophacial pain dental sleep medicine residency and from there moved back to Wisconsin to join the group practice that I'm now with currently. The objectives of tonight's talk are we'll start with a discussion around the history of TMD treatment strategies and then kind of taking that up to the state of the field today. This is going to be a good chunk of the presentation. I think it's really important if we're talking about the different paradigms that we kind of go back in time to see where we all started. We'll then consider the impact that substantially conflicting treatment approaches for the same diagnoses can have on the profession as a whole and on the public who we're treating and then at the end we'll do a kind of a high-level overview of current modern evidence-based treatment approaches for TMD and then we'll examine the importance as the title would suggest of a comprehensive whole person approach to care. All right so so doctor do I have TMJ? So this is a question that I hear probably at least once a week from from a new patient and I'm sure I'm not the only one in the audience who gets that question from time to time if you do treat these these patients. I think it kind of speaks to the lack of understanding that still exists in the public surrounding TMD and there are probably a number of reasons for this one being the fact that our understanding and philosophy surrounding TMD as doctors has evolved significantly in the past century century plus and we'll highlight that as I said in the timeline in a few slides but in my opinion the biggest reason why there's this sort of lack of understanding is that unlike other more straightforward if you want to think of it like that other straightforward medical conditions where there's clearly defined diagnostic criteria and then treatment algorithms once you've come to that diagnosis TMD encompasses kind of a wide array as we know of clinical presentations and depending on the philosophy and the training of the of the treating provider the treatment rendered can be highly variable and this can range from conservative fairly you know quick timeline maybe reasonably priced build medically treatments and it could also you know progress in some cases to more irreversible treatment modalities that can be more time-consuming more costly to the patient sometimes and oftentimes involving irreversible treatments you know orthodontics prosthodontics come to mind some cases even surgery and so I think because all of the symptoms and presentations of TMD are kind of lumped into those three letters of TMD patients come in and they're understandably curious and sometimes in some cases they're on edge when they come to our office for that first visit after they've spoken with friends family previous doctors who all have their own unique personal experiences and understanding of these these conditions and so my overarching goal for tonight's talk is to kind of review the history as I said of the condition show how our understanding has evolved over the years and then kind of discuss the challenges that the field continues to face to this day and kind of speak to the efforts being made to address those those concerns and clear things up to the public all right so we're gonna go way way back now to the 1910s dr. Prentice was probably one of the first people if we look into the literature that that comes up and in terms of you know our understanding of TMD he first described how the elevator force of masticatory muscles could lead to TMJ atrophy following dental extractions he stated that when when teeth are extracted the condyles are kind of pulled upward by the by the musculature of the jaw and that that pressure puts that's placed on meniscus can result in atrophy and and subsequently symptoms so a couple decades later we we get to Costin so many of us are familiar with with the name at least he was an ear nose and throat specialist who first connected ear symptoms and facial pain to the jaw joints so he related symptoms to dental and prosthetic misalignment reduced vertical dimension of occlusion tooth loss and excessive overbites proposing that these symptoms would improve once those issues were addressed and so he published I think about 12 papers in the 1930s and came up with a term Costin syndrome I think when other one was mandibular neuralgia to describe these these patients so his findings really sort of were the first to put ownership of TMD pain patients into the hands of dentists so it kind of made it our role as dentists to to develop and perform dental procedures aimed at treating these cases and so for many decades that followed and in some circles still to this day Costin sort of paved the way for what we what we now consider the the biomechanical or the mechanistic approach for TMD management where TMJ disorders are again thought to be caused by by dental factors and therefore must be treated by dental correction and so this this line of thinking does remain a point of controversy today so we'll fast forward then into the 40s and 50s and and into these mechanistic theories that sort of stemmed from Costin's work so Thompson was a was an orthodontist he suggested that an adequate condyle fossil relationship was important for jaw function and he suggested actually that that malocclusion would lead to misalignment of this condyle fossil relationship and so it was it was incumbent upon us as dentists to correct malocclusion so that the joints were seated properly and that would then treat these patients pain Moyers was another orthodontist he felt malocclusion was the cause of aberrant muscle activity in the jaw which was then treatable with orthodontics and Jerebec showed that patients with malocclusions and TMD symptoms had higher EMG mass vector muscle activity than healthy control so he assumed that occlusal interferences and reduced vertical dimensions of occlusion would lead to muscle spasm and this would result subsequently in TMD pain and in the decade or two following we these are more so those are those are orthodontists these are more prosthodontists but similar line of thinking so Stewart suggested that the CRMI discrepancies would would increase tooth wear and joint pain D'Amico would echo these theories and added also that canine guidance was also crucial not only for prevention of periodontal trauma but also TMJ trauma and then there was a famous study that came from Ram feared who concluded that occlusal equilibration to correct CRMI discrepancy would improve muscular balance eliminate sleep ruxism and then treat TMD so in his study he performed occlusal equilibration on 34 patients who were in the studies known severe Bruxers with so he'd measure them with EMG he'd measure their massatory muscle activity and then they would do occlusal adjustments to correct CRMI discrepancies and noted that the EMG activity decreased