Dental Practitioners behaviour,perspective and treatment approach towards management of TMJ Disorders

Abstract

Background

TMJ disorders often involve a multidisciplinary approach, clear understanding is a must for the treatment of TMDs. This study aimed to assess the behaviour, perspective and treatment approach of Dental Practitioners towards the management of TMJ Disorders. This would help in developing the census about the knowledge level and attitude towards TMD among dental practitioners.

Methods

A comprehensive cross-sectional investigation involving 1030 dentists was conducted through the implementation of a meticulously designed survey instrument created using Google Forms. The questionnaire contained 17 closed-ended questions with the ability to mark more than one option in a few questions. the first 5 questions (Q1-Q5) determined the behaviour of Dental practitioners when they initially face TMD patients, (Q6-Q8) were asked to determine the perspective regarding cause–effect relationship in TMD disorder,(Q10-Q17) determined the treatment approach of Dental practitioners. Dichotomic answers were compared using a binomial test and multiple answers were evaluated using a Clopper-Pearson test with significance set at p < 0.05.

Results

77.7% of participants reported that they receive potential TMD patients in their office most frequently found aetiology for the pain was occlusal discrepancy (48.5%) followed by trauma (39.8%). The most commonly referred specialities were maxillofacial surgery (57.3%) and Prosthodontics (29.1%). The majority of the Practitioners treated their TMD patients with occlusal splints.

Conclusion

The management of TMJ disorders requires a comprehensive and interdisciplinary approach. Practitioners clarified that TMD patients were mostly treated with conservative measures using occlusal splints. However, the dentist should have cooperative behaviour and a clear perspective for the proper management of TMDs.

Keywords

TMJ dental practitioners occlusal splint MPDS trauma occlusion

1 Introduction

Temporomandibular joint (TMJ) disorders refer to a group of conditions that affect the jaw joint and the muscles controlling jaw movement.¹ Temporomandibular disorders (TMDs) are a class of musculoskeletal and neuromuscular conditions that affect the temporomandibular joints (TMJs), the masticatory muscles, and all associated tissues. This was stated in a 2010 statement published by the American Association for Dental Research (AADR).^1–3

This complex joint connects the jawbone to the skull and is essential for activities such as talking, chewing, and yawning. TMJ disorders can manifest in various ways, leading to pain, discomfort, and restricted jaw movement. Diagnosis often involves a thorough examination by a dentist and treatment options vary based on the severity and underlying cause of the disorder. Some conservative approaches may include lifestyle modifications, stress management techniques, and the use of oral appliances to alleviate symptoms. In more severe cases, medical interventions such as physical therapy, medications, or, in rare instances, surgery may be recommended.³

Managing TMJ disorders often involves a multidisciplinary approach, and patients may benefit from collaboration between dentists, physical therapists, and other healthcare professionals. Early recognition and appropriate intervention can help alleviate symptoms and improve the overall function of the TMJ. Numerous significant studies have validated the multidimensional biopsychosocial model of TMD. According to the biopsychosocial paradigm, individuals with TMD should have comprehensive assessments of their mobility difficulties, psychological distress, chronic pain, and social conditions .

For many years of diagnosis and treatment of TMDs, attention has been placed on the TMJ's viewpoint; in the results of diagnosis from MRI and tomography, in the anamnesis, and the physiological response of muscles and articulations during sound contact. Nevertheless, the dental view, namely occlusal and its relation with the treatments, is equally necessary to obtain a harmonious stomatognathic function.⁴ The correct occlusal analysis provides valuable diagnostic information for TMDs. Tech-scan is incorporated as part of a new diagnostic system. The Tech-scan system, the T-scan, is a tool for measuring and recording occlusal contacts during jaw movement. The occlusal analysis is an important aspect in the evaluation of TMD treatment, and new technologies may enhance the diagnostic procedures. The occlusal discrepancies, which are high-risk factors of TMDs, could be visualised by the integration of new technologies or advanced diagnostic devices and techniques in the classical occlusal analysis.^5,6

Numerous treatment options exist for managing temporomandibular joint disorders (TMDs), but the optimal treatment approach for the management of TMDs is still not clear. TMD treatments can be approximately classified into three groups: a conservative approach including educational and psychological interventions and physical modalities, pharmacological methods, and surgical intervention in terms of invasiveness. These therapeutic agents or modalities can be used alone or in combination. Splint therapy approaches can be classified roughly into non-invasive modalities that do not have a direct influence on the masticatory system and central nervous system, and invasive ones with alteration of occlusion intended by wearing occlusal appliances for cognitive occlusal adjustments. It is important to have individual patient management based on functional, behavioural, and structural aspects and geared to the pain modulatory processes that may be largely generalised dysfunction of the somatosensory modulatory system.^4,7–10

