A Survey of the Management of Patients with Temporomandibular Disorders by General Dental Practitioners in Southern Brazil ´ Raquel H. S. Aldrigue, DDS,1 Alfonso Sanchez-Ayala, DDS, MS, PhD,1 Vanessa M. Urban, DDS, MS, PhD,1 2 Ana C. Pavarina, DDS, MS, PhD, Janaina H. Jorge, DDS, MS, PhD,2 & Nara H. Campanha, DDS, PhD1 1 2
Department of Dentistry, State University of Ponta Grossa, Ponta Grossa, Brazil Department of Dental Materials and Prosthodontics, Araraquara Dental School, University Estadual Paulista, Araraquara, Brazil
Keywords Temporomandibular joint disorders; dentist practice patterns; health care surveys. Correspondence ´ Alfonso Sanchez-Ayala, Department of Dentistry, State University of Ponta Grossa, Avenida General Carlos Cavalcanti, 4748, Ponta Grossa - PR, 84030-900, Brazil. E-mail: [email protected] The authors deny any conflicts of interest. Accepted July 30, 2014 doi: 10.1111/jopr.12255
Abstract Purpose: Temporomandibular disorders (TMD) are recognized as one of the most controversial topics in dentistry, despite the fact that both basic science and clinical researchers have currently reached some degree of consensus. This study aimed to conduct a questionnaire-based survey about the management of TMD patients by general dental practitioners (GDPs). Materials and Methods: One hundred fifty-one GDPs with a private practice in a city of southern Brazil were included, independent of school of origin, gender, graduation year, and curriculum content. All participants were administered a questionnaire about the management of patients with TMD, and the responses were analyzed by binomial and chi-square tests (α = 0.05). Results: Of the GDPs, 88.7% received TMD patients, who were primarily diagnosed on the basis of medical history (36.6%) or physical examination (30.4%). Of these, 65.4% referred the patients elsewhere, primarily to specialists in occlusion (36.1%) or orthodontics (29.7%). Occlusal splinting was the most commonly used management modality (20.8%), followed by occlusal adjustment (18.1%) and pharmacotherapy (16.6%). Splints were fabricated in maximum habitual intercuspation or centric relation depending on individual patient (54.8%). The hard stabilization form was the most common type of appliance used (35.0%). Moreover, 73.8% of the GDPs did not employ semi-adjustable articulators, and 69.5% adjusted the appliances at the time of fixing. The duration of splint use and the frequency of follow-up were considered patient dependent by 62.1% and 72.8%, respectively. GDPs considered the two major TMD etiologic categories as multifactorial (20.8%) and occlusion (19.9%). Multidisciplinary medical and dental treatment was considered necessary by 97.9%. Conclusions: The evaluated general dental practitioners manage TMD patients according to international guidelines.
The development of clinical dentistry requires the general dental practitioner (GDP) to be involved in more than just the diagnosis and treatment of diseases in the oral cavity. Dentists are increasingly responsible for the recognition and management of orofacial pain (OFP) and temporomandibular disorders (TMD) of the temporomandibular joint (TMJ) region, and disorders of the muscles of mastication and associated musculature.1 To determinate appropriate treatment strategies, GDPs should combine the patient’s treatment needs and preferences with the best available scientific evidence, in conjunction with their clinical expertise.2 Nevertheless, TMD are recognized as one of the most controversial topics in dentistry, even though both basic science and clinical researchers have currently reached
some degree of consensus.3 However, due to relatively longterm mainstream misconceptions within both dental education and clinical practice, evidenced-based diagnosis and treatment perspectives for TMD have failed to be adopted by much of clinical dentistry. The American Association for Dental Research (AADR) recommends that the diagnosis of TMD be primarily based on data obtained from the patient’s history, clinical examination, and, when specified, TMJ imaging findings.4 Standard medical diagnostics used for assessing analogous orthopedic, rheumatological, neurological, and psychosocial disorders may also be employed.5 In addition, it is strongly suggested that the initial treatment should be based on conservative, reversible,
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and evidence-based therapeutic alternatives unless there are specific and justifiable contraindications to the same. This is because the natural history of TMD suggests the tendency to improve or resolve over time, and conservative modalities are at least as effective in providing symptomatic relief as several invasive treatments.6 The Council of the European Academy of Craniomandibular Disorders also recommends an initial simple screening to detect the presence of a TMD and an assessment to establish a working diagnosis through general, maxillofacial, and oral histories and complementary imaging studies. This aids in distinguishing related head and neck medical disturbances and neurological and psychiatric conditions and in detecting the presence of psychosocial factors.7 Oral inspection should also rule out mucosal, dental, and periodontal diseases and evaluate the strongest occlusal factors and parafunction indicators. The diagnosis should identify the causes of TMD as specific or known (neoplasms, growth disturbances, systemic disease) and nonspecific (muscular, articular) related to occlusal overload or trauma, which impair the adaptation capacity of the joint.8 Patient referral to general or specialist medical practitioners when indicated is also recommended, as are general therapeutic modalities such as patient education, pharmacological therapy, occlusal appliances, physiotherapy, behavioral and psychological management, arthrocentesis, and eventual occlusal therapy such as prosthetic reconstruction, orthodontic therapy, joint surgery/orthognathic surgery, and arthroscopic surgery after pain relief.7 Despite the rationality of these suggestions, there are persistent disagreements within the practice community, probably because of the absence of a standard model for TMD education in predoctoral programs, nonadherence to a scientific protocol for patient assessment, absence of criteria for more accurate diagnoses and predictable treatments, and absence of a protocol for clinical research.3 Furthermore, the clinical sequence following the first visit of a potential TMD patient remains unknown, which may result in frustration among dental educators, confusion among students, and unfortunate consequences to patient care.3 An international survey conducted in 2013 showed that 76% of GDPs managed TMD patients, 97.6% used splints or mouthguards, 85.9% used selfcare, 84.6% used over-the-counter or prescription medications, 63.6% used occlusal adjustment, 53.2% used jaw exercises, and 35.0% referred patients to physical therapists.9 In southwestern Brazil, research performed in 2002 showed that 42% of the interviewed practitioners treated TMD patients with splints (19.2%), occlusal adjustment (16.3%), oral rehabilitation (12.8%), pharmacotherapy (10.0%), heat therapy (7.0%), relaxation techniques (7.0%), physiotherapy (6.4%), and diet counseling (6.4%).10 In an urban population in southwestern Brazil, at least one TMD symptom was reported by 39.2%, and pain related to TMD was observed in 25.6% of the sample.11 TMD patients treated in a conventional dental office are generally less complicated than referred patients in specialist centers, who are mostly characterized by chronicity, comorbidity, and complexity.7 According to the diagnosis, the dental surgeon has to decide when and how to treat or when and to whom to refer.9 To establish standard guidelines for the diagnosis and treatment of TMD, it is essential to know the current state of professionals in terms 34
Table 1 Frequency and percentages of the answers from each behavior question Questions B1 B2∗
B3∗
B4∗
B5∗
Answers
Frequency
Percentage
Yes∗ No Medical history Physical examination Imaging studies Study models Combination of these Refer to another dentist Offer treatment Refer to an academic institution Occlusion Orthodontics Prosthodontics Maxillofacial surgery Physiotherapy Neurology Otorhinolaryngology Occlusal splinting Occlusal adjustment Pharmacotherapy Counseling Oral rehabilitation Orthodontics Physiotherapy Diet plans Thermotherapy Another
134 17 141 117 78 34 15 119 50 13 96 79 32 19 17 12 11 84 73 67 52 43 35 18 14 13 5
88.7 11.3 36.6 30.4 20.3 8.8 3.9 65.4 27.5 7.1 36.1 29.7 12.0 7.1 6.4 4.5 4.1 20.8 18.1 16.6 12.9 10.6 8.7 4.5 3.5 3.2 1.2
*p < 0.05
of these issues. Therefore, the aim of this study was to elucidate the procedures employed for the management of TMD by GDP in a southern Brazilian city using a questionnaire-based survey.