with treatment there were a number of flaws with the studies such as the patients weren't randomly selected there was no blinding done there were there was no control group there was no information given to explain how Bruxism was diagnosed so there were a number of flaws but in spite of that for decades that followed a lot of a lot of dentists and a lot of people in the dental profession took those those findings to heart and a lot of studies kind of piggyback off of those piggybacked off of those findings and then we have dr. Bernard Yankelson who introduced the term neuromuscular dentistry in the late 1960s so many of us are familiar I'm assuming with neuromuscular dentistry if not it's a field sort of based on the concept that the ideal function of massatory muscles can be restored through dental work they so they'll kind of utilize technology like jaw tracking technology EMG things like that which are meant to allow clinicians to have a more objective way of assessing muscle activity and then jaw position so dentists who follow this approach typically will utilize a two-phased approach to treatment so if you've ever heard of phase one phase two treatment for TMD phase one typically is that the reversible part of the the treatment where maybe an appliance removable TMJ appliance is used for 24 hours a day in many cases for months at a time once the patient's symptoms have improved after you know three to six months or so then phase two treatment would follow which is generally going to be more irreversible treatment approaches like prosthodontics orthodontics in order to try to address the bite and put the put the jaw in a more relaxed position so essentially neuromuscular dentistry views the bite as the key component of the the master the masticatory system and you know remains a point of controversy for sure to this day now in parallel with the findings that I just mentioned those studies kind of touting the mechanistic theories we also have the development of the biopsychosocial model of TMD and then in the 1950s and 60s as well and so this is kind of a different approach where we're not only taking into consideration the the biological factors so things like the bite for instance and other biological factors obviously like you know systemic arthritic conditions and so forth but we're also taking into consideration the psychological aspects of the patient so you know mood disorders personality traits history of trauma those sorts of things that you know if you if you deal with enough TMD patients you you can't help but but see frequently and then also obviously social constructs so this is things like you know employment status family home life those sorts of things so it's taking in a way a more holistic approach to to viewing these these TMD patients so this is starting around the 50s and 60s as well Dr. Laszlo Schwartz was the the first to describe temporomandibular joint pain and dysfunction syndrome which was that you know kind of first transition away from the biomechanical model where it's actually looked at as you know more of a chronic health syndrome or pain syndrome he noted that many signs and symptoms of TMD were accompanied by emotional stress and identified predisposing emotional factors which could be psychological mood so forth contributing factors so you know occlusion is not completely you know insignificant there are there certainly was and still is you know a role in occlusion for our patients but it's looked at as not the not the sole contributing factor the sole cause of these patients symptoms precipitating factors so muscle imbalances and then aggregating factors could be you know alarmism or you know catastrophizing that sort of thing past trauma and so again taking a more kind of high-level overview of everything going on in that patient's body and mind as opposed to just looking inside of their mouth at their bite and then in the 1960s another important researcher Dr. Daniel Laskin described the pain dysfunction syndrome so this is again where doctors are starting to researchers are starting to recognize TMD as more of a more in line with other chronic pain models and so Dr. Laskin noted that most TMD signs and symptoms are related to the masticatory musculature the origin usually being psychophysiologic he coined it and so he looked at stress and tension as a big contributor leading to patients you know tensing their jaw bruxing those sorts of things and so this this diagram on the right came from his paper in 1969 where he looked at oral habits oral habits you know like like I mentioned bruxism or clenching as being caused by things like dental irritation but the bolder arrow on the left here for coming from tension is is signifying in his opinion that the psychological or psychosocial factors of maybe life stress and that sort of tension are are bigger drivers for those oral parafunctions ultimately those habits would lead to muscle fatigue muscle spasm and then ultimately patients get into this vicious cycle down at the bottom where they coined this myofascial pain dysfunction syndrome where they they get into this again this cycle that can be self-perpetuating and and you know it would explain why a lot of their patients that they were seeing were were difficult to treat and and not responding necessarily to more simplistic treatment approaches so then we have the 1960s to 80s so again biopsychosocial models kind of taking shape a little bit more here we have a number of researchers bell helcomo frictin and shiffman authoring studies aiming to standardize tmd diagnoses and improve our classification so in line with other other medical conditions as opposed to just looking at a patient who has you know tmd as saying that they have tmd we're going to kind of subcategorize their their diagnoses into you know massatory muscle disorders disc disorders inflammatory disorders and so forth and these studies kind of help pave the way for future epidemiologic and etiologic studies in tmd several controlled studies around that time also showed that placebo treatment and conservative treatment had similar outcomes to non-conservative treatment and so because of that a lot of research was starting to to steer practitioners towards more conservative approaches given that the outcomes were similar also in the 1980s we have the development of the uh the academy here so the american academy of cranio-mandibular orthopedics held its first meeting to improve the quality and diagnoses and management and orofacial pain of which temporomandibular disorders are probably the most common orofacial pain i shouldn't say probably they are the most common disorder seen in an orofacial pain practice and then they formed this also to facilitate communication and research across the field so this academy was then renamed a couple times but ultimately took the name the