DC/TMD has proposed the biopsychosocial model as one of the key tenets of clinical considerations. In daily clinical practice, it has been discovered that some dentists have very limited awareness of TMD and view it as a straightforward somatic symptom or organic lesion.^11–15 This frequently results in patients receiving an incorrect diagnosis or advice regarding treatment possibilities. There are many factors which may influence the existing motivation to obtain further skills in treating TMD patients. It may be intrinsic cognitive factors, personal satisfaction, and professional pride or other extrinsic factors including positive or negative recognition by another specialist, promotion of one's own dental office by providing high quality patient care, and the very perspective of achieving financial benefits. Failure to recognise the need for psycho-social, endocrine, or anti-inflammatory treatment in dentistry, related stigmatisation of people in pain, fear of tension and defence reaction on the part of the practitioner treating TMD, loss of prosthetic or pharmacological patients, lack of investment in this treatment by the patient, and stress due to unrealistic expectations are the most influencing factors.¹⁶ Thus, assessing dentists’ present knowledge of TMD diagnosis and treatment might aid in the development of effective educational initiatives to raise their degree of TMD-related knowledge and awareness. Numerous research involving dentistry students or practicing dentists in various countries have been conducted thus far to gain an understanding of the knowledge and attitudes surrounding TMD.¹⁷

A cross-sectional study reported that Iranian general dentists lacked sufficient information regarding chronic Orofacial Pain (OFP), particularly about therapy.¹⁸ Similarly, Indian post-graduate students have low confidence in their ability to manage diseases of the TMJ, according to a cross-sectional study.¹⁹ Patients’ normal lives, money, and exposure to needless treatment will all be impacted by the dentist's incapacity to diagnose OFP.

To evaluate dental professionals’ knowledge, attitudes, and practices (KAP) on TMDs, a few surveys have been conducted globally.²⁰ Nevertheless, no research has been conducted in India when searched using a PubMed data base.

This study aimed to assess the behaviour, perspective and treatment approach of Dental Practitioners towards the management of TMJ Disorders. This would help in developing the census about the knowledge level and attitude towards TMD among dental practitioners in India, thus revealing the current status of TMD education and helping in framing the policies and guidelines for the same.

2 Materials and method

2.1 Type of study and sampling

Data for this cross-sectional study were gathered from a representative sample of the western Central India region's registered dental practitioners, who finished their studies and practised dentistry in an institution, and dental practitioners, who finished their education and became licenced dentists. The non-probability sampling method, (quota sampling) was utilised. To calculate the sample size the following formula was used - sample Size = (Z-score)² × Standard Deviation × (1-Standard Deviation) / (confidence interval)² (Andrew Fisher's Formula- where standard deviation 0.5, Confidence level 95%, Z-score 1.96, confidence interval 6.),²¹ Considering a total of 1030 participants in the study.

2.2 Ethical considerations

This study was conducted in compliance with the Declaration of Helsinki; ethical approval (YCDC/IES-IRC/312/2023-24) was given by the ethics committee of the Yashwantrao Chavan Dental College, Ahmednagar, Maharashtra, India. The participants provided their informed consent. Participation was voluntary and there were no incentives. Data protection and anonymity were guaranteed.

2.3 Questionnaire

An online survey instrument was meticulously crafted utilising Google Forms. This digital questionnaire encompassed a spectrum of inquiries about the diagnosis, awareness levels concerning TMDs, the modalities of treatment employed, and the subsequent follow-up protocols for TMDs. The hyperlink to the Google Form was disseminated across a diverse cohort of dental practitioners using different platforms for communication, e.g., WhatsApp, e-mail., (including general dentists, Prosthodontists, Oral and maxillofacial surgeons, Orthodontists, Pedodontists, Periodontists, Oral Pathologists, and Public health dentists). The communication data of every participant was gathered and coded. Every participant received two weekly reminders to send in the completed questionnaire along with their answers. When necessary, the respondents were given the opportunity to have in-depth conversations and were given explanations about the study and its application.

A total of 1030 dentists participated in the survey. Inclusion in the sample was independent of the school of origin, age, gender, professional experience, or year of graduation. Informed consent was taken before the start of the survey.

The questionnaire contained 17 closed-ended questions with the ability to mark more than one option in a few questions. The survey instrument utilised in this investigation was analogous to one utilised by Aldrigue et al.³ in Brazil, which relied on information from the American Academy of Orofacial Pain, the European Academy of Craniomandibular Disorders, and the AADR. They informed that a systematic review of agreements based on international recommendations for TMD and OFP management was conducted to confirm the questionnaire used in their study.

The questionnaire used in the sample survey study was revised by adding five new questions. Its validity and reliability were evaluated by 4 senior dentists and a psychometrician for vetting and remarks. The suggested changes were made to guarantee its coherence. Additionally, 115 participants in pilot research validated the questionnaire. The pilot research dataset obtained was assessed to check the consistency in reply after analysis, strong internal consistency was found with an overall Cronbach's alpha of 0.82 for the questionnaire. There were three sections to the study's questionnaire.

In the present study, the first 5 questions (Q1-Q5) determined the behaviour of Dental practitioners when they initially face TMD patients, (Q6-Q8) were asked to determine the perspective regarding cause–effect relationship in TMD disorder,(Q10-Q17) determined the treatment approach of Dental practitioners. With the exception of the yes/no choice questions, participants were allowed to select more than one response on the questionnaire.