Materials and methods Brazil includes almost 19% (251,587) of the dentists in the world. In southern Brazil, 16,285 professionals are registered in the Brazilian Federal Council of Dentistry, indicating an estimated proportion of 644,000 individuals per practitioner (I/P). Among these, there are 90 specialists in TMD and OFP. The city of Ponta Grossa, Paran´a, has 730 dentists (426 I/P), with 3 specialists in TMD and OFP (http://cfo.org.br). Also, many patients are treated by a GDP. On the basis of these indicators, a sample size of 300 dentists with a private practice in the city of Ponta Grossa who were not affiliated with any academic institution were included; this sample size is generally accepted for this category of study.10 Inclusion was independent of school of origin, gender, graduation year, and curriculum content. Initially, the researchers sought contact information such as office addresses, commercial telephone numbers, or work e-mails of dentists from nongovernmental dentistry associations based in Ponta Grossa. Data for GDPs serving in government agencies were obtained from the City Hall of Ponta Grossa. Moreover, additional contacts were made from private
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Management of TMD Patients in Southern Brazil
Table 2 Frequency and percentages of the answers from each splint question Questions S1∗
S2 S3∗
S4 S5∗
S6∗
Answers
Frequency
Percentage
Hard stabilization appliances Soft stabilization appliances With chewing surfaces Anterior positioning appliances Anterior bite appliances Posterior bite appliances Yes∗ No Depending on individual patient CR MHI Yes∗ No Depending on individual patient Nocturnal Daytime All the time Depending on individual case Monthly Weekly
42 31 23 11 10 3 21 59 46 27 11 57 25 54 33 0 0 59 15 7
35.0 25.8 19.2 9.2 8.3 2.5 26.3 73.8 54.8 32.1 13.1 69.5 30.5 62.1 37.9 0 0 72.8 18.5 8.6
*p < 0.05
dental clinics and offices of the city. The objective and benefits of this research were explained during the first personal encounter with each professional. Subsequently, the questionnaires regarding TMD management were randomly administered to be answered on an anonymous basis. Of these, 149 questionnaires that were incompletely filled or not filled were discarded (n = 151). The research protocol was approved by the Ethics Committee of the State University of Ponta Grossa (57/2011-03034/11). A systematic review of agreements and arguments pertaining to the international recommendations for TMD and OFP management was conducted to justify the questionnaire used in this study.10 Data were obtained from the AADR, the European Academy of Craniomandibular Disorders, and the American Academy of Orofacial Pain. The search terms included policy statement on TMD, Charles Greene, and the name of each society mentioned above. The inclusion criteria for the initial selection of suitable articles on the basis of available abstracts were articles, editorials, or letters to the editor pertaining to the latest official recommendations of these groups. The search was electronically conducted on MEDLINE using the search engine PubMed and manually conducted using retrieved article references (2000 to May 2014). From the 131 abstracts retrieved, 21 were associated with articles containing relevant material.1,4-8,12-26 The following behavior-related questions were included: B1. Potential TMD patients sought treatment at your office? Answer: Yes or No; B2. What procedures do you use to diagnose these patients? Answer: medical history, physical examination, imaging studies, study models, or a combination of these;
B3. What is your approach toward these patients? Answer: offer treatment, refer to another dentist, or refer to an academic institution; B4. If you do not treat these patients, what specialty do you refer them to? Answer: prosthodontics, occlusion, orthodontics, otorhinolaryngology, physiotherapy, neurology, or maxillofacial surgery; B5. If you do treat these patients, what treatments do you offer them? Answer: counseling, diet plans, thermotherapy, physiotherapy, pharmacotherapy, occlusal splinting, occlusal adjustment, orthodontics, oral rehabilitation, or another. Considering that splints are the most common choice of treatment for TMD,2 the following questions were included: S1. What kind of splint do you employ? Answer: anterior bite appliances, posterior bite appliances, hard stabilization appliances with chewing surfaces, anterior positioning appliances, or soft stabilization appliances; S2. Do you use semi-adjustable articulators? Answer: Yes or No; S3. In what occlusal relationship do you fabricate the splint? Answer: maximum habitual intercuspation (MHI), centric relation (CR), or depending on individual case; S4. Do you adjust the occlusal surface of the splint at the time of fitting? Answer: Yes or No; S5. What are your instructions regarding the duration of splint use? Answer: nocturnal, daytime, all the time, or depending on individual patient; S6. How often do the patients return to the office for followup? Answer: weekly, monthly, or depending on individual patient. Furthermore, two questions about the cause/effect relationship were included: C-E1. What do you attribute the TMD etiology to? Answer: stress, parafunction, trauma, occlusion factors, medical muscle-skeletal disorders, or multifactorial; C-E2. Do you believe in multidisciplinary medical and dental treatment? Answer: Yes or No. A pilot study (n = 10) identified minor difficulties and interpretations, which were revised in the final document. A single calibrated examiner conducted all procedures. For each question, multiple options could be selected, thus, the total percentages of answers may not add to 100. Data R R were analyzed using IBM SPSS Statistics 20 software (SPSS Inc., Chicago, IL), and all statistical inferences were derived using 2-tailed trials with a significance level of 95% and statistical power of 80%. Dichotomic answers were compared using a binomial test with the confidence interval of Clopper-Pearson (an exact interval based on the cumulative binomial distribution). Multiple answers were evaluated using the chi-square test for a single sample.