american academy of orofacial pain in 1992 and that's the name that that this academy takes or keeps to this day the aop is the is the academy that that a few years back in 2020 was was able to help the american dental association of the ada recognize orofacial pain as a as the 12th specialty in dentistry the first tmd position paper coined the term cranio-mandibular disorders which described multifactorial and complex etiologic factors again kind of more in line with that biopsychosocial model that we just discussed and then you also have in the late 80s a few of the preeminent pain societies in medicine the isp and the international association of headache disorders recognizing tmd as a chronic pain disorder so into the 90s and 2000s now we have growing research in trigeminal system neurobiology and psychopathology which helped to reshape how we view the etiology of tmd dr sam dworkin published the rdc tmd and so this is one of the most cited papers still today in the dental literature guided tmd research for in the future by kind of removing subjectivity and providing more objective tmd assessments which were guided by biopsychosocial principles and so that means basically they they subdivided to like an axis one and an axis two in this diagnostic criteria where axis one is is taking into consideration all of the the your muscle pain disorders your disc disorders your arthralgias your your physical manifestations of these symptoms and then access to gave gave researchers a way to utilize valid psychosocial testing measures and metrics in order to also help us understand this population better and so really following this publication in uh in 1992 the majority of peer-reviewed literature in tmd used protocols from this this paper we also had a few a few studies around that time this is in 1999 and 2001 showing uh the offering reviews so there were the review studies systematic reviews which found minimal evidence to support the role of occlusal adjustments in treating tmds and so tsukiyama study for instance reviewed 11 studies noted methodology shortcomings including again lack of operate operator blinding uh poor calibration of the of the operators lack of valid tmd assessments and general low power so there were just they found a number of flaws in studies that had previously spoken to the importance of occlusal adjustments in treating tmd and we have the creation of postgraduate or facial pain programs and many rdc tmd based papers books and lectures we're also helping to kind of steer the field the field further towards that biopsychosocial model around this time then into the 2000s we have evidence-based dentistry continuing to support the biopsychosocial and multifactorial models of TMD, the multifactorial model is pretty similar. It's basically just taking into consideration that TMD etiology stems from kind of a mix of intrinsic and extrinsic factors. And so just a slightly different way of looking at that but kind of still a more holistic approach if you want to look at it that way. Then we have a paper by Chuck Green in 2001. He's written probably hundreds at this point. He's very an instrumental figure in TMD research. And I chose this one in 2001. It was a paper that in it, he basically stated that he believed the biomechanical theories or concepts of TMD etiology were wrong but he also acknowledged that as a field the biopsychosocial and multifactorial frameworks were also flawed and imperfect. So he claimed that every individual TMD patient should be viewed as an idiopathic case because ultimately we don't know and we don't have the ability to measure enough to say with certainty what causes the symptoms of a lot of our patients. But in spite of this imperfection in our understanding it doesn't have to prevent us from providing care with successful outcomes. He noted that there are enough controlled studies supporting the use of conservative TMD treatment approaches and in that when possible conservative TMD treatment approaches should be implemented as first-line treatment. He also cautioned against the use of more aggressive and irreversible treatment approaches in the majority of cases. Then in 2011, we have the OPERA study which was a huge study from which came 35 plus papers over the next decade or so. This was a multi-site NIDCR funded prospective longitudinal study following more than 4,000 men and women over a five-year period. They identified a number of things including risk factors, sign symptoms, genetic and environmental factors all contributing to the onset and chronicity of painful TMD. Findings supported the multifactorial etiology of TMD and the biopsychosocial illness model. I think of note here to some of the attendees in the group if you're not familiar with this paper there were some pertinent findings to sleep dentists which were that OSA signs and symptoms which are things like hypertension, BMI being elevated to a certain point, heavy snoring, witnessed apneas. So those would be the OSA signs and symptoms. Those were associated in one of these studies with a 73% greater incidence of first onset TMD as compared to controls. And then another one of the studies showed that chronic TMD was more than three times as frequent among adults with high relative to low risk for sleep apnea. So there seems to certainly be a relationship or a correlation between sleep apnea and TMD. So from this study, just picking one subset of data here the prospective cohort study of first onset TMD. So they took just over 2,700 healthy men and women around 18 to 44 years of age. They followed up just under three years and found that 260 patients developed first onset TMD. So there's an average annual incidence rate of 4% in this group. And the key findings from the study were that health status variables were most strongly linked to TMD incidents. And these included the presence of other regional pain disorders primarily. So things like headache, irritable bowel syndrome, low back pain, genital pain. So patients self-reported their poor health were also, they performed basically a global self rating of overall health. And that was also found to be a strong predictor. And so this is something that, again, is kind of lines up with our view of TMD as a functional pain syndrome in alignment with a number of other chronic pain disorders like chronic migraine, fibromyalgia, those sorts of things. We've seen especially chronic pain or chronic TMD patients. We know that when we look at their health history, we see a lot of circles on their review systems. And then they also noted that there was a strong link with psychological domains and clinical or facial pain domains with first onset TMD. So 2014, Dr. Schiffman from Minnesota, he published the DCTMD, which was an expansion of the RDC TMD. And it was geared more for clinical application. Just wanted to share just a few pictures here. So this is when I mentioned before the AXIS-1 and AXIS-2. These are good papers to reference if you're ever interested in being a little bit more regimented with your TMD exams. AXIS-1, again, being those clinical TMD conditions and then AXIS-2 being the more psychological testing measures. So this is all kind of just helping us further taxonomize our TMD patients and get to a point where we can have more predictable outcomes, which are linked specifically to more accurate diagnoses. 