Temporomandibular (Craniomandibular) Disorders
The American Dental Association developed these dental practice parameters for voluntary use by practicing dentists. The parameters are intended, foremost, as an aid to clinical decision making and thus, they describe clinical considerations in the diagnosis and treatment of oral health conditions. Evaluation in the context of these parameters includes diagnosis.
Additionally, parameters will assist the dental profession by providing the basis on which the profession's commitment to high-quality care can be demonstrated and can continue to be improved.
The dental practice parameters are condition-based, presenting an array of possible diagnostic and treatment considerations for oral health conditions. Condition-based parameters, rather than procedure-based parameters, were determined to be the most useful because this approach recognizes the need for integrated treatments of oral conditions rather than emphasizing isolated treatment procedures. The parameters are also oriented toward the process of care and describe elements of diagnosis and treatment.
While the parameters describe the common elements of diagnosis and treatment, it is acknowledged that unique clinical circumstances, and individual patient preferences, must be factored into clinical decisions. This requires the dentist's careful professional judgment. Balancing individual patient needs with scientific soundness is a necessary step in providing care.
It is understood that treatment provided by the dentist may deviate from the parameters, in individual cases, depending on the clinical circumstances presented by the patient. This should be documented and explained to the patient.
The elements of care that are described in the parameters were derived from a consensus of professional opinion. This consensus included expert opinion on the topic and the clinical experience of practicing dentists. In addition, the research literature, and parameters and guidelines of other dental organizations were reviewed.
The American Dental Association recognizes that other interested parties, such as payers, courts, legislators and regulators may also opt to use these parameters. The Association encourages users to become familiar with these parameters as the profession's statement on the scope of clinical oral health care.
However, these parameters are not designed to address considerations outside of the clinical arena and, therefore, may not be directly applicable to all health policy issues.
Furthermore, these parameters are intended to describe the range of acceptable treatment modalities. They are intended as educational resources, not legal requirements. As such, the parameters are not intended to establish standards of dental care, which are rigid and inflexible, and represent what must be done; nor are they guidelines which are less rigid, but represent what should be done; nor are they intended to undermine or restrict the dentist's exercise of professional judgment. In this context, considerable thought was given to the use of the verbs "may," "should" and "must." The verb "may" clearly allows the practitioner to decide whether to act.
The verb "should" indicates a degree of preference and differs in meaning from "must" or "shall" (which require the practitioner to act).
Throughout the parameter document, "dentist" refers to the patient's attending dentist. Additionally, elements of the parameters concerned with patient consent refer to the patient's parent, guardian or other responsible party, when the patient is a minor or is incompetent.
The Association intends to continually develop, revise and maintain parameters, in order to include all dental conditions and to accommodate advances in dental technology and science.
Adopted 1996, Revised 1997
The key element in the design of this set of parameters for temporomandibular (TM) disorders is the professional judgment of the attending dentist, for a specific patient, at a specific time.
The patient's chief complaint, concerns and expectations should be considered by the dentist.
Following oral evaluation (see limited, comprehensive, periodic, detailed and extensive evaluation parameters) and consideration of the patient's needs, the dentist should provide the patient with information about TM disorders prior to obtaining consent for treatment.
The dental and medical histories should be considered by the dentist to identify medications and predisposing conditions that may affect the prognosis, progression and management of TM disorders.
The dentist should consider that TM disorders are characterized by craniofacial, musculoskeletal, stomatognathic and/or dental interrelationships, and/or psychological influences that are dynamic throughout life and that the etiology of TM disorders may be multifactorial.
The dentist should consider a differential disease classification that may include neuromuscular pain, myofascial pain, neurogenic pain, neurovascular pain, sympathetic and/or referred pain involving the trigeminal and/or oropharyngeal systems, or other medical conditions, which may contribute to or mimic TM disorders.
Following oral evaluation (see limited, comprehensive, periodic, and detailed and extensive evaluation parameters) and consideration of the patient's needs, the dentist is responsible for providing the patient with information about the nature of TM disorders prior to obtaining consent for treatment.
The dentist should consider that TM disorders may be self-limiting, episodic and/or progressive and may recommend that the patient return for further evaluation. The frequency and type of evaluation(s) should be determined by the dentist, based on the patient's risk factors, and the nature and severity of the patient's disorder.
When the dentist considers it necessary, (an)other health care professional(s) should be consulted to acquire additional information.
The dentist should refer the patient to (an)other health professional(s) when the dentist determines that it is in the best interest of the patient.
Craniofacial relationships, musculoskeletal relationships, and the status of the temporomandibular joints, should be considered by the dentist in developing a treatment plan.
Factors affecting the patient's speech, function, and orofacial aesthetics should be considered by the dentist in developing a treatment plan.
The behavioral, psychological, anatomical, developmental and physiological limitations of the patient should be considered by the dentist in developing a treatment plan.
Restorative implications, pulpal/endodontic status, tooth position, and periodontal status and prognosis should be considered in developing a treatment plan.
The dentist may counsel the patient concerning the potential effects of the patient's health condition, medication use and behaviors on his or her oral health.