Statistical Analysis: For all statistical tests, SPSS Software, IBM version 24.0 software was used. Descriptive statistics(frequency and percentage) and inferential statistics were calculated for all variables. Dichotomic answers were compared using a binomial test and multiple answers were evaluated using a Clopper-Pearson test with significance set at p < 0.05

3 Results

The results of the study can be considered under the behaviour, perspective and treatment approach of the participants. On analysing the results of the study for the behaviour towards TMD, it can be ascertained that knowledge plays an important role in developing the behaviour. Of the dental practitioners surveyed, 77.7% reported that they receive potential TMD patients in their office (p < 0.001). The majority of the participants 80% knew the diagnosis but very less cohorts had treatment knowledge for TMD. The diagnostic procedure employed, the approach toward each patient, and the place of referral were significantly different among dental practitioners (p < 0.001). A combination (78.6%) of the medical history, physical examination, radiological visualisation and Study models were the most frequently employed strategies for obtaining a diagnosis. Of the practitioners who responded, 80.6% reported that they offered treatment to the patients. Maxillofacial surgery and (57.3%) Prosthodontics (29.1%) were common specialities for patient referral. (Table 1, Figure 1 and 2).

Figure 1.

Figure depicting the responses for the cause of Pain.

Figure 2.

Figure depicting the responses related to speciality for referral of TMD patients.

Table 1.

Distribution of behaviour-related questions.

		Frequency	Percentage
Q. No.	Questions	(n = 1030)	(%)	P value
1.	Have potential TMD patients sought treatment at your dental clinic?			0.000**
	Yes	800	77.7
	No	230	22.3
			100
2.	Do you know in detail about TMD?
	Diagnosis-
	Yes	803	78%
	No	227	22%
	Treatment-
	Yes	670	65%
	No	360	35%
3.	What is the most common underlying cause for the pain?			0.000**
	Systemic	20	1.9
	Trauma	410	39.8
	Iatrogenic	60	5.8
	Occlusal	500	48.5
	Mental health	40	3.9
4.	What procedures do you use to diagnose these patients?			0.000**
	Medical history	20	1.9
	Physical examination	90	8.7
	Radiological visualisation	90	8.7
	Study model	20	1.9
	Combination of these methods	810	78.6
5.	What is your approach toward these patients?			0.000**
	Offer treatment	830	80.6
	Refer to another dentist	70	6.8
	Refer to an academic institution	130	12.6
6.	If you do not treat these patients, to what specialty do you refer them?			0.000**
	Prosthodontics	300	29.1
	Orthodontics	110	10.7
	Otorhinolaryngology	10	1
	Physiotherapy	10	1
	Neurology	10	1
	Maxillofacial surgery	590	57.3

The perspective of the participants overall shows positive towards the TMDs. This perspective is mainly governed by the attitude, the majority of participants feel that TMDs should be treated on a priority basis and it affects not only the stomatognathic system but also the whole body. Table 2 indicates the responses to the cause–effect relationship questions for TMD. All the practitioners were aware of the relationship between TMD and malocclusion. Half of the practitioners considered the occurrence of MPDS(52.4%) to be more common while the other half (53.5%) considered clicking and deviation to be more prevalent.

Table 2.

Questions regarding cause–effect relationship in TMDs.

	QUESTIONS	FREQUENCY	PERCENTAGE	P VALUE
7.	Do you feel that TMD causes derangement of whole body system?
	Yes	951	92.30
	No	79	7.70

8.	Do you feel that TMD should be treated in priority basis?
	Yes	997	96.8
	No	33	3.2
9.	Are you aware of the relationship between TMJ and malocclusion?			0.000**
	Yes	1030	100
	No	0	0

10.	What is the most common temporomandibular disorder which you have come across?			0.000**
	MPDS	540	52.4
	Ankylosis	120	11.7
	Internal derangement	130	12.6
	None of the above	240	23.3

11.	If your option was 4, please specify the temporomandibular disorder which you have come across			0.000**
	Subluxation	333	32.3
	Clicking and deviation	551	53.5
	Mandibular deviation	63	6.1
	Dislocation of joint	52	5.1
	Disc displacement	31	3

Table 3 shows the responses to the treatment approach employed occlusal splinting(33%) followed by oral rehabilitation and prosthetic treatment(22%)were the most common treatments. 48.5% practitioners responded to the usage of soft stabilisation appliances fabricated by conventional technique(59.2%) used. During splint fabrication, 80.6% of practitioners used semi-adjustable articulators, for occlusal adjustments at the time of application. Occlusal splints were made in maximum intercuspation(30.1%) or a centric relationship by (34%) of the practitioners, with the treatment based on the features of the individual patients (p < .001).

Table 3.

Distribution of questions on the treatment approach employed.

	QUESTIONS	FREQUENCY	PERCENTAGE	P VALUE
12.	If you do treat these patients, what treatments do you offer them?			0.000**
	Counselling	107	10.4
	Diet plans	51	4.9
	Thermotherapy	20	1.9
	Physiotherapy	60	5.8
	Pharmacotherapy	30	2.9
	Occlusal splinting	340	33
	Occlusal adjustment	165	16
	Oral rehabilitation and prosthetic treatment	227	22
	Other	30	2.9
			99.8
13.	What type of splint do you employ?			0.000**
	Anterior bite appliances	190	18.4
	Posterior bite appliances	130	12.6
	Hard stabilisation appliances	90	8.7
	Anterior positioning appliances	120	11.7
	Soft stabilisation appliances	500	48.5
14.	Which technique do you employ for fabrication of 4 splint?			0.000**
	Conventional technique	610	59.2
	Milling	110	10.7
	3 D printing	310	30.1
15.	Do you use semi-adjustable articulators?			0.000**
	Yes	830	80.6
	No	200	19.4
16.	In what occlusal relationship do you fabricate the splint?			0.762#
	Maximum habitual intercuspation	310	30.1
	Centric relationship	350	34
	Depends on the individual patient	370	35.9
17.	By how much do you increase the occlusal vertical dimension with the splint?			0.000**
	1mm	110	10.7
	2mm	400	38.8
	3mm	80	7.8
	≥4 mm	30	2.9
	Depends on the individual patient	410	39.8