2017, there was a paper from Manfredini, which was a review looking to answer the question, is there any association between features of dental occlusion and temporomandibular disorders? So in this paper, they looked at 17 articles comparing TMD patients with non-TMD individuals and eight papers comparing features of dental occlusion in individuals with TMD and healthy subjects in non-patient populations. They showed correlation. They looked at over 40 occlusal factors and found that there were two that were correlated in over 50% of the studies. And even in those cases, the authors concluded that the correlation in those two occlusal features was not enough to show causation. In fact, they felt those occlusal features or that malocclusion could have been actually the result as opposed to the cause of those patients' TMD. And so ultimately the findings supported the absence of a disease-specific correlation between TMD and dental occlusion. So where are we now? So we'll jump ahead to 2020. The National Academy of Science, Engineering, and Medicine reports on TMDs, recommended that all dental and medical schools include TMD in their curriculum. CODA, they said, should amend the accreditation standards for pre-doc dental programs to include the screening risk assessment and appropriate evidence-based interventions for TMDs. So this was a really important paper. Shortly after this, actually the ADA recognized orophacial pain as a specialty, like within months. CODA subsequently approved a revised standard to include TMD education pre-doc curriculums of all U.S. dental schools by 2022. In 2021, so based on the goals from the NASEM's paper and the plan for CODA to amend their standards, the AOP developed a committee on pre-doc education and a few excerpts from their proposal. They said that the disease model for TMDs is changing from a dental-based biomechanical model to a whole person biopsychosocial model. And current evidence indicates the TMD management should be and therefore is moving toward multidisciplinary care. So this is basically an acknowledgement that we need to approach these patients with humility as dentists and understand that in the majority of cases, we can't do it ourselves. We need to rely on our colleagues in physical therapy and pain management and health psychology in order to provide these patients with the best care. They also went on to say that our understanding of TMDs regarding basic and clinical science is still evolving. And when evidence on an evaluation method or treatment approach is lacking, the principle of do no harm should be followed. And so this is sort of another way of saying that conservative treatment approaches should be prioritized in most of these patients. So the revised standard came out in 2022 and this is what it says. So at a minimum, graduates from dental school must be competent in temporomandibular disorders. So obviously, as you can see here, CODA does not mandate how these standards are defined, implemented or assessed. And so the main limitation from a high level view from an orophacial pain specialist and somebody who wants to disseminate knowledge on evidence-based treatment in these cases, the main limitation is that the new standard is the main limitation of this new standard is that you're kind of handcuffed by the training and the philosophy of the faculty at your dental school. And so there's a lot of revolving doors in dental school faculty, a lot of turnover, and there's quite simply just a lot of differences in philosophy in this field, depending on which region of the country you are in. And so this ultimately is gonna result in students or graduates from dental school not being well calibrated in terms of, you know, having similar understandings as they graduate from dental school with regard to TMD specifically. So in March, 2022, the ADA recognized the American Board of Orophacial Pain as the national certifying board of the specialty. This is a group kind of closely affiliated with the AOP. There are currently 13 CODA accredited advanced education or facial pain programs graduating a total of about 25, maybe slightly more specialists per year. Now, obviously you don't need to be a specialist to treat these patients. You know, and I think it's important to note also just taking a step back that, you know, graduating as an orophacial pain specialist is not just focusing on TMD. We deal with a number of other, you know, orophacial pain diagnoses, neuropathic pain, headache management, neurovascular pain disorders, movement disorders, and all sorts of these other issues. So these graduates are coming out well-equipped, but they are being trained based on the most evidence-based treatment philosophy. And so, you know, ultimately the point I guess I'm trying to get across as I ramble here is that clearly there aren't enough specialists as the specialty is in its relative infancy. So this kind of, this makes it, in my opinion, that much more important to improve the education of dental students and the dental profession as a whole on evidence-based best practices for TMD. All right, so this is a cheesy segue into the next segment of the talk. So every one of us as dentists goes to work each day with a toolbox, right? So the toolbox is made up of skills, knowledge, and beliefs that we've accumulated from years of ongoing education, personal experiences, and clinical experiences, both successes and failures. I think an ideal goal for our profession is to have every dentist's toolbox as standardized as possible, where every clinician offers the most evidence-based treatment for each patient for their particular diagnosis, understanding obviously that each dentist is going to have their own clinical interests and we're not all going to be experts in everything. Obviously, though, this is easier said than done. And the dental education, you know, is geared more towards certain areas of care than others, as we know, you know, with TMD being maybe less taught in dental schools than, you know, your drill-and-fill dentistry, your prosthodontist, your orthodontist, those sorts of things. So in the case of TMD and orophageal pain, our profession, in my opinion, continues to kind of strive towards a more standardized toolbox. And it's unrealistic to expect, obviously, that all of us are going to be clones in terms of our treatment approaches, but