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Table 3 Frequency and percentages of the answers from each causeeffect question Questions C-E1∗
C-E2
Answers Multifactorial Occlusion factors Stress Parafunction Medical muscle-skeletal disorders Trauma Yes∗ No
Frequency Percentage 90 86 78 67 61 50 142 3
20.8 19.9 18.1 15.5 14.1 11.6 97.9 2.1
*p < 0.05
Results The number and percentages for answers to each behavior question are shown in Table 1. Of the GDPs, 88.7% received potential TMD patients in their office (p < 0.05). The diagnostic procedure employed, approach toward each patient, place of referral, and treatment alternatives were significantly different among practitioners (p < 0.05). Medical history (36.6%) and physical (30.4%) examination were more frequently employed for diagnosis. Most practitioners (65.4%) referred their patients to another professional. Occlusion (36.1%) and orthodontics (29.7%) were the most common specialties for patient referral. The most common treatment modality was splinting (20.8%), followed by occlusal adjustment (18.1%) and pharmacotherapy (16.6%). Table 2 shows the responses to the splint-related questions. Hard stabilization appliance was the type of splint most commonly used (35.0%). Despite type of splint used, they were fabricated in MHI or CR by 54.8% of GDPs depending on individual patient (p < 0.05). During splint fabrication, 73.8% did not employ semi-adjustable articulators, and 69.5% performed occlusal adjustments at the time of fixing. Furthermore, 62.1% and 72.8% of GDPs believed that the duration of splint use and frequency of follow-up, respectively, should be patient dependent (p < 0.05). The responses to the cause/effect relationship questions (Table 3) indicated that 20.8% of GDPs considered the etiology of TMD to be multifactorial, with 19.9% considering occlusion to play an important role (p < 0.05). Finally, 97.9% considered multidisciplinary medical and dental treatment to be necessary (p < 0.05).
Discussion Most GDPs received patients and primarily diagnosed them on the basis of medical history and physical examination. The superiority of evidence-based clinical diagnosis methods against advanced technological methods has been exhaustively discussed.4-6,12-22,24,25 The use of auxiliary diagnostic tools (except for several imaging alternatives) did not result in a significantly improved diagnosis rate for TMD and OFP compared with the use of history and examination protocols.4-6 These procedures may increase the risk of false-positive results that may lead to unnecessary treatments. Patients without 36
symptoms are often diagnosed with TMD, and their true diagnosis is masked by successive treatments.16-18 On the other hand, sophisticated techniques for TMD diagnosis are also essential to comprehensive patient evaluation, because mandibular postural analysis and function studies are established to measure the parameters/dynamics of musculoskeletal problems.14 Patients were mostly referred to specialists in occlusion or orthodontics. At present, despite curricular deficits, emerging predoctoral guidelines for TMD and OFP establish that new graduates must be competent in the diagnosis, management, and prognosis of these disorders, at least for early or simple cases.3 Although occlusion is not an official specialization, and orthodontics is not a preventive procedure or a treatment option for TMD,27 these professionals may be considered as substitutes for TMD and OFP specialists in this region because of the extremely low proportion of the latter. Another reason for referral could be the knowledge of orthodontists with regard to occlusal abnormalities, which could guarantee an objective identification or exclusion of the involvement of occlusal factors. Essentially, crossbite, Angle’s class II malocclusion and increased overjet, large MHI-CR discrepancy, loss of posterior support, occlusal instability, and anterior occlusal wear and its progression in relation to age are potential risk factors for the development of TMD symptoms.7 However, the etiology per se has not been studied, and there is no evidence for preventive and predictable strategies.28 Dentists who choose to treat TMD patients commonly use splints, occlusal adjustment, and pharmacotherapy. Splints are recommended by international councils as a patient-centered and more passive modality.8 A current meta-analysis29 found moderate-quality evidence suggesting a decrease in pain in the TMJ area after splint therapy, but low to very low quality evidence showing no differences between splint therapy and control therapy in terms of quality of life or depression. Furthermore, no trial reports describing any functional effects have been identified. Another up-to-date meta-analysis concluded that hard stabilization appliances, when adjusted properly, show modest efficacy in the treatment of TMD pain compared with nonoccluding appliances and no treatment.30 Therefore, splint therapy, similar to every treatment for pain, can be a good example of a powerful placebo for TMD. While the deceptive use of placebos must be considered unethical, professionals treating patients with pain must be aware of this phenomenon in order to take advantage of its huge potential.2,9 The role of occlusion in the pathogenesis of TMD has been shown to be minor in a systematic review.28 Another study failed to show evidence that occlusal adjustment treats or prevents TMD.2 A minimal influence means that occlusal features may possibly contribute in one or more subsets of TMD patient populations; however, Turp and Schindler28 noted that an absence of any relationship between form and function should not be inferred. Also, this may tend to undervalue the advantages of using rules to guide treatment plans. A simplistic view of occlusion may be harmful to the individual patient with longstanding TMD signs and symptoms, who may be at a greater risk of developing TMD because of an apparently decreased adaptive capacity of the formerly compromised structures of the masticatory system.28 Occlusal adjustment is definitely indicated to prevent occlusal trauma, overload, and consequent wear or
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fatigue of dentures, injury of residual ridges, and tooth wear (by anterior guidance in harmony with the posterior disclusion). Despite the absence of meta-analyses due to heterogeneity among studies,2 pharmacotherapy is recommended by the international councils.1,7,8 This includes the prescription of analgesics, antidepressants, antianxiety agents, muscle relaxants, corticosteroids, antihistaminics, local anesthetics, antihypertensives, antiepileptic drugs, adjunctive neuropathic pain medications, tryptans, and ergot derivatives.1 However, there is not strong evidence to support the effectiveness of drugs, as well as occlusal appliances, acupuncture, behavioral therapy, jaw exercises, postural training, electrophysical modalities, and surgery (with improved mandibular functionality) in the management of TMD; furthermore, they found no scientific proof for the efficacy of occlusal adjustment.2 Because of the various categories of drugs, their routine use in the dental setting requires an in-depth knowledge of their nature and physiological interactions.1-3 Also, the positive effects of drugs must be weighed against the possible adverse effects and risk of dependency, because there is currently no standard criteria for the pharmacological treatment of chronic OFP.2 In this study, the majority of GDPs used hard stabilization appliances, and all type of splints were fabricated in MHI or CR depending on the individual patient. Most did not employ semi-adjustable articulators and adjusted the appliances at the time of fixing. Because of structural deterioration of the TMJ, pain, or record limitations, CR may not be an absolute position indicating neuromuscular or physiological equilibrium. Therefore, there is no conclusive evidence for any maxillomandibular relationship as the preferred treatment position, but as with any oral rehabilitation treatment, MHI may conveniently be used in patients without the occlusal abnormalities mentioned above.7,31 The duration of splint use and frequency of followup were considered to be patient dependent by most GDPs. Evidence on this topic is limited, and justifiably so because each condition may have different healing periods. Symptom improvement may take several weeks to a year after initial treatment.29,30 However, it is difficult to evaluate the long-term outcomes of stabilization appliance therapy because patients may require additional treatments. The majority of GDPs considered the etiology of TMD to be multifactorial, with a considerable proportion giving importance to occlusion, and the majority considered multidisciplinary medical and dental treatment to be necessary; however, to create a protocol it is necessary to link the steady flow of new findings with predoctoral dental education, considering the actual applicability of those in practice.3 Research implications are skewed for GDPs whose patients are rarely represented in the research population. An interprofessional model should include knowledge pertaining to diagnostic reasoning and the principles of basic radiology, neurology, physical medicine, and pharmacology, with focus on physical, psychosocial, and behavioral aspects.1-3 Dental educational institutions need to recognize pain in the orofacial region from a broader perspective, without limiting their knowledge only to that caused by the intraoral structures. Furthermore, they should be aware that pain is indeed a health problem that can and needs to be addressed by the GDP. Some of the limitations of this study include the generality of questions and a convenience sample.