18.	Do you adjust the occlusal surface of the splint at the time of fitting?			0.000**
	Yes	740	71.8
	No	290	28.2

19.	What are your instructions regarding the duration of splint use?			0.004**
	Nocturnal	300	29.1
	Daytime	130	12.6
	All the time	220	21.4
	Depends on the individual patient	380	36.9

20.	How often do the patients return to the office for follow-up?			0.413#
	Weekly	280	27.2
	Monthly	380	36.9
	Depends on the individual patient	370	35.9
Binomial test: Clopper Pearson test - P < 0.05 – significant , P < 0.001 – highly significant *, P > 0.05 – not significant #
21	Do you feel that you received sufficient education and training for TMD management in dental school?			-
	Yes	587	57.00
	No	443	43.00

22	Do you want to learn more about TMDs and its management?			-
	Yes	958	93.00
	No	72	7.00
23	Which method do you think is most effective way for learning TMDs and its management?			-
	Incorporating in UG dental education system	880	85.4
	Post-graduation	113	11
	CDE programmes and workshops	37	3.6

39.8% of practitioners considered that the increase in vertical dimension should done depending upon individual patient. (p < .001).71.8% of practitioners made adjustments to the splint's occlusal surface during fitting.29.1% of practitioners gave their patients instructions on how to use night-time splints. In contrast, 36.9% thought that the length of time a splint should be used depended on the patient (p < .001). A majority of practitioners (36.7%) conducted monthly follow-ups with their patients (p < .001).

4 Discussion

Temporomandibular joint (TMJ) disorders are a complex and often misunderstood set of conditions that affect the jaw joint and surrounding muscles. The TMJ is a hinge joint connecting the jawbone to the skull, and it plays a crucial role in various daily activities such as speaking, eating, and facial expressions. When dysfunction occurs in this joint, it can lead to a range of symptoms, including pain, stiffness, clicking or popping sounds, and difficulty in jaw movement. Understanding the intricacies of TMJ disorders is vital for healthcare professionals to provide accurate diagnosis and effective management strategies.^14,22–24

One of the key challenges in dealing with TMJ disorders is the diversity of symptoms and the multifactorial nature of the condition. The exact causes of TMJ disorders can vary, encompassing factors such as genetics, trauma, stress, or dental issues.²⁴ This complexity underscores the importance of a comprehensive approach to diagnosis and treatment. Dentists, oral and maxillofacial surgeons, and physical therapists play crucial roles in addressing TMJ disorders. A thorough evaluation, including a detailed medical history, clinical examination, and often imaging studies, is essential to identify the underlying causes and determine the most appropriate course of action.

In more severe cases or when conservative measures prove ineffective, surgical interventions may be considered. Arthrocentesis, a minimally invasive procedure involving the flushing of the joint with sterile fluids, can provide relief by removing inflammatory byproducts. Arthroscopy, another surgical option, allows for a more detailed examination of the joint and the removal of damaged tissue.^13,25 For more complex cases, open-joint surgery may be necessary to address structural abnormalities or reposition the disc within the joint. The decision to pursue surgical intervention should be based on a thorough assessment of the individual's condition, considering factors such as the severity of symptoms, response to conservative treatments, and overall health.

Collaboration among different healthcare professionals is paramount in the management of TMJ disorders. Dentists and oral surgeons work hand in hand to diagnose and treat dental issues that may contribute to the dysfunction of the TMJ. A multidisciplinary approach ensures that all aspects of the condition are addressed comprehensively, leading to more effective and lasting outcomes. The difficulties in the management of TMD arise from the fact that it is a multifactorial disorder and the importance of having multidisciplinary care with various kinds of specialists. Interdisciplinary teams of dental practitioners, medical specialists, clinical psychologists, social workers, and physical therapists have been assembled for the management of TMD patients.^19,20 To develop expertise in treating TMD, several factors can influence this process. Educational programmes provide most healthcare professionals with fundamental theoretical information and procedural skills. The essentials of knowledge invested in professional improvement in diagnosing and treating TMD will give them a clear understanding of the complexity and a need for collaboration in the treatment approach, amalgamating knowledge from dentistry and physical examination, communication, and cooperation with other medical specialists and psychologists. Ongoing training in this field serves as a supplementary source of new knowledge and experience. Practical professional improvement in treating TMD is also crucial, this will not only benefit the clinicians but also help in influencing the patients with jaw related problems and providing the valuable and effective treatment.⁸

Patient education is an integral component of TMJ disorder management. Many individuals may not be aware of the potential causes and risk factors associated with TMJ disorders, and misconceptions abound. Providing patients with clear and accurate information about their condition, treatment options, and expected outcomes is essential for empowering them to actively participate in their care. Educating patients about self-management techniques, such as stress reduction strategies and proper jaw habits, can significantly contribute to the success of treatment plans.

