Treatment of Orofacial Pain and TMD: Greatest Red Flags to Watch Out for

Treatment of Orofacial Pain and TMD: Greatest Red Flags to Watch Out for

There are a number of red flags one needs to be cognisant of when it comes to the treatment of orofacial pain and TMD (Temporomandibular Joint Disorders). There exists a worrisome group of ‘neuromuscular’ dental practitioners who render ‘treatment’ for orofacial pain and TMD, yet their interpretation of science is dodgy at best, and disingenuous at worst.

It is common in my dental practice to see patients in abject and abysmal pain, despite having gone through the rigmarole of extensive and expensive dental treatment. They are often told they need to change the way they ‘bite’ (change their occlusion), in a futile attempt to curb the pain.

*Disclaimer: The term ‘Orofacial Pain Specialist‘ is made within the context of the USA and not Singapore. Please visit our Disclaimers and FAQ pages to learn more.

‘Treatments’ for Orofacial Pain and TMD that Patients Tried, Before Visiting Our Clinic

Most of the time, patients will be advised (usually by well-meaning dental practitioners) that their ‘bites’ are unsatisfactory, and that their jaw muscles need to be ‘relaxed’. This is the so-called phase 1 of pain treatment. In phase 2, the patient undergoes the painstaking ‘reconstruction’ of their bites. This process involves one or more of these so-called treatment modalities:

  1. Incredibly expensive intraoral orthotic devices (a.k.a. mouth guards) which can cost SGD5,000 or more.
  2. Orthodontic Treatment (braces or retainers) that can easily go up into the 5-figure realm.
  3. Extensive Prosthodontics Treatment, or “Occlusal Rehabilitation”. These can include treatments or modifications such as veneers, dental implants, crowns, bridges, dentures and such.
  4. Jaw surgical procedures that are invasive and extensive, and also prohibitively expensive.
  5. No procedures in particular. Just vague concepts of ‘neuromuscular dentistry’ that are not evidence-based.

As you can see, lots of the terms above come in quotation marks, as there is a lot of verbiage surrounding the treatment of orofacial pain and TMD. These procedures might have been attempted in the past, but the science at present proves otherwise.

The Role of an Orofacial Pain Specialist vs Other Specialists in Dentistry

Before I go further, I’d like to make it clear that many orthodontists, prosthodontists and Oral Maxillofacial Surgeons are extremely skilled at what they do. These are all important specialties within the field of dentistry. There are many such specialists who are updated with the science and treatment of orofacial pain and TMD, and whom I work closely with.

However, it is also important to realise that these various specialties in dentistry exist for specific purposes. If your intention is to have straight teeth, nice-looking jaws, and upper/lower teeth that meet well, then orthodontics, prosthodontics and/or jaw surgeries may be necessary.

If, however, you have been suffering from orofacial pain or TMD / TMJ Disorders and wish to improve your quality of life, then you need to see someone like an Orofacial Pain Specialist instead. Undergoing ‘occlusal rehabilitation’ or trying to ‘fix your bite’ for the purpose of solving this issue might even trigger more pain and damage.

What is Orofacial Pain and TMD, Exactly?

As stated on the AAOP’s (American Academy of Orofacial Pain) website:

“Orofacial Pain is the specialty of dentistry that encompasses the diagnosis, management and treatment of pain disorders of the jaw, mouth, face, head and neck.”

TMD is a painful condition that causes facial pain with many possible root causes, some of which include: Bruxism (teeth grinding), inflammatory or musculoskeletal disorders, very rarely from severely misaligned or missing back teeth, and even from orthodontic braces. You can read more about the symptoms and treatment of TMD here.

TMD is one manifestation of Orofacial Pain, but not the only one. Other causes of Orofacial Pain can be systemic, neuropathic or neurovascular in nature. There can also be many different types of problems with the TMJ (temporomandibular joint) itself, such as disc displacement, osteoarthritis or subluxation (partial dislocation) (Badel et al., 2019). Orofacial pain is a pretty wide umbrella term and therefore, proper diagnosis is crucial for effective pain management and treatment.