Management of TMD Patients in Southern Brazil
Conclusion The management of TMD patients by the GDPs in Ponta Grossa was in accordance with international guidelines. These practitioners diagnosed TMD primarily based on medical history and physical examination and referred patients to orthodontists and professionals with knowledge on occlusion, or managed them using occlusal splinting, occlusal adjustment, or pharmacotherapy.
References 1. Heir GM, Haddox JD, Crandall J, et al: Position paper: appropriate use of pharmacotherapeutic agents by the orofacial pain dentist. J Orofac Pain 2011;25:381-390 2. List T, Axelsson S: Management of TMD: evidence from systematic reviews and meta-analyses. J Oral Rehabil 2010;37:430-451 3. Klasser GD, Gremillion HA: Past, present, and future of predoctoral dental education in orofacial pain and TMDs: a call for interprofessional education. J Dent Educ 2013;77:395-400 4. Greene CS: Diagnosis and treatment of temporomandibular disorders: emergence of a new “standard of care”. Quintessence Int 2010;41:623-624 5. Greene CS: Diagnosis and treatment of temporomandibular disorders: emergence of a new care guidelines statement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:137-139 6. Greene CS: Management of patients with TMDs: a new “standard of care”. Int J Prosthodont 2010;23:190-191 7. De Boever JA, Nilner M, Orthlieb JD, et al: Recommendations by the EACD for examination, diagnosis, and management of patients with temporomandibular disorders and orofacial pain by the general dental practitioner. J Orofac Pain 2008;22:268-278 8. Davies S: EACD GDP guidelines. Dent Update 2008;35:210-211 9. Velly AM, Schiffman EL, Rindal DB, et al: The feasibility of a clinical trial of pain related to temporomandibular muscle and joint disorders: the results of a survey from the Collaboration on Networked Dental and Oral Research dental practice-based research networks. J Am Dent Assoc 2013;144:e1-e10 10. Venancio RA, Camparis CM: Disfunc¸o˜ es temporomandibulares: estudo dos procedimentos realizados por profissionais. Rev Odontol UNESP 2002;31:191-203 11. Goncalves DA, Dal Fabbro AL, Campos JA, et al: Symptoms of temporomandibular disorders in the population: an epidemiological study. J Orofac Pain 2010;24:270-278 12. Buck SD: Letters from those who take issue with AADR’s revised policy and Dr. Greene’s statement: ‘disordered alignment’. J Am Dent Assoc 2010;141:1412; author reply 1416-1417 13. Chase MR: Letters from those who take issue with AADR’s revised policy and Dr. Greene’s statement: ‘personal opinions’. J Am Dent Assoc 2010;141:1410-1412; author reply 1416-1417 14. Chase PF: Letters from those who take issue with AADR’s revised policy and Dr. Greene’s statement: ‘misguided’ perspective. J Am Dent Assoc 2010;141:1408; author reply 1416-1407 15. Crandall JA, Tanenbaum DR: Letters in support of the revised AADR guidelines and Dr. Greene’s statement: ‘conservative and reversible’. J Am Dent Assoc 2010;141:1415; author reply 1416-1417 16. Greene CS: Managing patients with temporomandibular disorders: a new “standard of care”. Am J Orthod Dentofacial Orthop 2010;138:3-4
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17. Greene CS: Managing the care of patients with temporomandibular disorders: a new guideline for care. J Am Dent Assoc 2010;141:1086-1088 18. Greene CS, Klasser GD, Epstein JB: Revision of the American Association of Dental Research’s Science Information Statement about Temporomandibular Disorders. J Can Dent Assoc 2010;76:a115 19. Gross T: Letters from those who take issue with AADR’s revised policy and Dr. Greene’s statement: ‘archaic’ guidelines. J Am Dent Assoc 2010;141:1408, 1410; author reply 1416-1407 20. Jehenson M: Letters in support of the revised AADR guidelines and Dr. Greene’s statement: ‘gratitude’ expressed. J Am Dent Assoc 2010;141:1415-1416; author reply 1416-1417 21. Lytle K: Letters from those who take issue with AADR’s revised policy and Dr. Greene’s statement: ‘unsubstantiated conjecture’. J Am Dent Assoc 2010;141:1412-1415; author reply 1416-1417 22. Norman A: Letters from those who take issue with AADR’s revised policy and Dr. Greene’s statement: ‘negative impact’. J Am Dent Assoc 2010;141:1410; author reply 14161417 23. Reiter S, Goldsmith C, Emodi-Perlman A, et al: Masticatory muscle disorders diagnostic criteria: the American Academy of Orofacial Pain versus the research diagnostic criteria/ temporomandibular disorders (RDC/TMD). J Oral Rehabil 2012;39:941-947 24. Sasaki K, Yatani H, Kuboki T: Basic position of the Japan Prosthodontic Society with respect to the policy statement on TMD by the American Association for Dental Research (AADR). J Prosthodont Res 2010;54:151-152
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25. Simmons HC, 3rd: A critical review of Dr. Charles S. Greene’s article titled “Managing the Care of Patients with Temporomandibular Disorders: a new Guideline for Care” and a revision of the American Association for Dental Research’s 1996 policy statement on temporomandibular disorders, approved by the AADR Council in March 2010, published in the Journal of the American Dental Association September 2010. Cranio 2012;30:9-24 26. Simmons HC, 3rd: Guidelines for anterior repositioning appliance therapy for the management of craniofacial pain and TMD. Cranio 2005;23:300-305 27. Leite RA, Rodrigues JF, Sakima MT, et al: Relationship between temporomandibular disorders and orthodontic treatment: a literature review. Dental Press J Orthod 2013;18:150-157 28. Turp JC, Schindler H: The dental occlusion as a suspected cause for TMDs: epidemiological and etiological considerations. J Oral Rehabil 2012;39:502-512 29. Ebrahim S, Montoya L, Busse JW, et al: The effectiveness of splint therapy in patients with temporomandibular disorders: a systematic review and meta-analysis. J Am Dent Assoc 2012;143:847-857 30. Fricton J, Look JO, Wright E, et al: Systematic review and meta-analysis of randomized controlled trials evaluating intraoral orthopedic appliances for temporomandibular disorders. J Orofac Pain 2010;24:237-254 31. Lee DJ, Wiens JP, Ference J, et al: Assessment of occlusion curriculum in predoctoral dental education: report from ACP Task Force on Occlusion Education. J Prosthodont 2012;21:578-587
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Department of Dentistry, State University of Ponta Grossa, Ponta Grossa, Brazil Department of Dental Materials and Prosthodontics, Araraquara Dental School, University Estadual Paulista, Araraquara, Brazil
Keywords Temporomandibular joint disorders; dentist practice patterns; health care surveys. Correspondence ´ Alfonso Sanchez-Ayala, Department of Dentistry, State University of Ponta Grossa, Avenida General Carlos Cavalcanti, 4748, Ponta Grossa - PR, 84030-900, Brazil. E-mail: [email protected] The authors deny any conflicts of interest. Accepted July 30, 2014 doi: 10.1111/jopr.12255