Furthermore, ongoing research is critical for advancing our understanding of TMJ disorders and refining treatment approaches. The development of more targeted and personalised interventions relies on a deepened knowledge of the underlying mechanisms and contributing factors. Researchers are exploring the role of genetics, inflammatory processes, and biomechanical factors in the development and progression of TMJ disorders. By uncovering these complexities, scientists aim to identify novel therapeutic targets and refine existing treatment protocols, ultimately improving outcomes for individuals affected by TMJ disorders . Education programmes with a focus on patients’ experiences, applied through learning activities that emphasise a broad perspective on the patient, better clinical reasoning, and the development of communication strategies, may help to foster effective practice. This education should challenge dental practitioners to become curious, try new things, and put extra emphasis on the social learning environment in multiple contexts. We recommend education that stimulates learning in a community of practice in which collaboration between professionals of different backgrounds is encouraged. The ability to communicate and work together with other medical professions is important since physical care for patients with TMDs should be managed interdisciplinary. Again, this way may be conducive to practical and acute application in educational settings as well as help to guide improvements in educational content. In the long run, to enhance TMDs, dental professionals should put their efforts into policy changes in the aforementioned domains.²⁶

In this study, more than 75% of the participants had TMD patients in their clinical set-up and almost 65% treated them at the clinic, while 35% of dentists referred treatment to other specialists which is an important finding as participants consider the TMD to be treated with priority (96.8%) but when it comes to treating them major section is referring them. The reason may be many but the most important is the lack of complete knowledge about TMDs and its treatment. This is a fact that should be given due consideration as most of the time it is the dentist who will be approached first by the patients for any issues related to TMJ. The Council of the European Academy of Craniomandibular Disorders also recommends a basic initial examination to rule out a TMD and an assessment using oral, maxillofacial, and general histories together with relevant imaging studies to establish a workable diagnosis. This aids in the classification of illnesses including neurological, mental, and head and neck disorders as well as the detection of psychosocial variables.²⁷ It is recommended that dentists should be ready to learn always, and it is a proven fact that the more the dentist examines and gives treatment the more confident and skilled the practitioner gets and gain confidence.

About 78.6% of the cohort use combination methods to diagnose patients in 8.7% use physical and radiological methods mainly. Numerous research has addressed the prevalence of evidence-based clinical diagnosis techniques compared to cutting-edge technical techniques.^1,20,28 It is always better to have a combined assessment modality over a particular one. This finding of the present study is in accordance with many previous studies where a physical examination and the patient's medical history are the main approaches used by GDPs to diagnose TMD, while other diagnostic techniques have also been covered in earlier research.^28–31 In contrast, all GDPs diagnosed TMD based on the patient's medical history and physical examination; none used a radiological visualisation or created a study model, according to a study by Tamer et al. conducted in Istanbul.³²

The primary goal of an effective TMD treatment plan should be to reduce the signs and symptoms of TMDs.³³ The existence of joint sounds (clicking and crepitation), decreased mouth opening, and abnormal jaw motions are the most pertinent indications of TMD.^34,35 However, the main issue with this condition is pain, which is usually the reason these individuals seek medical attention. Additionally, it is probably the reason why the majority of research has focused on assessing the efficacy of different intervention strategies with as the primary variable.^36,37

The bar graph (Figure 1) reveals trauma (38.7%) and occlusal factors (48.6%) as predominant contributors to reported pain, while systemic, iatrogenic, and mental health factors exhibit comparatively lower impact. These findings underscore the distinct hierarchy of pain aetiology within the surveyed cohort. In the present study, Dental practitioners who referred their TMD patients to a specialist preferred to refer them to Oral surgeons (57.3%), Prosthodontists(29.1%) and Orthodontists (10.7%) (Figure 2). In the present study, choice of speciality for referral was oral surgeon which is in contrast to the practitioners of the Istanbul who preferred the Prosthodontists and Orthodontists more, also the study by Aldrigue et al.³ indicated that most GDPs in Brazil referred their TMD patients to orthodontists. Irrespective of the speciality it should be kept in mind by the treating dentist that the TMDs should be treated with the most conservative and reversible treatment, and the same has been documented and enforced by two consensus publications, on treatment techniques for TMD patients^1,27 most of the time the approach by the Prosthodontists and Orthodontists is conservative and reversible, on other hand maxillofacial surgeons are aggressive in approach but for sure each has their scientific proof to perform a particular treatment.

Of the surgical treatments available, arthrocentesis based on articular lavage with or without pharmaceutical injection and arthroscopy are the two most commonly utilised methods for internal derangements of the TMJ or degenerative disease. When comparing arthroscopy with arthrocentesis, there are no differences in terms of discomfort or mandibular function.³⁸ Nevertheless, there is insufficient data to suggest that arthrocentesis is a more effective therapeutic intervention than nonsurgical methods.^39,40 Patients with symptomatic disc dislocation without reduction should be treated with the simplest and least invasive method⁴¹; medicinal therapy or rehabilitation is preferred over other surgical options for internal derangement of the TMJ. In addition, there is mounting proof that platelet-rich plasma injections are superior to hyaluronate with arthrocentesis in treating TMJ osteoarthritis; nevertheless, additional clinical trials are required.