Dental Occlusion in Relation to the Treatment of Orofacial Pain and TMD - What the Latest Science Says

As we talked about earlier, many patients are often advised by well-meaning dental practitioners to ‘change their bite’. The idea behind this is to ‘realign’ the teeth such that they fit back into the ‘ideal’ position. This practice was executed in the past to try and relieve pain caused by TMD, but doing so did not deliver the desired results.

One big problem behind this idea is that majority of TMD patients do not have malocclusion. Malocclusion may not be a problem in itself as well – whether on its own, or as a cause of TMD (Türp et al., 2008). In fact, many people live with malocclusion without interference to their everyday lives, and without specific health risks such as TMD.

TMDs themselves can also alter the position of the jaw or change the way you move it, meaning that they can also be a contributing factor to the occlusion. According to Manfredini (2017):

“Despite the fact that dental literature has predominantly been directed towards the view of dental occlusion as the cause of TMDs, the inverse relationship may even be more plausible and should have been considered to explain the occasionally described association between cross-sectionally observed phenomena.”

It is important to note that there is no strong or credible evidence (in the forms of systematic reviews, meta-analyses, blinded randomised controlled trials or even larger longitudinal studies) that changing the bite and correcting malocclusion in patients with orofacial pain and/or TMD is effective in reducing their pain.

There are a few biased (non-randomised) studies found – but these do not provide any sound evidence-backed basis for orthodontic treatment as a legitimate treatment modality of orofacial pain.

Having said that, orthodontic treatment may be useful in the correction of permanent malocclusion brought about by certain TMD conditions, and thus has a specific place in Orofacial Pain and TMD treatment.

Some Things to Watch Out for When Doing Research for Malocclusion and Treatment for TMD

There are quite a number of research papers on dental occlusion for treatment of orofacial pain and TMD, but one needs to be careful of how such research is done and concluded as well. Take this paper on malocclusion and TMD by Al-Moraissi et. al (2017) for example, which concludes that:

“The results of this study show that patients who are going to have a correction of their malocclusion by orthodontics and orthognathic surgery have a significant incidence of TMDs when compared to a control population, but that after treatment, the incidence of TMDs does not differ from a control population. The reasons for these findings are not clear.”

Brignardello-Petersen (2018) provides an excellent rebuttal of this paper, and points out some common fallacies when it comes to research regarding orthognathic (corrective jaw) surgery to correct malocclusions for the purpose of TMD prevention. The four main points being:

  1. Insufficient details were provided for the search and selection methods, therefore, one cannot be sure that all relevant medical literature has been taken into account for a complete overview.
  2. Searches that only use comparative studies, meaning that it is biased and supports what they want to conclude to begin with.
  3. Lack of details pertaining to how they evaluated the quality of their assessments and studies.
  4. Misclassification in the designs of included studies, which is obviously a big problem in itself. Such methodological issues invariably lead to bias in the research.

Therefore, it is often not enough to only read the conclusion of a research paper, but to also evaluate how the research was conducted, and to cross-research with other credible sources. You can read Brignardello-Petersen’s rebuttal here:

Jada Clinical Scans - Malocclusion and TMD

“Occlusal Rehabilitation” for the Treatment of Orofacial Pain and TMD

The aim of occlusal rehabilitation is to restore faulty or missing teeth, so that a person may regain stability, function and aesthetics of their mouth area. Occlusal rehabilitation is not wrong or bad per sé, and is necessary for many scenarios.

At Nourish Dental Sleep & TMJ Care, we do dental implants for patients who clearly need them. We also make customised mandibular devices, but only for suitable patients. And the only way to know which type of treatments are most effective, is for the patient to undergo a proper clinical assessment by a trained Orofacial Pain Specialist.

When it comes to occlusal rehabilitation for the treatment of orofacial pain and TMD, great caution needs to be exercised, as the latest science shows that TMD is often of multifactorial aetiology (Palmer and Durham, 2021). Occlusal adjustment and other irreversible procedures are usually not only unsuccessful, but can damage patients unnecessarily.

Who to Seek for Treatment of Orofacial Pain and TMD

Patient safety should be of paramount importance, and irreversible procedures should not be carried out without reliable evidence (Caldas et al., 2016). TMD is a complex pain disorder of which the causes and effects are manifold, and should be treated as such (Ohrbach and Dworkin, 2016). There is a growing body of research that supports a biopsychosocial (biological, psychological, social) model for TMD pain instead.