the degree of variability in our understanding of TMD and philosophy related to treatment does have a huge effect, not only on us as a profession, but on the public. And so that's what I want to spend a little time on here now. So the talk was titled Paradigm Traps of TMD. So I want to talk about some of the paradigms that I see in my community. And I'm sure I'm not capturing all of them, but these are some of the more common ones, right? So the biopsychosocial model, obviously we've spent enough time on that. You guys are probably sick of hearing me say biopsychosocial. So this is the conservative, multidisciplinary, and evidence-supported treatment approach. And then we have the biomechanical or mechanistic model, which is going to be more focused on occlusal disharmony, ideal condylar position, phase one, phase two treatment, as in the case of neuromuscular dentistry. I'm well aware that this is still a popular philosophy among many practitioners across the country. I, in the last six months, did a talk to a local dental organization, and I was confronted afterwards by an area prosthodontist and orthodontist claiming that they have a 100% success rate in treating TMD pain through CRCO or CRMI equilibration. And so there are people who feel very passionately one way or another about this. And I think it's going to be probably still a while until all sides are sort of aligned, especially with these top two bullets. Other models here, I kind of coined this one size fits all model. The first would be like TMD equals bruxism equals OSA. And we know that there are relationships certainly between these conditions or symptoms, right? So TMD we know is correlated, as I mentioned earlier, from the OPRA study with sleep apnea. We know that patients who have sleep apnea are more likely to have bruxism issues. There's actually maybe surprising to some, not a ton of evidence for a strong correlation between TMD and bruxism. But what I've seen in my community anyways is that there are some doctors who will see a patient who has TMD symptoms, and they could be chronic debilitating, they could be as mild as a click, and they will get treated as if they also have concurrent bruxism and sleep apnea. And meaning that regardless of risk factors, regardless of history, they're going to get a sleep study. And in some cases, patients will actually get a mandibular advancement appliance when they were only seeking to be treated with or treated for their TMD symptoms. And so I think that there's a problem here that we're just kind of, we're not giving ourselves a chance to critically think and give the patient and treat the patients, you know, for their goals, right? They come in looking for one treatment and we end up sending them down kind of a rabbit hole with other referrals. And I think problems can come from that both financially and obviously in the side effects of the treatment that you're offering. So again, not discounting the relationship between these conditions, but I think we need to, you know, think critically also. Botox is another one that kind of falls into this one size fits all model. There are a lot of dentists who, anytime they see a patient with TMD pain or dysfunction, will give them Botox because that's the tool that they have in their toolbox. And I've, you know, I use Botox in my practice. I've had quite a bit of success with it, but I think it, you know, again, we need to critically think about the patients that we're offering that treatment to because it's not for everybody. And then TMJ surgery. So obviously TMJ surgery is appropriate in some cases, yet I still feel it's in many areas still over and prematurely utilized. The reason for this is variable. This could be philosophical that, you know, people think, you know, they've got TMJ dysfunction. This should be first treated surgically, which is a little bit of an outdated mindset, not supported by evidence. But I think another reason some communities could also be lack of access to care to practitioners who treat these issues conservatively. So examples of this would be things like disc repositioning procedures, condylotomy, and a discectomy, all as options to treat an early, as early treatment for disc displacement. So, you know, we know that disc displacement's present in 30%, I mean, a third of all people, you know, unless it's associated with pain or dysfunction, probably doesn't need to be treated, but we will still see patients getting surgical consults and surgical treatments early on in these cases. So these are some of the, and I'm sure, as I said, there are probably many more, but some of the prevalent paradigms in existence today. All right, so this paper came out last year, and it was a really, I think, important paper out of the Journal of Oral and Facial Pain and Headache titled, Overtreatment Successes, What are the Negative Consequences for Patients, Dentists, and the Profession? And so the paper highlights some of the current philosophies that I just mentioned in the world of TMD treatment, specifically focusing on the topic of overtreatment. So the author's kind of highlighted the fact that just because patients improve with treatment doesn't make that treatment necessary or a success. So particularly in the case of TMD, which often improves on its own, as we know, without treatment, if given enough time. In other considerations, you also have, you know, the possibility of a placebo effect where, you know, if you have a patient who's suffering and in pain, any intervention that you offer will likely result in some sort of symptom relief because they feel validated, vindicated, and that they're given something, right? And so I think it's natural as a provider to feel, you know, like vindicated and like you're a success when a service that you offer, a treatment that you offer, results in a positive outcome. It's a normal human feeling. But we need to understand our duty to the public is to offer the most evidence-based treatment approaches to our patients. And there have been and will continue to be patients whose TMD symptoms improve with things like TMJ or pre-mature TMJ surgery, or with phase one, phase two treatment approaches and so forth. But the bigger question I think we need to ask ourselves is do those individual examples justify using this as a standard treatment approach? Or is this just, you know, our confirmation bias that we're using to justify making that as our standard practice, right? And so the authors sort of discussed the detrimental, the potential detrimental consequences that can come from patients who don't see their symptoms improve with more aggressive, you know, treatment approaches that they consider over-treatment. And this can be both in the form of, you know, higher financial costs incurred, time spent in treatment, and also, you know, in some cases, in many cases, seeing