In my practice, the patient themselves have to be the "star of the show." The most valuable "treatment" I can perform is to be an effective coach, teacher, and trainer for the patient.
I believe it is critically important to emphasize to the TMD patient that the treatment recommendations you give them are the minimum necessary to insure treatment goals are met. Also emphasize that the recommendations are not a “menu of choices” they can pick and choose from (see the FAQ section for the typical treatment modalities I employ). If patients are not committed to following through with all your recommendations, they should be told they might be wasting their time and money. Also tell them that if they only want to go to a physical therapist who is on their insurance that the treatment will probably not be successful (very few P.T's have the specialized training and experience to effective treat a TMD patient).
Too often, it is the patient who has not followed the instructions and recommendations of myself, and the other clinicians they are referred to, who returns and complains that they are not getting better. To these patients, I say something like “The good news is there are answers for your problems. The bad news is there are not easy answers.” Review with them again the things they will have to follow through on to get the results they are seeking. Remind them that it often takes 4-6 months to achieve optimum results.
Patients are seen every 2-3 weeks. Review their chief complaints each time, review how they are following through on all recommended treatment, re-examine them, insure they are making progress in range of motion, resolution of joint inflammation and muscle tenderness, and re-balance their splint if necessary. Make other treatment recommendations, as needed. Consult with the other clinicians they have been referred to, to coordinate care and get feedback from them regarding patient compliance and progress.
In the end, it is the patient who has to be a primary member of the treatment team. I tell patients we can only help them if they are fully dedicated to doing everything necessary to resolve their symptoms. If the patients are not committed to helping themselves, no treatment efforts on our part will be successful. Besides the treatment you render, you are there to encourage them, reassure them, and coordinate their care.
The goal is to give them a long-term solution, so they are not experiencing symptom recurrences on a regular basis. For most TMD patients, the trigger for symptom exacerbations is stress. Tell them this up front, so it does not sound like an excuse when they come back later wondering why they have symptoms again. Try to give them tools and resources so they can manage exacerbations on their own. Following this approach will greatly reduce the need for frequent recalls or re-treatment.
This is a better approach than just trying a splint first, and if that does not help, to then recommend something else. The patient perceives this approach as the doctor just playing a guessing game.
It takes more than a piece of plastic to effectively manage a TMJ patient. However, by tailoring the treatment to the individual patient’s needs, treatment time and expense is greatly reduced, and they can avoid expensive restorative work or orthodontics in the vast majority of cases.
In addition, I strongly recommend that you read the FAQ and Appendix sections of this syllabus, as they amplify the importance of the statements made on this page.
What is the take-home message?
There are several.
If you have an interest in treating these patients, spend the time and money to build a sound foundation using the resources listed on this site. Remember what Yoda said:
“A weekend course does not a sound foundation make.”
- Attend the annual conference of the TMD organizations (web sites of the organizations are listed above). See which one you feel most comfortable with, in terms of the philosophy and treatment approaches being advocated.
- Use the information contained in this paper to assist you in recognizing the hidden agendas and marketing hype of those with something to sell.
- Learn to read between the lines of the research literature that has been published in this field.
- Be the best student you know how to be.
"Learning is not attained by chance. It must be sought for with ardor and attended to with diligence."
The old saying is still true: “Patients don’t care how much you know until they know how much you care.” Treating TMD patients is fundamentally different than treating routine dental patients. Too many TMD patients suffer in silence because they don’t want to be a burden to their family, and they don’t want to complain. They will tell you, without realizing it, what the diagnosis is and how to treat them; but only after they are assured that you will take the time to really listen with empathy and understanding, and without preconceived ideas of how you can make them accept one of the treatments you perform. Sometimes the greatest gift you can give them is simply acknowledging the pain and suffering they have been enduring, because they have learned that no one else understands.
Treating TMD patients is highly rewarding. However, if you treat them in the manner I have recommended above you will not get rich. The reward is in knowing that you provided a service that no one else could, because you are a doctor of the masticatory system. It is also rewarding because you recommended the treatment that is best for the patient, not that which is best for your production goals. Sometimes the best treatment for the patient is not to treat them at all, but rather to refer them to someone in a different discipline, who can treat the source of their jaw pain rather than the site of their jaw pain.
Much of the confusion surrounding the TMD field is self-inflicted. As a profession, we have made it confusing because we have failed to reach a consensus on how to diagnose and treat these problems. This syllabus is an attempt to enumerate some of the reasons for this lack of consensus.
Thirty-five years ago, when I was immersing myself in this field, I assumed that in twenty years hence we, as a profession, would have worked out our differences, to the great benefit of our patients. Sadly, I have to report that we not only have not resolved our differences, we now disagree in much more sophisticated ways. This helps insure that our patients are not insured for the treatment they require. It also insures that it is the patient making the differential diagnosis, based on whom they choose to go to for help.
Hopefully, the reader of this paper will be much better equipped to see the “lay of the land” in the TMD field, and be able to make more informed choices as they seek to increase their understanding of this condition. You should also be in a better position to counsel your patients about reasonable courses of action.