Abstract Purpose: Temporomandibular disorders (TMD) are recognized as one of the most controversial topics in dentistry, despite the fact that both basic science and clinical researchers have currently reached some degree of consensus. This study aimed to conduct a questionnaire-based survey about the management of TMD patients by general dental practitioners (GDPs). Materials and Methods: One hundred fifty-one GDPs with a private practice in a city of southern Brazil were included, independent of school of origin, gender, graduation year, and curriculum content. All participants were administered a questionnaire about the management of patients with TMD, and the responses were analyzed by binomial and chi-square tests (α = 0.05). Results: Of the GDPs, 88.7% received TMD patients, who were primarily diagnosed on the basis of medical history (36.6%) or physical examination (30.4%). Of these, 65.4% referred the patients elsewhere, primarily to specialists in occlusion (36.1%) or orthodontics (29.7%). Occlusal splinting was the most commonly used management modality (20.8%), followed by occlusal adjustment (18.1%) and pharmacotherapy (16.6%). Splints were fabricated in maximum habitual intercuspation or centric relation depending on individual patient (54.8%). The hard stabilization form was the most common type of appliance used (35.0%). Moreover, 73.8% of the GDPs did not employ semi-adjustable articulators, and 69.5% adjusted the appliances at the time of fixing. The duration of splint use and the frequency of follow-up were considered patient dependent by 62.1% and 72.8%, respectively. GDPs considered the two major TMD etiologic categories as multifactorial (20.8%) and occlusion (19.9%). Multidisciplinary medical and dental treatment was considered necessary by 97.9%. Conclusions: The evaluated general dental practitioners manage TMD patients according to international guidelines.
The development of clinical dentistry requires the general dental practitioner (GDP) to be involved in more than just the diagnosis and treatment of diseases in the oral cavity. Dentists are increasingly responsible for the recognition and management of orofacial pain (OFP) and temporomandibular disorders (TMD) of the temporomandibular joint (TMJ) region, and disorders of the muscles of mastication and associated musculature.1 To determinate appropriate treatment strategies, GDPs should combine the patient’s treatment needs and preferences with the best available scientific evidence, in conjunction with their clinical expertise.2 Nevertheless, TMD are recognized as one of the most controversial topics in dentistry, even though both basic science and clinical researchers have currently reached
some degree of consensus.3 However, due to relatively longterm mainstream misconceptions within both dental education and clinical practice, evidenced-based diagnosis and treatment perspectives for TMD have failed to be adopted by much of clinical dentistry. The American Association for Dental Research (AADR) recommends that the diagnosis of TMD be primarily based on data obtained from the patient’s history, clinical examination, and, when specified, TMJ imaging findings.4 Standard medical diagnostics used for assessing analogous orthopedic, rheumatological, neurological, and psychosocial disorders may also be employed.5 In addition, it is strongly suggested that the initial treatment should be based on conservative, reversible,
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and evidence-based therapeutic alternatives unless there are specific and justifiable contraindications to the same. This is because the natural history of TMD suggests the tendency to improve or resolve over time, and conservative modalities are at least as effective in providing symptomatic relief as several invasive treatments.6 The Council of the European Academy of Craniomandibular Disorders also recommends an initial simple screening to detect the presence of a TMD and an assessment to establish a working diagnosis through general, maxillofacial, and oral histories and complementary imaging studies. This aids in distinguishing related head and neck medical disturbances and neurological and psychiatric conditions and in detecting the presence of psychosocial factors.7 Oral inspection should also rule out mucosal, dental, and periodontal diseases and evaluate the strongest occlusal factors and parafunction indicators. The diagnosis should identify the causes of TMD as specific or known (neoplasms, growth disturbances, systemic disease) and nonspecific (muscular, articular) related to occlusal overload or trauma, which impair the adaptation capacity of the joint.8 Patient referral to general or specialist medical practitioners when indicated is also recommended, as are general therapeutic modalities such as patient education, pharmacological therapy, occlusal appliances, physiotherapy, behavioral and psychological management, arthrocentesis, and eventual occlusal therapy such as prosthetic reconstruction, orthodontic therapy, joint surgery/orthognathic surgery, and arthroscopic surgery after pain relief.7 Despite the rationality of these suggestions, there are persistent disagreements within the practice community, probably because of the absence of a standard model for TMD education in predoctoral programs, nonadherence to a scientific protocol for patient assessment, absence of criteria for more accurate diagnoses and predictable treatments, and absence of a protocol for clinical research.3 Furthermore, the clinical sequence following the first visit of a potential TMD patient remains unknown, which may result in frustration among dental educators, confusion among students, and unfortunate consequences to patient care.3 An international survey conducted in 2013 showed that 76% of GDPs managed TMD patients, 97.6% used splints or mouthguards, 85.9% used selfcare, 84.6% used over-the-counter or prescription medications, 63.6% used occlusal adjustment, 53.2% used jaw exercises, and 35.0% referred patients to physical therapists.9 In southwestern Brazil, research performed in 2002 showed that 42% of the interviewed practitioners treated TMD patients with splints (19.2%), occlusal adjustment (16.3%), oral rehabilitation (12.8%), pharmacotherapy (10.0%), heat therapy (7.0%), relaxation techniques (7.0%), physiotherapy (6.4%), and diet counseling (6.4%).10 In an urban population in southwestern Brazil, at least one TMD symptom was reported by 39.2%, and pain related to TMD was observed in 25.6% of the sample.11 TMD patients treated in a conventional dental office are generally less complicated than referred patients in specialist centers, who are mostly characterized by chronicity, comorbidity, and complexity.7 According to the diagnosis, the dental surgeon has to decide when and how to treat or when and to whom to refer.9 To establish standard guidelines for the diagnosis and treatment of TMD, it is essential to know the current state of professionals in terms 34
Table 1 Frequency and percentages of the answers from each behavior question Questions B1 B2∗
B3∗
B4∗
B5∗
Answers
Frequency
Percentage
Yes∗ No Medical history Physical examination Imaging studies Study models Combination of these Refer to another dentist Offer treatment Refer to an academic institution Occlusion Orthodontics Prosthodontics Maxillofacial surgery Physiotherapy Neurology Otorhinolaryngology Occlusal splinting Occlusal adjustment Pharmacotherapy Counseling Oral rehabilitation Orthodontics Physiotherapy Diet plans Thermotherapy Another
134 17 141 117 78 34 15 119 50 13 96 79 32 19 17 12 11 84 73 67 52 43 35 18 14 13 5
88.7 11.3 36.6 30.4 20.3 8.8 3.9 65.4 27.5 7.1 36.1 29.7 12.0 7.1 6.4 4.5 4.1 20.8 18.1 16.6 12.9 10.6 8.7 4.5 3.5 3.2 1.2
*p < 0.05
of these issues. Therefore, the aim of this study was to elucidate the procedures employed for the management of TMD by GDP in a southern Brazilian city using a questionnaire-based survey.