their symptoms persist or significantly worsen. So from this study, or I shouldn't call it a study, from this paper, they discuss the impact of over-treatment on the patient. Some examples of this would be expenses are much greater, length of treatment can be much longer, as I mentioned. There's a risk of significant discomfort due to the more invasive nature of treatment and potential for post-operative pain, especially if we're, you know, starting to do, get into prosthodontic treatment, you know, selective endodontic treatment, those sorts of things. Altered chewing and phonetics, given the new position of the mandible. Treatment ultimately is irreversible, so it can't be undone. And I think just, you know, a big one here is that we're sending the wrong message to the patient. So the message that should be conveyed to the patient in modern medicine is that the health of the patient is a collaborative effort between the doctor and the patient. And in cases of over-treatment, the patient sort of ends up looking to the doctor to fix their condition, which, you know, in the world of TMD, especially as cases become more complex and chronic, it just ends up being a recipe for disaster. So the authors also discussed how differing TMD ideologies affect the dentist and the dental profession as a whole. So as examples, or as one example, we've all seen, you know, the news in the past year. We've seen a number of articles come out in media shedding light on high costs of TMD treatment, horror stories and irreversible harm that's caused by these treatments. So ultimately this publicity leads to, I think a general skepticism among not only the public, but other medical colleagues. And so this harms us as treating providers, right? As well as the patient clearly. So as these stories continue to come out, we kind of, it's natural for us to start to feel like we're fighting an uphill battle trying to provide evidence-based treatment. So ultimately, it doesn't necessarily benefit any of us. And so I think with that, what we'll do is we'll sort of start to segue here into evidence-based treatment strategies. So I mentioned that one size fits all model. So another cheesy meme here. No two TMD treatments are the same. So ultimately there can't be a universal TMD treatment algorithm, or at least if there is one, we don't have access to it yet with what we know. There are many tools at our disposal, as we'll touch on in the coming slides here as clinicians to help manage these patients. And it's really our responsibility to understand the evidence for these treatment options and to then select the right options for each patient while taking into consideration a number of factors. The most important, in my opinion of which, is the patient's treatment goal. And so I ask at the end of my history for every new TMD patient, I ask the same question, which is, what is your goal with treatment? I think it's a really good exercise if you haven't done it already, because what you'll find is that patients vary substantially, not only in their presentation, but also in what their goals and expectations are with the treatment. So a simple example of this could be a 45-year-old female patient who comes in with a, she's got a bad bite, she's got a unilateral crossbite posteriorly, she's got jaw pain, she's a Bruxer, she's got headaches, she's been clicking for years, but it's getting painful, and she has trouble opening, right? So she's this typical TMD patient who finally makes it into your tertiary care practice with a number of classic TMD symptoms. So come to find that she just got a new job, she's got increased stress in her life, she lost a loved one recently, and her symptoms have kind of gotten to the point where now she's again seeking your care. So if you ask this patient what her goals are with treatment, depending on the patient, you're gonna get a ton of different answers, right? They've got so many symptoms that could be treated and everyone's threshold for these symptoms is different and their expectations are different. So she could tell you that she only wants to decrease her headaches, right? And that's gonna educate you or that's gonna kind of steer the way that you treatment plan for her. Maybe she tells you she wants to get rid of her clicking and protect her teeth from grinding. Maybe she tells you that she wants not only to stop the grinding, stop her jaw pain, fix her headaches, but she also wants her bite corrected. And so we need to take into consideration the patient's goals when we're treatment planning for them. And so the tools that we'll talk about here, the evidence-based treatment strategies in the coming slides are really sort of a, they're menu items, right? So I describe that to patients when I see them, that they have a large, a substantial menu. Some of those menu items are more evidence-based than others. We all have our favorites that we kind of lean on and our preferences based on our past experiences and our comfort level. But ultimately we have to listen to the patient's goals to help steer them towards which menu items are probably most likely to take them across the finish line. And so, like I mentioned, we've got a lot of different options here and I wanna jump into those now. And so for every TMD patient that we see, and this is sort of pretty basic, right? But we're gonna educate them on their condition and then we're gonna go over self-care, right? So things like posture, both sleep and awake posture, oral parafunctional habits, gum chewing, caffeine intake, right? Muscle tensors, those sorts of things. A lot of patients aren't aware of the driving forces of their pain, right? And so we need to make them very aware of these issues. And so I offer all of these patients both verbally and in writing information at that first visit. Then we're gonna talk about, in many cases, psychological treatment approaches. So if we're gonna be following the biopsychosocial illness model, we need to be taking not only a bottom-up approach to treatment, but a top-down approach to treatment. And so this isn't necessary for every single patient that we see, but as patients' symptoms become more chronic, more complex, as they have more chronic overlapping pain disorders, as they have comorbid psychological diagnoses, it becomes more and more incumbent on us to be mindful of the top-down component of their pain. And so we have resources in medicine, health psychologists, pain psychologists, people who are experts in helping patients manage the top-down components of their pain and help them, help give them the tools and build up their resilience so that they don't allow external stresses in their life to manifest in physical tension that presents above the shoulders in many of our patients' cases. So other evidence-based treatment strategies, physical therapy, manual therapy, home