The dentist should counsel the patient that TM disorders are often managed, rather than resolved, and that symptoms of TM disorders may persist, change, or recur intermittently.
The patient should be informed that the success of treatment is often dependent upon patient compliance with prescribed treatment and recommendations for behavioral modifications. Lack of compliance should be recorded.
Medications should be prescribed, modified and/or administered for dental patients whose known conditions would affect or be affected by dental treatment provided without the medication or its modification. The dentist should consult with the prescribing health care professional(s) before modifying medications being taken by the patient for known conditions. (See: ADA Statement on Antibiotic Prophylaxis, Prevention of Bacterial Endocarditis: A Statement for the Dental Profession (PDF), and A-Z Topic: Antibiotic Prophylaxis.)
After consideration of the individual circumstances, the dentist should decide whether the TM disorders should be monitored or treated.
Following evaluation, treatment priority should be given to the management of pain, infection, traumatic injuries or other emergency conditions.
The dentist should recommend treatment; present treatment options, if any; and discuss the probable benefits, limitations and risks associated with treatment and the probable consequences of no treatment.
The dentist should treat patients for TM disorder only when there is associated craniomaxillofacial pain and/or functional impairment.
Initially the dentist should select the least invasive and most reversible therapy that may ameliorate the patient's pain and/or functional impairment.
Any treatment performed should be with the concurrence of the patient and the dentist. If the patient insists upon treatment not considered by the dentist to be beneficial for the patient, the dentist may decline to provide treatment. If the patient insists upon treatment considered by the dentist to be harmful to the patient, the dentist should decline to provide treatment.
The dentist should evaluate the effectiveness of initial therapy prior to considering more invasive and/or irreversible therapy.
Before initiating invasive and/or irreversible therapy, the dentist should attempt to determine the likelihood of its therapeutic success.
Relevant and appropriate information about the patient and any necessary coordinated treatment should be communicated between the referring dentist and the health professional(s) accepting the referral.
The dentist should consider the individual needs and desires of each patient in selecting material(s) and treatment(s).
The dentist should emphasize the prevention and early detection of oral diseases through patient education in preventive oral health practices.
The dentist should determine the frequency and type of preventive treatment based on the patient's risk factors or presence of oral disease(s).
The dentist should be responsible for educating the patient about the increased difficulty of maintaining good oral hygiene when TM disorders limit the range of jaw motion, and for instruction in methods to achieve an appropriate level of oral hygiene.
The dentist should be responsible for educating the patient concerning self-management and the elimination of behaviors that may contribute to TM disorders.
The dentist should consider, and inform the patient, that treatment for TM disorders may include multiple phases of treatment and multiple health care disciplines.
The dentist should consider that TM disorders requiring treatment may develop at any time during an individual's lifetime, regardless of the patient's previous treatment history.
The dentist may prescribe or administer physical medicine (therapy) modalities.
The dentist should attempt to manage the patient's pain, anxiety and behavior during treatment to facilitate safety, efficiency and patient cooperation. (See: ADA Policy Statement: The Use of Sedation and General Anesthesia by Dentists and Guidelines for the Use of Sedation and General Anesthesia by Dentists.)
When articular derangement and/or condylar dislocation has been determined to be the etiology of the patient's pain and/or functional impairment, manual manipulation of the mandible may be performed by the dentist.
The dentist may prescribe and/or administer pharmacological agents.
The dentist should periodically evaluate the patient's medication regimen to determine the effectiveness and appropriateness of continued pharmacological therapy.
Oral orthotics (guards/splints) may be used by the dentist to enhance diagnosis, facilitate treatment or reduce symptoms.
The dentist should periodically evaluate oral orthotics (guards/splints) for their effectiveness, appropriateness and possible risks associated with continued use.
Before restorative and/or occlusal therapy is performed, the dentist should attempt to reduce, through the use of reversible modalities, the neuromuscular, myofascial and temporomandibular joint symptoms.
The dentist may replace teeth, alter tooth morphology and/or position by modifying occluding, articulating, adjacent or approximating surfaces, and by placing or replacing restorations (prostheses) to facilitate treatment.
Transitional or provisional restorations (prostheses) may be utilized by the dentist to facilitate treatment.
Intracapsular and/or intramuscular injection, and/or arthrocentesis may be performed for diagnostic and/or therapeutic purposes.
Orthodontic therapy may be utilized to facilitate treatment.
Orthognathic surgery may be performed to facilitate treatment.
When internal derangement or pathosis has been determined to be the cause of the patient's pain and/or functional impairment, arthroscopic or open resective or reconstructive surgical procedures may be performed by the dentist.
The dentist should communicate, by prescription, necessary information and authorization for the fabrication of the appliance(s) or prosthesis(es) to the dental laboratory technician. Although the fabrication may be delegated, the dentist is responsible for the accuracy and delivery of the appliance(s) or prosthesis(es).
The dentist should inform the patient that he or she should participate in a prescribed program of continuing care to allow the dentist to evaluate the effectiveness of the treatment provided and the status of the TM disorder.
Documentation of treatment provided, counseling and recommended preventive measures, as well as consultations with and referrals to other health care professionals should be included in the patient's dental record.