Materials and methods Brazil includes almost 19% (251,587) of the dentists in the world. In southern Brazil, 16,285 professionals are registered in the Brazilian Federal Council of Dentistry, indicating an estimated proportion of 644,000 individuals per practitioner (I/P). Among these, there are 90 specialists in TMD and OFP. The city of Ponta Grossa, Paran´a, has 730 dentists (426 I/P), with 3 specialists in TMD and OFP (http://cfo.org.br). Also, many patients are treated by a GDP. On the basis of these indicators, a sample size of 300 dentists with a private practice in the city of Ponta Grossa who were not affiliated with any academic institution were included; this sample size is generally accepted for this category of study.10 Inclusion was independent of school of origin, gender, graduation year, and curriculum content. Initially, the researchers sought contact information such as office addresses, commercial telephone numbers, or work e-mails of dentists from nongovernmental dentistry associations based in Ponta Grossa. Data for GDPs serving in government agencies were obtained from the City Hall of Ponta Grossa. Moreover, additional contacts were made from private
C 2015 by the American College of Prosthodontists Journal of Prosthodontics 25 (2016) 33–38
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Management of TMD Patients in Southern Brazil
Table 2 Frequency and percentages of the answers from each splint question Questions S1∗
S2 S3∗
S4 S5∗
S6∗
Answers
Frequency
Percentage
Hard stabilization appliances Soft stabilization appliances With chewing surfaces Anterior positioning appliances Anterior bite appliances Posterior bite appliances Yes∗ No Depending on individual patient CR MHI Yes∗ No Depending on individual patient Nocturnal Daytime All the time Depending on individual case Monthly Weekly
42 31 23 11 10 3 21 59 46 27 11 57 25 54 33 0 0 59 15 7
35.0 25.8 19.2 9.2 8.3 2.5 26.3 73.8 54.8 32.1 13.1 69.5 30.5 62.1 37.9 0 0 72.8 18.5 8.6
*p < 0.05
dental clinics and offices of the city. The objective and benefits of this research were explained during the first personal encounter with each professional. Subsequently, the questionnaires regarding TMD management were randomly administered to be answered on an anonymous basis. Of these, 149 questionnaires that were incompletely filled or not filled were discarded (n = 151). The research protocol was approved by the Ethics Committee of the State University of Ponta Grossa (57/2011-03034/11). A systematic review of agreements and arguments pertaining to the international recommendations for TMD and OFP management was conducted to justify the questionnaire used in this study.10 Data were obtained from the AADR, the European Academy of Craniomandibular Disorders, and the American Academy of Orofacial Pain. The search terms included policy statement on TMD, Charles Greene, and the name of each society mentioned above. The inclusion criteria for the initial selection of suitable articles on the basis of available abstracts were articles, editorials, or letters to the editor pertaining to the latest official recommendations of these groups. The search was electronically conducted on MEDLINE using the search engine PubMed and manually conducted using retrieved article references (2000 to May 2014). From the 131 abstracts retrieved, 21 were associated with articles containing relevant material.1,4-8,12-26 The following behavior-related questions were included: B1. Potential TMD patients sought treatment at your office? Answer: Yes or No; B2. What procedures do you use to diagnose these patients? Answer: medical history, physical examination, imaging studies, study models, or a combination of these;
B3. What is your approach toward these patients? Answer: offer treatment, refer to another dentist, or refer to an academic institution; B4. If you do not treat these patients, what specialty do you refer them to? Answer: prosthodontics, occlusion, orthodontics, otorhinolaryngology, physiotherapy, neurology, or maxillofacial surgery; B5. If you do treat these patients, what treatments do you offer them? Answer: counseling, diet plans, thermotherapy, physiotherapy, pharmacotherapy, occlusal splinting, occlusal adjustment, orthodontics, oral rehabilitation, or another. Considering that splints are the most common choice of treatment for TMD,2 the following questions were included: S1. What kind of splint do you employ? Answer: anterior bite appliances, posterior bite appliances, hard stabilization appliances with chewing surfaces, anterior positioning appliances, or soft stabilization appliances; S2. Do you use semi-adjustable articulators? Answer: Yes or No; S3. In what occlusal relationship do you fabricate the splint? Answer: maximum habitual intercuspation (MHI), centric relation (CR), or depending on individual case; S4. Do you adjust the occlusal surface of the splint at the time of fitting? Answer: Yes or No; S5. What are your instructions regarding the duration of splint use? Answer: nocturnal, daytime, all the time, or depending on individual patient; S6. How often do the patients return to the office for followup? Answer: weekly, monthly, or depending on individual patient. Furthermore, two questions about the cause/effect relationship were included: C-E1. What do you attribute the TMD etiology to? Answer: stress, parafunction, trauma, occlusion factors, medical muscle-skeletal disorders, or multifactorial; C-E2. Do you believe in multidisciplinary medical and dental treatment? Answer: Yes or No. A pilot study (n = 10) identified minor difficulties and interpretations, which were revised in the final document. A single calibrated examiner conducted all procedures. For each question, multiple options could be selected, thus, the total percentages of answers may not add to 100. Data R R were analyzed using IBM SPSS Statistics 20 software (SPSS Inc., Chicago, IL), and all statistical inferences were derived using 2-tailed trials with a significance level of 95% and statistical power of 80%. Dichotomic answers were compared using a binomial test with the confidence interval of Clopper-Pearson (an exact interval based on the cumulative binomial distribution). Multiple answers were evaluated using the chi-square test for a single sample.
