Summer 2000 Editorial:

Charles McNeill, DDS, and Patricia Rudd PT, of the UCSF Center for Orofacial Pain, presented to the Marin County Study Club this spring. Your editor was fortunate to be present. Dr. McNeill founded and has directed the Center since 1969. He has managed facial pain for thousands of patients, many of who have the intractable problems at which we private practitioners throw up our hands and then refer to the Pain Center. Ms. Rudd, who has been with the Pain Center since 1978, is a physical therapist who specializes in relief of facial pain.

The following are some highlights from the seminar discussion led by Charles and Patricia:

• The consensus is that there is a familial component to parafunction and TMD symptoms, but there is much variation in the symptoms each family member could experience.
• A team approach to TMD diagnosis and management was emphasized. Players include the dentist, physician, physical therapist, radiologist, and psychologist.
• Stress is a component, and so are alcohol, anti-depressants, and recreational drugs.
• Typically, orthodontists encounter musculoskeletal disorders with the following two general diagnoses:

  Articular Disorders

  • Disc derangement disorders -(most common)
  • Osteoarthritis with associated synovitis
  • Developmental disorders
  • Condylar dislocation
  • Ankylosis
  • Condylar fracture

Masticatory Muscle Disorders

• Myofascial pain: deep, achy pain with trigger points. Not inflammatory, patient may focus on a tooth
• Tendonitis: sharp pain with movement. Long lasting due to poor circulation
• Myositis: Muscle inflammation from over-use or trauma
• Contracture: usually after immobilization (post sx)
• Neoplasia

• Differential diagnosis red flag: If the patient eats normally, the pain is not a jaw function problem. Think systemic disease, tumor, or infection.
• Symptoms of TMD are most prevalent from age 20-45. Symptoms may drop off at 50 while parafunction continues.
• We can consider clicking in the joint to be a normal variation, since it is present in 60% of the population.
• Women suffer from TMD five times more than men, which is probably due to joint laxity and to estrogen.
• Ideopathic condylysis (typically in the 16-year-old female) can cause a severe open bite occlusion. Cause is unknown. Wait for completion of the cycle before beginning orthognathic correction. Verify the completion of the cycle with tomograms and/or a bone scan.
• In the normal symptom-free patient, the teeth are together only eight minutes a day.
• Soft splint vs. hard splint. While Okeson's study showed more clenching with a soft splint, Chuck thinks it was because the splints were not adjusted to occlusion of the lower dentition. The molar region of the splint for med a fulcrum for the jaw. He likes to use soft splints for clenching patients, but says it makes no difference.
• Use ice for the first 72 hours of a TMD episode, then switch to heat. Ice restricts swelling and inflammation. Heat washes out toxins.
• They have produced an excellent patient handout which explains heat/ice therapy. You can download it from the website http://itsa.ucsf.edu/~ucsftmd/self.htm
• Patty suggests a dixie cup of ice. In the shower, first heat the muscle, then rub it with ice, alternating several times.
• Advice to orthodontists about pain
  • Take a more complete social history. It helps patients to understand that stress is a factor. Encourage them to change their behavior.
  • If the patient experiences a TMD episode during orthodontic treatment, make a careful diagnosis. If it is a muscle disorder, advise relaxation, keeping teeth apart, and use of anti-inflammatories, ice, and physical therapy. Prescribe 0.5 mg of Flexaril. Use the splint as a last resort.

Click on the names of documents to view two documents we have used in our own practice. The first is a handout of self-help instructions for the patient, and the second is a permission form for the use of a TMD splint.

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