It is not advisable that you spend thousands of dollars on a ‘neuromuscular’ intraoral device with little sound science behind its existence – and that’s probably just for starters. The orofacial pain and TMD patient probably needs to go on in search of something else that might help to relieve their pain, wasting yet more time and money. In the meantime, the pain continues to torment and interfere with their lives.

Instead, an evidence-based Orofacial Pain Specialist should be sought for pain management and treatment of such disorders. Someone who is not only knowledgeable and experienced enough to recognise the symptoms of Orofacial Pain and TMD, but who is also updated on the medical literature of related health conditions that can mimic these disorders. They should be able to assess the extent of damage or potential dangers, and come up with a plan for further investigations or treatments.

How Nourish Dental Sleep & TMJ Care Can Help with the Treatment of Orofacial Pain & TMD

Dr. Eric Chionh runs the practice at Nourish Dental Sleep & TMJ Care in Singapore, together with a dedicated team. Our clinic uses the necessary technology to diagnose, treat and manage each patient’s condition at our clinic. We never generalise, and take into account every individual’s personal medical history, lifestyle, pain experience, pain threshold and specific symptoms. What works for one patient might not be ideal for another.

Dr. Chionh has had many years of hands-on experience in the treatment of Orofacial Pain and TMD / TMJ Disorders, and is passionate about improving his patients’ quality of life using evidence-based medicine. He keeps himself updated on the latest scientific and dental literature, in order to serve his patients to the best of his ability.

He is formally trained in Oral Medicine and Orofacial Pain, and holds a Singapore Dental Council approved qualification in these areas. You can learn more about Dr. Eric Chionh on our About page, and view all services provided by Nourish Dental Sleep & TMJ Care here.

References:

  • Al-Moraissi, E. A., Perez, D., & Ellis III, E. (2017). Do patients with malocclusion have a higher prevalence of temporomandibular disorders than controls both before and after orthognathic surgery? A systematic review and meta-analysis. Journal of Cranio-Maxillofacial Surgery, 45(10), 1716-1723. https://doi.org/10.1016/j.jcms.2017.07.015
  • Badel, T., Zadravec, D., Kes, V. B., Smoljan, M., Lovko, S. K., Zavoreo, I., … & Milošević, S. A. (2019). Orofacial pain–diagnostic and therapeutic challenges. Acta Clinica Croatica, 58(Suppl 1), 82. https://doi.org/10.20471/acc.2019.58.s1.12
  • Brignardello-Petersen, R. (2018). The association between malocclusions and temporomandibular disorders in patients undergoing orthognathic surgery is uncertain owing to limitations in a systematic review summarizing the relevant evidence. The Journal of the American Dental Association, 149(1), e15. https://doi.org/10.1016/j.adaj.2017.09.041
  • Caldas, W., Conti, A. C. D. C. F., Janson, G., & Conti, P. C. R. (2016). Occlusal changes secondary to temporomandibular joint conditions: a critical review and implications for clinical practice. Journal of Applied Oral Science, 24, 411-419. https://doi.org/10.1590/1678-775720150295
  • Manfredini, D., Lombardo, L., & Siciliani, G. (2017). Temporomandibular disorders and dental occlusion. A systematic review of association studies: end of an era?. Journal of oral rehabilitation, 44(11), 908-923. https://doi.org/10.1111/joor.12531
  • Ohrbach, R., & Dworkin, S. F. (2016). The evolution of TMD diagnosis: past, present, future. Journal of dental research, 95(10), 1093-1101. https://doi.org/10.1177/0022034516653922
  • Palmer, J., & Durham, J. (2021). Temporomandibular disorders. BJA education, 21(2), 44-50. https://doi.org/10.1016/j.bjae.2020.11.001
  • Türp, J. C., Greene, C. S., & Strub, J. R. (2008). Dental occlusion: a critical reflection on past, present and future concepts. Journal of oral rehabilitation, 35(6), 446-453. https://doi.org/10.1111/j.1365-2842.2007.01820.x