The cohort in the present study reported MPDS as the most common TMJ problem followed by Ankylosis and Internal derangement. Effective management of TMJ disorders requires a combination of conservative and, in some cases, surgical interventions. Conservative measures often include lifestyle modifications, such as stress management techniques, dietary adjustments, and the application of heat or cold packs to alleviate pain and reduce inflammation. Physical therapy exercises aimed at strengthening and stretching the jaw muscles can be beneficial in restoring normal function. In addition, the use of oral appliances, such as splints or mouthguards, may be recommended to help stabilise the joint and prevent teeth grinding or clenching, which can exacerbate TMJ symptoms.

The most popular treatment option provided by dental professionals in the survey was the splint (33%), which was followed by counselling, occlusal adjustment (16%), oral rehabilitation and prosthetic treatment (22%), and counselling (9.7%). According to a 2013 survey, 76% of GDPs treated patients with TMD, 97.6% provided mouthguards or splints, 85.9% encouraged self-care, 84.6% gave prescriptions for over-the-counter drugs, and 63.6% performed occlusal adjustment.

In comparison to non-occluding splints or no treatment, hard occlusal splints have shown a respectable level of success in treating temporal muscle dysfunction discomfort, according to a meta-analysis.⁴² On the other hand, research has shown that the results of patients treated with active and placebo splints were comparable. Alencar and Becker⁴³ treated three groups of patients with hard splints, soft splints, or non-occlusal splints after randomly selecting 42 patients with myofascial pain. According to their study's findings, all three appliances helped with symptom relief, and after 90 days, there were no appreciable differences between the three groups. As a result, the current study suggests that, as a conservative measure, using splints (soft stabilisation equipment) as the initial treatment for TMD patients is reasonable regardless of the contact surfaces of the splints or the material / technique from which they are produced.

According to Terebesi et al.'s,⁴⁴ investigation into the connection between motor unit recruitment and vertical alterations in the jaws, the degree of vertical splint separation was positively correlated with the patients’ therapeutic outcomes for myofascial pain syndrome. In the current study, dental professionals (39.8%) changed the occlusal splint's thickness based on the requirements of specific patients, and 38.8% changed it by two millimetres.

Dental schools should identify pain in the orofacial region more broadly, rather than restricting their expertise to pain that is solely related to intraoral structures. They should also understand that pain is a legitimate health concern that the dentist should be handling.³ This present study's findings are comparable to those of a study by Aldrigue RHS et al.,³ which found that 81% of GDPs are comfortable treating patients at their dental clinic, whereas 19% of GDPs are referred to another dentist or academic institution because they lack the necessary skills and expertise. However, comparable research carried out in other regions of the world revealed that GDPs felt uneasy about the diagnosis and treatment of TMDs. They also underlined the need to develop and strengthen undergraduate dental course curricula and continuing education in TMD.

Almost the entire cohort (93%) was willing to learn about TMDs in detail. Learning is a curve which will never flatten, as illustrated by the results of our study: almost all participants were ready to enhance their knowledge. They feel the amount of knowledge that they have received during education is not sufficient and the majority consider the incorporation of a detailed pain management curriculum in the Undergraduate dental education system would enhance the understanding and provide better care to patients. Also there are many factors which may influence the existing motivation to obtain further skills in treating TMD patients. It may be intrinsic cognitive factors, personal satisfaction, and professional pride or other extrinsic factors including positive or negative recognition by another specialist, promotion of one's own dental office by providing high quality patient care, and the very perspective of achieving financial benefits. The perception of opportunities for the exchange of experience with well-known experts in the field, especially during residency, for being a potential successor, or the lack of a supportive work environment are some factors that could affect the motivation of dental expert for TMDs treatment. Failure to recognise the need for psycho-social, endocrine, or anti-inflammatory treatment in dentistry, related stigmatisation of people in pain, fear of tension and defence reaction on the part of the practitioner treating TMD, loss of prosthetic or pharmacological patients, lack of investment in this treatment by the patient, and stress due to unrealistic expectations are the most influencing factors.⁴⁵

5 Limitations

There are some limitations in this study. The extended questionnaire length contributed to insufficient responses, and the absence of information about the participating dentists, the inherent limitation of the close-end questions, open-ended questions with the ability to express the views would give a better perspective about the topic. In the present the closed-ended questionnaires (participants may provide suggestions or ideas, simple answers may be given to complex questions, and participants may misinterpret questions), and nonprobability sampling technique (which significantly depends on the researchers’ experience) are used which is a major limitation because participants were not able to present their view. It is recommended to use open end questions in future work. We felt that the questions in the study should include the level of education, experience and training associated with the practitioners to get a clear idea about the understanding of the TMDs by the clinicians.

The small sample size and poor response rate in comparison to the covered area. Thus, it is not appropriate to generalise the results. It's important to consider the inherent limitations of cross-sectional studies (participants may not respond).

It is advised that future research be conducted nationwide, for example, in cooperation with government organisations. This would present a more comprehensive picture of TMDs among dentists in practice. It would be better to create a new curriculum that places more of an emphasis on TMDs and how to manage them. Additionally, regular continuing dental education courses should be held to improve dentists’ understanding of TMDs and their sophisticated management techniques. Additionally, dental practitioners should be taught about and inspired to use these techniques in order to give better care when necessary.