exercises, all very well-researched, these are conservative approaches in most cases and extremely effective. In our practice, I see a lot of TMD or facial pain patients. We have physical therapy as part of our program and we would not be able to have nearly the successful outcomes that we do without our physical therapists. It's just, it's as simple as that. A lot of the patients that we see benefit probably more from what the PT does for them than, you know, any appliance that I'm gonna make for them or any treatment that I'm gonna offer them. So it's really important that we lean on these skilled specialists also. You know, as I said earlier, there's varying levels of evidence for some of these more, I call them evidence-based treatment strategies, but low-level laser therapy, there's sort of low to moderate evidence for it. It's been more and more researched of late. It is a conservative treatment approach. So it's something that has shown some potential efficacy, some promise, it can help improve the emotional and psychological aspects of pain for sure, just by again, maybe giving them some treatment, some fix and potentially part of that's placebo, but there does seem to be some therapeutic benefit there as well. Occlusal appliance therapy. So we're all pretty familiar with this. There's a ton of different options as far as designs go that we can utilize. Evidence for the positive impact of splint therapy in TMD is actually mixed, surprising to some. So some studies suggest there's a positive impact on TMD pain. Others suggest there's no clear superiority with splint therapy as compared to physical therapy. So I'd say anecdotally, I do definitely believe there's a value in splint therapy, but it's generally, I think, most effective when used in combination with other conservative evidence-based treatment strategies, such as physical therapy and top-down approaches like stress management techniques and those sorts of things. And that's especially the case as pain becomes more chronic. The more chronic the pain presentation is, the less effective acrylic therapy in and of itself is going to help. So as far as the design of an appliance goes, many different types, obviously the most common being in the lower left, the hard full coverage stabilization appliance. Other designs can be useful in certain indications. It's just really important to be mindful of the potential side effects, especially as we reposition the jaw on some of them. And in cases where we're not covering all of the teeth, we open up the door for potential occlusal changes. So we need to be cognizant of that. Injections are a common part of evidence-based practice. So intramuscular injections could be things like trigger point injections, Botox injections I mentioned. There's some mixed evidence for Botox. I've had success with it when used in certain cases for sure. Acupuncture. So acupuncture is a conservative treatment approach, you know, a fairly conservative treatment approach. Obviously there's needles involved, but this has been going on for practice for over 3000 years now, can be used for TMD cases. I've had a number of patients benefit from it. There was a systematic review last year showing I think 20 to 30 studies, and they did find a positive impact in TMD pain with acupuncture, but did admit that the quality of evidence was low. And dry needling is another modality used by some physical therapists and chiropractic specialists. Intraarticular injections can be utilized in some cases, both diagnostically and therapeutically. There's growing evidence for certain types of intraarticular injections. Things that come to mind are dextrose or prolotherapy. There are, you can do intraarticular steroid injections in select cases, hyaluronic acid, PRP. These are, you know, we don't have time to dive into the evidence of each of these procedures during this talk, but there are a number of different techniques coming out now. Orthocentesis, this is a minimally invasive surgical treatment approach, which can be useful in patients with arthritic conditions or disc displacements with and without reduction. And we also have medication management of our TMD patients, including anti-inflammatory medications, muscle relaxants, antidepressants, anticonvulsants. So some of the latter cases are useful more when there's comorbid psychosocial conditions, or when there's more chronic widespread pain or neuropathic pain in addition to TMD. That's not as much the focus today. And then TMJ surgery. So talked briefly there about arthrocentesis, but other surgical approaches are also available to patients with refractory pain, dysfunction, or severe arthritic conditions. These would include things like what you see here in this picture, which is a total joint replacement, but also arthroscopy, discectomy, a condylectomy, lots of different other approaches. Now, there's not a ton of oral surgeons in most regions that treat these conditions. So you'd wanna make sure if you're sending a patient for surgery, that you're finding somebody who has quite a bit of experience in this area, because it's not a very common practice. All right, so in summary, the field of orophacial pain is evolving along with our understanding of how to best diagnose and manage patients with TMD. The biopsychosocial model of care is currently the accepted evidence-based treatment philosophy for management of TMD and other orophacial pain disorders. As a profession, efforts are being made to calibrate providers who manage TMD patients through increased undergraduate and graduate dental education. And recognition of the orophacial pain specialty is an important step towards increasing access to evidence-based care for this patient population. And I believe that is all I have for you guys tonight. Thank you. All right, beautiful, beautiful topic, Dr. Baek. So to our audience, if anyone has any question for our speaker, please submit your question using the Q&A button on the bottom of the screen. I see two questions so far. I'll be reading them to you. Also, in some instances, if you have any questions, I may be able to answer that. And also, I wanted to, before we start with the questions, I think you mentioned on the OPERA study that a 260 patient over 2.8 years study that was conducted and was, I think you answered my question, but on your patient, do you find any relationship with an OSA and the TMD, whether clinically or based on the OPERA study? Clinically, for sure. I mean, we see a lot of crossover. We have a lot of patients who come in with chronic TMD conditions. And as we were doing our screening, we've come to find that they have a lot of risk factors for sleep apnea, and this is obviously anecdotal. The data from the OPERA study kind of speaks for itself. But yeah, there's a ton of overlap between the two patients. We have a number of patients where