C 2015 by the American College of Prosthodontists Journal of Prosthodontics 25 (2016) 33–38
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Table 3 Frequency and percentages of the answers from each causeeffect question Questions C-E1∗
C-E2
Answers Multifactorial Occlusion factors Stress Parafunction Medical muscle-skeletal disorders Trauma Yes∗ No
Frequency Percentage 90 86 78 67 61 50 142 3
20.8 19.9 18.1 15.5 14.1 11.6 97.9 2.1
*p < 0.05
Results The number and percentages for answers to each behavior question are shown in Table 1. Of the GDPs, 88.7% received potential TMD patients in their office (p < 0.05). The diagnostic procedure employed, approach toward each patient, place of referral, and treatment alternatives were significantly different among practitioners (p < 0.05). Medical history (36.6%) and physical (30.4%) examination were more frequently employed for diagnosis. Most practitioners (65.4%) referred their patients to another professional. Occlusion (36.1%) and orthodontics (29.7%) were the most common specialties for patient referral. The most common treatment modality was splinting (20.8%), followed by occlusal adjustment (18.1%) and pharmacotherapy (16.6%). Table 2 shows the responses to the splint-related questions. Hard stabilization appliance was the type of splint most commonly used (35.0%). Despite type of splint used, they were fabricated in MHI or CR by 54.8% of GDPs depending on individual patient (p < 0.05). During splint fabrication, 73.8% did not employ semi-adjustable articulators, and 69.5% performed occlusal adjustments at the time of fixing. Furthermore, 62.1% and 72.8% of GDPs believed that the duration of splint use and frequency of follow-up, respectively, should be patient dependent (p < 0.05). The responses to the cause/effect relationship questions (Table 3) indicated that 20.8% of GDPs considered the etiology of TMD to be multifactorial, with 19.9% considering occlusion to play an important role (p < 0.05). Finally, 97.9% considered multidisciplinary medical and dental treatment to be necessary (p < 0.05).
Discussion Most GDPs received patients and primarily diagnosed them on the basis of medical history and physical examination. The superiority of evidence-based clinical diagnosis methods against advanced technological methods has been exhaustively discussed.4-6,12-22,24,25 The use of auxiliary diagnostic tools (except for several imaging alternatives) did not result in a significantly improved diagnosis rate for TMD and OFP compared with the use of history and examination protocols.4-6 These procedures may increase the risk of false-positive results that may lead to unnecessary treatments. Patients without 36
symptoms are often diagnosed with TMD, and their true diagnosis is masked by successive treatments.16-18 On the other hand, sophisticated techniques for TMD diagnosis are also essential to comprehensive patient evaluation, because mandibular postural analysis and function studies are established to measure the parameters/dynamics of musculoskeletal problems.14 Patients were mostly referred to specialists in occlusion or orthodontics. At present, despite curricular deficits, emerging predoctoral guidelines for TMD and OFP establish that new graduates must be competent in the diagnosis, management, and prognosis of these disorders, at least for early or simple cases.3 Although occlusion is not an official specialization, and orthodontics is not a preventive procedure or a treatment option for TMD,27 these professionals may be considered as substitutes for TMD and OFP specialists in this region because of the extremely low proportion of the latter. Another reason for referral could be the knowledge of orthodontists with regard to occlusal abnormalities, which could guarantee an objective identification or exclusion of the involvement of occlusal factors. Essentially, crossbite, Angle’s class II malocclusion and increased overjet, large MHI-CR discrepancy, loss of posterior support, occlusal instability, and anterior occlusal wear and its progression in relation to age are potential risk factors for the development of TMD symptoms.7 However, the etiology per se has not been studied, and there is no evidence for preventive and predictable strategies.28 Dentists who choose to treat TMD patients commonly use splints, occlusal adjustment, and pharmacotherapy. Splints are recommended by international councils as a patient-centered and more passive modality.8 A current meta-analysis29 found moderate-quality evidence suggesting a decrease in pain in the TMJ area after splint therapy, but low to very low quality evidence showing no differences between splint therapy and control therapy in terms of quality of life or depression. Furthermore, no trial reports describing any functional effects have been identified. Another up-to-date meta-analysis concluded that hard stabilization appliances, when adjusted properly, show modest efficacy in the treatment of TMD pain compared with nonoccluding appliances and no treatment.30 Therefore, splint therapy, similar to every treatment for pain, can be a good example of a powerful placebo for TMD. While the deceptive use of placebos must be considered unethical, professionals treating patients with pain must be aware of this phenomenon in order to take advantage of its huge potential.2,9 The role of occlusion in the pathogenesis of TMD has been shown to be minor in a systematic review.28 Another study failed to show evidence that occlusal adjustment treats or prevents TMD.2 A minimal influence means that occlusal features may possibly contribute in one or more subsets of TMD patient populations; however, Turp and Schindler28 noted that an absence of any relationship between form and function should not be inferred. Also, this may tend to undervalue the advantages of using rules to guide treatment plans. A simplistic view of occlusion may be harmful to the individual patient with longstanding TMD signs and symptoms, who may be at a greater risk of developing TMD because of an apparently decreased adaptive capacity of the formerly compromised structures of the masticatory system.28 Occlusal adjustment is definitely indicated to prevent occlusal trauma, overload, and consequent wear or
C 2015 by the American College of Prosthodontists Journal of Prosthodontics 25 (2016) 33–38
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fatigue of dentures, injury of residual ridges, and tooth wear (by anterior guidance in harmony with the posterior disclusion). Despite the absence of meta-analyses due to heterogeneity among studies,2 pharmacotherapy is recommended by the international councils.1,7,8 This includes the prescription of analgesics, antidepressants, antianxiety agents, muscle relaxants, corticosteroids, antihistaminics, local anesthetics, antihypertensives, antiepileptic drugs, adjunctive neuropathic pain medications, tryptans, and ergot derivatives.1 However, there is not strong evidence to support the effectiveness of drugs, as well as occlusal appliances, acupuncture, behavioral therapy, jaw exercises, postural training, electrophysical modalities, and surgery (with improved mandibular functionality) in the management of TMD; furthermore, they found no scientific proof for the efficacy of occlusal adjustment.2 Because of the various categories of drugs, their routine use in the dental setting requires an in-depth knowledge of their nature and physiological interactions.1-3 Also, the positive effects of drugs must be weighed against the possible adverse effects and risk of dependency, because there is currently no standard criteria for the pharmacological treatment of chronic OFP.2 In this study, the majority of GDPs used hard stabilization appliances, and all type of splints were fabricated in MHI or CR depending on the individual patient. Most did not employ semi-adjustable articulators and adjusted the appliances at the time of fixing. Because of structural deterioration of the TMJ, pain, or record limitations, CR may not be an absolute position indicating neuromuscular or physiological equilibrium. Therefore, there is no conclusive evidence for any maxillomandibular relationship as the preferred treatment position, but as with any oral rehabilitation treatment, MHI may conveniently be used in patients without the occlusal abnormalities mentioned above.7,31 The duration of splint use and frequency of followup were considered to be patient dependent by most GDPs. Evidence on this topic is limited, and justifiably so because each condition may have different healing periods. Symptom improvement may take several weeks to a year after initial treatment.29,30 However, it is difficult to evaluate the long-term outcomes of stabilization appliance therapy because patients may require additional treatments. The majority of GDPs considered the etiology of TMD to be multifactorial, with a considerable proportion giving importance to occlusion, and the majority considered multidisciplinary medical and dental treatment to be necessary; however, to create a protocol it is necessary to link the steady flow of new findings with predoctoral dental education, considering the actual applicability of those in practice.3 Research implications are skewed for GDPs whose patients are rarely represented in the research population. An interprofessional model should include knowledge pertaining to diagnostic reasoning and the principles of basic radiology, neurology, physical medicine, and pharmacology, with focus on physical, psychosocial, and behavioral aspects.1-3 Dental educational institutions need to recognize pain in the orofacial region from a broader perspective, without limiting their knowledge only to that caused by the intraoral structures. Furthermore, they should be aware that pain is indeed a health problem that can and needs to be addressed by the GDP. Some of the limitations of this study include the generality of questions and a convenience sample.