6 Conclusion

In conclusion, the management of TMJ disorders requires a comprehensive and interdisciplinary approach. Dental professionals must navigate the intricate web of symptoms, causes, and contributing factors to provide accurate diagnoses and effective treatments. Conservative measures, including lifestyle modifications and physical therapy, are often the first line of defence, while surgical interventions may be considered in more severe cases. Collaboration among dentists, oral and maxillofacial surgeons, physical therapists, and other healthcare providers is essential to address the multifaceted nature of TMJ disorders. They should have cooperative behaviour and a clear perspective for the management of TMDs, because operating alone has the danger of failing to notice important problems that could have a negative long-term treatment and patient outcome impact.

Footnotes

Abbreviations

Acknowledgement

This work was been done in collaboration with YCMM RDF's Dental college Ahmednagar Maharashtra (India) with College of Dentistry, King Khalid university, ABHA, Saudi Arabia.

ORCID iD

Mohasin Abdul Khader

Ethics approval and consent to participate

Availability of data and materials

All data generated or analysed during this study are included in this published article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors extend their appreciation to the Deanship of Scientific Research at King Khalid University for funding this work through a Small Group Research Project under grant number RGP 1/298/45.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

References

Miller

. Diagnosis and treatment of temporomandibular disorders: emergence of a new care guidelines statement. Oral Surg Oral Med Oral Pathol Oral Radiol Endodontol 2011; 111: 33.

Heir

Haddox

Crandall

, et al. Position paper: appropriate use of pharmacotherapeutic agents by the orofacial pain dentist. J Orofac Pain 2011; 25(4): 381-390.

Aldrigue

RHS

Sánchez-Ayala

Urban

, et al. A survey of the management of patients with temporomandibular disorders by general dental practitioners in Southern Brazil. J Prosthodont. 2016; 25: 33–38.

Constantinescu

Savastano

Perlea

, et al. Complete morphofunctional oral rehabilitation by physiological increase of occlusal vertical dimension according to computerized mandibular scanner. Rom J Morphol Embryol. 2022; 63: 245–251.

Chaturvedi

Addas

Alqahtani

, et al. Computerized occlusal forces analysis in complete dentures fabricated by additive and subtractive techniques. Technol Health Care. 2021; 29: 781–795.

Chaturvedi

Addas

Alqahtani

, et al. Clinical analysis of CAD-CAM milled and printed complete dentures using computerized occlusal force analyser. Technol Health Care. 2021; 29: 797–811.

Derwich

Mitus-kenig

Pawlowska

. Mechanisms of action and efficacy of hyaluronic acid, corticosteroids and platelet-rich plasma in the treatment of temporomandibular joint osteoarthritis—a systematic review. Int J Mol Sci 2021; 22: 7405.

Derwich

Mitus-Kenig

Pawlowska

. Interdisciplinary approach to the temporomandibular joint osteoarthritis—review of the literature. Medicina (Lithuania) 2020; 56: 25.

Khachatryan

Hambartsoumian

Tatintsyan

, et al. Efficacy of the transcutaneous electrostimulation in treatment dysfunctions of the TMJ associated with occlusion distortions. BMC Oral Health 2023; 23(1): 937.

10.

Liu

Fang

. Arthrocentesis vs conservative therapy for the management of TMJ disorders: a systematic review and meta-analysis. J Stomatol Oral Maxillofac Surg 2023; 124: 101283.

11.

Chaturvedi

Thombare

. Cephalometrically assessing the validity of superior, middle and inferior tragus points on ala-tragus line while establishing the occlusal plane in edentulous patient. J Adv Prosthodontics 2013; 5: 58.

12.

Chaturvedi

Khaled Addas

Al Humaidi

ASA

, et al. A novel approach to determine the prevalence of type of soft palate using digital intraoral impression. Int J Dent 2017; 2017: –9.

13.

Suleman

Chaturvedi

Shareef

, et al. An assessment of dentist’s attitudes to the shortened dental arch concept. Open Access Maced J Med Sci 2020; 8: 14–22.

14.

Naqash

Chaturvedi

Yaqoob

, et al. Evaluation of sagittal condylar guidance angles using computerized pantographic tracings, protrusive interocclusal records, and 3D-CBCT imaging techniques for oral rehabilitation. Niger J Clin Pract 2020; 23: 50.

15.

Gupta

Kumar

Kukkamalla

, et al. Dental management considerations for patients with cardiovascular disease—A narrative review. Rev Cardiovasc Med 2022; 23: 61.

16.

Kapos

Exposto

Oyarzo

, et al. Temporomandibular disorders: a review of current concepts in aetiology, diagnosis and management. Oral Surg 2020; 13: 321–334.

17.

De Medeiros Tormes

Lemos

Da Silva

PLP

, et al. Temporomandibular disorders: knowledge, competency, and attitudes of predoctoral dental students. Cranio - J Craniomandibular Sleep Pract 2023; 41: 32–40.

18.

Rezaei

Sharifi

Shahrezaee

, et al. Knowledge about chronic orofacial pain among general dentists of kermanshah, Iran. Open Dent J 2017; 11: 221–229.

19.

. Assessment of knowledge, attitude and practice on temporomandibular joint disorders among postgraduate dental students. Int J Dent Res 2018; 3: 59–62.

20.

Patil

Iyengar

Ramneek . Assessment of knowledge, attitude and practices of dental practitioners regarding temporomandibular joint disorders in India. J Adv Clin Res Insights 2016; 3: 64–71.

