Treatment Sequencing

THE PRECEDING FIVE CHAPTERS have described the specific treatment for each major temporomandibular disorder (TMD). Treatment sequencing is also an important part of managing these problems. Knowing when to institute a specific treatment in the overall management of a disorder is critical. Sometimes the success or failure of a treatment can be determined by the relative sequence in which it is introduced. In an attempt to enhance treatment effects and assist in managing these patients, this chapter describes the proper sequence of treatment for the major TMDs.

Each of the treatment sequences described is designed as an algorithm to help the therapist manage the disorder. Treatment options are described for both success and failure of the previous treatment. The treatments identified are described only briefly. The appropriate chapter for each disorder should be reviewed for more specific details regarding a given treatment.

It is important to recognize that these sequencing diagrams are designed for the general management of a disorder and, although appropriate for most patients, may not be suitable in every instance. It should also be recognized that they are designed to accommodate a single diagnosis. When more than one diagnosis is established, the therapist must follow more than one sequencing diagram. This can become quite complicated and difficult. Therefore a good rule to follow is that if two diagnoses have been established and a conflict in treatment results, the primary diagnosis should take precedence over the secondary one.

For example, a common finding is a masticatory muscle disorder and a disc derangement disorder present concomitantly. As described in Chapter 11, these frequently appear simultaneously, since one can lead to the other. When this occurs, it is helpful to determine the primary disorder so that effective treatment directed to it may also eliminate the secondary disorder. This is sometimes a difficult task. A good history and clinical examination are essential. In many patients the primary disorder becomes the one that most closely relates to the chief complaint. This is not always an accurate assumption; but when the primary diagnosis is difficult to determine, it is a good beginning point.

When a person has a disc derangement disorder and a masticatory muscle disorder concomitantly and a primary diagnosis cannot be established, it is generally advisable to treat the masticatory muscle disorder as the primary diagnosis. This is reasonable, since muscle pain is more common than intracapsular pain and its management is more conservative. Therefore treatment is initially directed toward the muscle symptoms. If the symptoms are not decreased in a reasonable time, therapy is then directed to the disc derangement disorder.

Another general rule in treating patients is that reversible and noninvasive forms of treatment should be initially used to manage the disorder. The results of this treatment can be helpful in determining the need, if any, for more aggressive or irreversible treatment. This general rule is always applied in treating TMDs; in this manner, unnecessary irreversible treatment will be avoided.

Occasionally treatment will fail to eliminate the symptoms. When this occurs, the patient should be reexamined to confirm the diagnosis. Continuing to offer the same therapy will only lead to chronicity of the problem making it more difficult to treat. It is not uncommon for a clinician to misdiagnose a patient’s problem. In fact, as mentioned earlier, misdiagnosis is the most common reason for treatment failure. In the present of treatment failure, one must always reevaluate the patient’s signs and symptom, assessing for the presences of another diagnosis.

Some instances may arise in which the diagnosis is accurate but the treatment cannot alter the etiologic factors. A typical example is a permanent anterior dislocation of the disc. An occlusal appliance and supportive therapy may fail to reduce the symptoms. When severe pain persists, a surgical procedure may be the only alternative. The decision to undergo surgical correction of an intracapsular disorder must be made by the patient and not by the therapist. The patient must therefore be well informed in order to make the proper decision for him or herself. The patient should decide whether to undergo surgery based on two considerations. First, the patient must understand the implications of success versus failure, advantages versus disadvantages, and both risks and expected results from the surgical procedure. The second consideration should be the level of pain caused by the condition. Since pain is a very personal, individual experience, only the patient can know the degree of suffering involved. When suffering is only occasional and mild, a surgical procedure may not be indicated. However, when it alters the quality of life, surgery becomes a viable consideration. Only the patient can decide whether to proceed with a surgical procedure.

There are 11 flowcharts in this chapter designed to help the therapist select and sequence the appropriate treatment: 4 for masticatory muscle disorders, 4 for disc derangement disorders, and 3 for inflammatory disorders. Once the proper diagnosis has been established, these charts can be used. The list of diagnoses and appropriate char/>