Current Evidence for Ethical Treatment of TMD

Current Evidence for Ethical Treatment of TMD

Diagnosis and Treatment of Temporomandibular Disorder: An Ethical Analysis of Current Practices.

Reid KI, Greene CS:

J Oral Rehabil 2013; 40 (July): 546-561


The current literature supports conservative and reversible treatment for temporomandibular disorders, with expensive and invasive changes to the occlusion and jaws showing no additional benefits in most patients.

Article Reviewed: Diagnosis and Treatment of Temporomandibular Disorders: An Ethical Analysis of Current Practices. Reid KI, Greene CS: J Oral Rehabil; 2013;40 (July): 546-561.

Background: Clinical management for temporomandibular disorders (TMDs) varies widely based on the training and treatment philosophies of different dentists, ranging from inexpensive and conservative techniques to costly and invasive treatment for the same symptoms.

Objective: To suggest an ethical framework for the treatment of TMDs based on current scientific literature.

Design: Retrospective review.

Methods: The methodology for article selection was not described, but 131 current scientific articles found on PubMed (November 9, 2009) were included.

Results: The current literature has repeatedly shown that TMDs are often self-limiting and generally not progressive (although symptoms may fluctuate over time). Cases most frequently occur in women between 15 and 45 years of age. Occlusion, maxillomandibular relationships, condylar position, and other structural factors generally do not cause TMD. Additional diagnostic aids such as electromyography and electronic jaw tracking have not been found to have the sensitivity and specificity to add diagnostic value. Many patients have been shown to have significant improvement in TMD solely by proper explanation of the issue, good pain management, home self-care, and possibly splint therapy. This biopsychosocial medical model for treatment differs greatly from many older invasive treatment techniques, such as occlusal equilibration, orthodontic treatment, bite opening, prosthodontic treatment, or surgical intervention. These techniques are based on the belief that static and dynamic occlusion relationships are the primary etiological factors of TMD, which is not supported by the current literature.

Conclusions: Multiple systematic review articles have shown that conservative and reversible management of TMDs can successfully treat most cases. There is no evidence to justify routine initial treatments that are invasive, irreversible, and expensive. With this evidence, the ethical principles of respect for patient autonomy and non-malfeasance support proper patient education about current scientific evidence and providing conservative, reversible initial treatment for TMD.

Reviewer's Comments: As orthodontists, we routinely work to create ideal occlusion, and it can be difficult to see a malocclusion and not associate it with a patient's TMD. This article has some very nice tables summarizing the evidence of multiple systematic reviews. When considering this evidence, it is hard to justify orthodontic treatment as a first line of care in cases in which TMD is the only concern.(Reviewer–Brent E. Larson, DDS, MS).

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