21.

Jung

. Stratified fisher’s exact test and its sample size calculation. Biom J. 2014; 56: 129–140.

22.

Chaturvedi

Elmahdi

Abdelmonem

, et al. Predoctoral dental implant education techniques—students’ perception and attitude. J Dent Educ 2021; 85: 392–400.

23.

Abouzeid

Chaturvedi

Abdelaziz

, et al. Role of robotics and artificial intelligence in oral health and preventive dentistry - knowledge, perception and attitude of dentists. Oral Health Prev Dent. 2021; 19: 353–363.

24.

Shah

Thakur

Gill

, et al. Validation of digital impressions’ accuracy obtained using intraoral and extraoral scanners: a systematic review. J Clin Med 2023; 12: 5833.

25.

Alqahtani

Chaturvedi

Alshahrani

, et al. Online questionnaire-based study to evaluate the attitudes and use of rubber dental dams by Saudi Dental Practitioners. Med Sci Monit 2023; 29: e938672.

26.

Wong

Mavondo

, et al. Patient feedback to improve quality of patient-centred care in public hospitals: A systematic review of the evidence. BMC Health Serv Res 2020; 20(1): 530.

27.

De Boever

Nilner

Orthlieb

, 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(3): 268–278.

28.

Greene

. American Association of Dental Research. Management of patients with TMDs: a new “standard of care”. Int J Prosthodont 2010; 23: 190–191.

29.

Schiffman

Ohrbach

Truelove

, et al. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for clinical and research applications: recommendations of the international RDC/TMD consortium network* and orofacial pain special interest group†. J Oral Facial Pain Headache 2014; 28: 6–27.

30.

Schiffman

Truelove

Ohrbach

, et al. The research diagnostic criteria for temporomandibular disorders. I: overview and methodology for assessment of validity. J Orofac Pain 2010; 24(1): 7–24.

31.

Dworkin

LeResche

. Research diagnostic criteria for temporomandibular disorders: review, criteria, examinations and specifications, critique. J Craniomandib Disord 1992; 6(4): 301–355.

32.

Celakil

Saruhanoğlu

. Knowledge and attitude toward temporomandibular disorders: a survey in İstanbul. Turk J Orthod 2022; 35:39–45.

33.

Liu

Steinkeler

. Epidemiology, diagnosis, and treatment of temporomandibular disorders. Dent Clin North Am 2013; 57: 465–479.

34.

Dworkin

Huggins

LeResche

, et al. Epidemiology of signs and symptoms in temporomandibular disorders: clinical signs in cases and controls. J Am Dent Assoc 1990; 120: 273–281.

35.

Suvinen

Reade

Kemppainen

, et al. Review of aetiological concepts of temporomandibular pain disorders: towards a biopsychosocial model for integration of physical disorder factors with psychological and psychosocial illness impact factors. Eur J Pain. 2005; 9: 613–613.

36.

Oral

Küçük

Ebeoǧlu

, et al. Etiology of temporomandibular disorder pain. Agri 2009; 21(3): 89–94.

37.

Ghurye

McMillan

. Pain-related temporomandibular disorder - current perspectives and evidence-based management. Dent Update 2015; 42: 533–546.

38.

Al-Moraissi

. Open versus arthroscopic surgery for the management of internal derangement of the temporomandibular joint: a meta-analysis of the literature. Int J Oral Maxillofac Surg 2015; 44: 763–770.

39.

Bouchard

Goulet

El-Ouazzani

, et al. Temporomandibular lavage versus nonsurgical treatments for temporomandibular disorders: a systematic review and meta-analysis. J Oral Maxillofac Surg. 2017; 75: 1352–1362.

40.

al-Baghdadi

Durham

Araujo-Soares

, et al. TMJ Disc displacement without reduction management: a systematic review. J Dent Res 2014; 93: 37S–51S.

41.

Schiffman

Look

Hodges

, et al. Randomized effectiveness study of four therapeutic strategies for TMJ closed lock. J Dent Res 2007; 86: 58–63.

42.

Fricton

Look

Wright

, et al. Systematic review and meta-analysis of randomized controlled trials evaluating intraoral orthopedic appliances for temporomandibular disorders. Evidence-Based Orthodontics 2018; 24(3): 237–254.

43.

Alencar

Becker

. Evaluation of different occlusal splints and counselling in the management of myofascial pain dysfunction. J Oral Rehabil 2009; 36: 79–85.

44.

Terebesi

Giannakopoulos

Brüstle

, et al. Small vertical changes in jaw relation affect motor unit recruitment in the masseter. J Oral Rehabil 2016; 43: 259–268.

45.

Feller

Lemmer

Nemutandani

, et al. Judgment and decision-making in clinical dentistry. J Int Med Res. 2020; 48: 030006052097287.

Dental Practitioners behaviour,perspective and treatment approach towards management of TMJ Disorders - An observational study

Abstract

Background

Methods

Results

Conclusion

Keywords

1 Introduction

2 Materials and method

2.1 Type of study and sampling

2.2 Ethical considerations

2.3 Questionnaire

3 Results

5 Limitations

6 Conclusion

Footnotes

Abbreviations

Acknowledgement

ORCID iD

Ethics approval and consent to participate

Availability of data and materials

Funding

Declaration of conflicting interests

References