we've treated their TMD and we subsequently, you know, come to find through referrals and diagnostic studies that they have apnea and we end up converting them over to kind of a two birds, one stone approach with an MAD. Okay, beautiful. So let me go to the first question is by Ryan. He's asking, do you bill pain to medical insurances? Yep, yep. So I am a dentist, but we bill purely medical in our practice. So we essentially function as a medical practice. Beautiful. Question number two, well, let's see. Question number two, how do you make a patient understand that a guard bought on Amazon, for example, cannot possibly cure the bruxism at two patients locking their jaw while using over-the-counter night guards? Yeah, so this is a great question. You know, I think curing bruxism is, we need to be careful with how we verbalize that because even a custom appliance isn't gonna cure bruxism. Most of our patients will still brux on a custom appliance. Now their risk for that type of dysfunction with locking and significant pain, I would say as well as the risk long-term for occlusal side effects is gonna be substantially less with a custom appliance that's, you know, well-adjusted by the dentist as compared to an over-the-counter appliance. But yeah, we've seen, you know, we see that all the time where patients, you know, try to take maybe the less costly route, try to self-treat, and it sometimes gets them into more trouble, unfortunately. Yeah, you're absolutely right, I agree. Next question is how do you choose a psychotherapist? Yeah, great question. So sometimes you have to ask around. Now there is a website and I can look it up. I think that it's a bunch of letters. It's the PTBCTT or something like that, but it's a PTBCTT. Yeah, so this is PTBCCT, and this is a website with a directory of physical therapists with special training in orophageal pain disorders. So you can try to find somebody who's credentialed with them in your area. Otherwise, you know, call around, you know, do some Google searching, speak to the people, the physical therapists in your community, see how they've been trained. And I think as you develop those relationships, you share patients, you'll start to kind of figure out who you like and, you know, who you want to stay away from. Okay, beautiful. Now Jerry is asking, you only briefly mentioned chiropractic treatment. I have had several patients find a significant relief with chiropractic treatment. Yeah, no, I think a good chiropractor can be really, really helpful for TMD patients. There's more, if we're looking at the evidence, there's more research and more evidence for the benefit of physical therapy. Just in terms of the way that I look at it as chiropractors, oftentimes it's more of a, you know, it's a fix. You go in for your weekly or every other week appointment, you get your adjustment, you feel better, but then you need to keep going back. And the difference tends to be with physical therapy. And this is obviously not across the board. There are awesome chiropractors that give patients the wings to be independent and give them the skills to manage their symptoms on their own. But in general, I think a lot of physical therapists, you know, tend to try to promote independence with the patients as opposed to needing them to keep coming back long-term. Beautiful. I already know what you're going to say on this question, which I agree with you, but yes, I would say yes. The question is, I think one important objective consideration on any TMD patient is to either rule out or diagnose any possibility of cellular distorted breathing. Yeah. So I absolutely screen every patient, every orophageal pain patient, every TMD patient, especially with, or I screen them for sleep apnea. Now I will ask questions about their sleep quality. You know, do you snore? Or is your sleep fragmented? How is your sleep quality? Ask them if they have ever had a study done, if they're bothered by their sleep, all those important questions to ask. Now, the fact is some patients are more at risk, have more risk factors for apnea than others. We'll look at anatomy too, do the malaparty classification, all that important stuff. But if a patient tells me that they have no concerns with sleep, they've never had issues with snoring, they feel great throughout the day, they have low risk anatomically, but they're coming to see me because they have a disc displacement. I have no real necessity in my mind, or I have no drive or motivation to send them for a sleep study, just to rule that out. So that's my philosophy personally, I'm not gonna send every patient for a study, but I do screen them in my own way. Okay, I think we're running out of time, so I'm only gonna answer the next three questions. So Anita wants to know, do you use laser? If so, what laser do you use? I have used a laser, we have five offices around the Milwaukee area, one of our offices has it, it is an MLS laser, I can't remember the specific name for it, but I haven't used it recently, I did have some success with it, it's used more by our physical therapy team now, and so I would have to walk upstairs to get it, and so I don't use it as often. Last two questions, tell us about your interlink between the sleep and TMD, do you ask for polysomno for all cases of TMD? Yeah, so I just answer that one, no, I don't, but when it's indicated, when there's risk factors, then I often do refer patients for sleep evals. Beautiful, all right, and the last question of the night, I have a patient has a chronic TMD condition, bilateral no clicking, limited opening, no glide along articular eminence, and the pain with opening has their end point, so the question is, a patient has a history of mixed martial arts, multiple concussion, I noticed that there seems to be no master of function, what might be the problem? Yeah, so that is a, I think there's probably a lot to dig into there, I'd need to know a lot more about the history, first of all, is there a history of clicking and that stopped and now they're limited, we wanna rule out, is this a disc issue, is this more of a muscular issue, when we say there's no master function, some patients you feel their masters as they clench and you can, your finger moves an inch and some patients they clench and you barely feel it and that sometimes depends on the build of the patient, so I'm assuming this isn't anything more serious neurologically, with their motor system, but this could be a, with their history of trauma, most likely I would say, if they're that limited, there's no translation, maybe they're a closed lock, but you could assess better with maybe getting an MRI. Right, well, definitely a CVCT will help in that case as well.

TMD

webinar

AADSM

evidence-based

biopsychosocial model

occlusion

conservative treatments

historical perspectives

multidisciplinary

holistic approaches