Management of TMD Patients in Southern Brazil
Conclusion The management of TMD patients by the GDPs in Ponta Grossa was in accordance with international guidelines. These practitioners diagnosed TMD primarily based on medical history and physical examination and referred patients to orthodontists and professionals with knowledge on occlusion, or managed them using occlusal splinting, occlusal adjustment, or pharmacotherapy.
References 1. Heir GM, Haddox JD, Crandall J, et al: Position paper: appropriate use of pharmacotherapeutic agents by the orofacial pain dentist. J Orofac Pain 2011;25:381-390 2. List T, Axelsson S: Management of TMD: evidence from systematic reviews and meta-analyses. J Oral Rehabil 2010;37:430-451 3. Klasser GD, Gremillion HA: Past, present, and future of predoctoral dental education in orofacial pain and TMDs: a call for interprofessional education. J Dent Educ 2013;77:395-400 4. Greene CS: Diagnosis and treatment of temporomandibular disorders: emergence of a new “standard of care”. Quintessence Int 2010;41:623-624 5. Greene CS: Diagnosis and treatment of temporomandibular disorders: emergence of a new care guidelines statement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:137-139 6. Greene CS: Management of patients with TMDs: a new “standard of care”. Int J Prosthodont 2010;23:190-191 7. De Boever JA, Nilner M, Orthlieb JD, et al: Recommendations by the EACD for examination, diagnosis, and management of patients with temporomandibular disorders and orofacial pain by the general dental practitioner. J Orofac Pain 2008;22:268-278 8. Davies S: EACD GDP guidelines. Dent Update 2008;35:210-211 9. Velly AM, Schiffman EL, Rindal DB, et al: The feasibility of a clinical trial of pain related to temporomandibular muscle and joint disorders: the results of a survey from the Collaboration on Networked Dental and Oral Research dental practice-based research networks. J Am Dent Assoc 2013;144:e1-e10 10. Venancio RA, Camparis CM: Disfunc¸o˜ es temporomandibulares: estudo dos procedimentos realizados por profissionais. Rev Odontol UNESP 2002;31:191-203 11. Goncalves DA, Dal Fabbro AL, Campos JA, et al: Symptoms of temporomandibular disorders in the population: an epidemiological study. J Orofac Pain 2010;24:270-278 12. Buck SD: Letters from those who take issue with AADR’s revised policy and Dr. Greene’s statement: ‘disordered alignment’. J Am Dent Assoc 2010;141:1412; author reply 1416-1417 13. Chase MR: Letters from those who take issue with AADR’s revised policy and Dr. Greene’s statement: ‘personal opinions’. J Am Dent Assoc 2010;141:1410-1412; author reply 1416-1417 14. Chase PF: Letters from those who take issue with AADR’s revised policy and Dr. Greene’s statement: ‘misguided’ perspective. J Am Dent Assoc 2010;141:1408; author reply 1416-1407 15. Crandall JA, Tanenbaum DR: Letters in support of the revised AADR guidelines and Dr. Greene’s statement: ‘conservative and reversible’. J Am Dent Assoc 2010;141:1415; author reply 1416-1417 16. Greene CS: Managing patients with temporomandibular disorders: a new “standard of care”. Am J Orthod Dentofacial Orthop 2010;138:3-4
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17. Greene CS: Managing the care of patients with temporomandibular disorders: a new guideline for care. J Am Dent Assoc 2010;141:1086-1088 18. Greene CS, Klasser GD, Epstein JB: Revision of the American Association of Dental Research’s Science Information Statement about Temporomandibular Disorders. J Can Dent Assoc 2010;76:a115 19. Gross T: Letters from those who take issue with AADR’s revised policy and Dr. Greene’s statement: ‘archaic’ guidelines. J Am Dent Assoc 2010;141:1408, 1410; author reply 1416-1407 20. Jehenson M: Letters in support of the revised AADR guidelines and Dr. Greene’s statement: ‘gratitude’ expressed. J Am Dent Assoc 2010;141:1415-1416; author reply 1416-1417 21. Lytle K: Letters from those who take issue with AADR’s revised policy and Dr. Greene’s statement: ‘unsubstantiated conjecture’. J Am Dent Assoc 2010;141:1412-1415; author reply 1416-1417 22. Norman A: Letters from those who take issue with AADR’s revised policy and Dr. Greene’s statement: ‘negative impact’. J Am Dent Assoc 2010;141:1410; author reply 14161417 23. Reiter S, Goldsmith C, Emodi-Perlman A, et al: Masticatory muscle disorders diagnostic criteria: the American Academy of Orofacial Pain versus the research diagnostic criteria/ temporomandibular disorders (RDC/TMD). J Oral Rehabil 2012;39:941-947 24. Sasaki K, Yatani H, Kuboki T: Basic position of the Japan Prosthodontic Society with respect to the policy statement on TMD by the American Association for Dental Research (AADR). J Prosthodont Res 2010;54:151-152
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25. Simmons HC, 3rd: A critical review of Dr. Charles S. Greene’s article titled “Managing the Care of Patients with Temporomandibular Disorders: a new Guideline for Care” and a revision of the American Association for Dental Research’s 1996 policy statement on temporomandibular disorders, approved by the AADR Council in March 2010, published in the Journal of the American Dental Association September 2010. Cranio 2012;30:9-24 26. Simmons HC, 3rd: Guidelines for anterior repositioning appliance therapy for the management of craniofacial pain and TMD. Cranio 2005;23:300-305 27. Leite RA, Rodrigues JF, Sakima MT, et al: Relationship between temporomandibular disorders and orthodontic treatment: a literature review. Dental Press J Orthod 2013;18:150-157 28. Turp JC, Schindler H: The dental occlusion as a suspected cause for TMDs: epidemiological and etiological considerations. J Oral Rehabil 2012;39:502-512 29. Ebrahim S, Montoya L, Busse JW, et al: The effectiveness of splint therapy in patients with temporomandibular disorders: a systematic review and meta-analysis. J Am Dent Assoc 2012;143:847-857 30. Fricton J, Look JO, Wright E, et al: Systematic review and meta-analysis of randomized controlled trials evaluating intraoral orthopedic appliances for temporomandibular disorders. J Orofac Pain 2010;24:237-254 31. Lee DJ, Wiens JP, Ference J, et al: Assessment of occlusion curriculum in predoctoral dental education: report from ACP Task Force on Occlusion Education. J Prosthodont 2012;21:578-587
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