CRANIO®

The Journal of Craniomandibular & Sleep Practice

ISSN: (Print) (Online) Journal homepage: www.tandfonline.com/journals/ycra20

Temporomandibular disorders: INfORM/IADR key

points for good clinical practice based on standard
of care

Daniele Manfredini, Birgitta Häggman-Henrikson, Ahmad Al Jagshi, Lene

Baad-Hansen, Emma Beecroft, Tessa Bijelic, Alessandro Bracci, Lisa
Brinkmann, Rosaria Bucci, Anna Colonna, Malin Ernberg, Nikolaos N.
Giannakopoulos, Susanna Gillborg, Charles S. Greene, Gary Heir, Michail
Koutris, Axel Kutschke, Frank Lobbezoo, Anna Lövgren, Ambra Michelotti,
Donald R. Nixdorf, Laura Nykänen, Juan Fernando Oyarzo, Maria Pigg,
Matteo Pollis, Claudia C. Restrepo, Roberto Rongo, Marco Rossit, Ovidiu
I. Saracutu, Oliver Schierz, Nikola Stanisic, Matteo Val, Merel C. Verhoeff,
Corine M. Visscher, Ulle Voog-Oras, Linnéa Wrangstål, Steven D. Bender,
Justin Durham & International Network for Orofacial Pain and Related
Disorders Methodology

To cite this article: Daniele Manfredini, Birgitta Häggman-Henrikson, Ahmad Al Jagshi,

Lene Baad-Hansen, Emma Beecroft, Tessa Bijelic, Alessandro Bracci, Lisa Brinkmann,
Rosaria Bucci, Anna Colonna, Malin Ernberg, Nikolaos N. Giannakopoulos, Susanna Gillborg,
Charles S. Greene, Gary Heir, Michail Koutris, Axel Kutschke, Frank Lobbezoo, Anna Lövgren,
Ambra Michelotti, Donald R. Nixdorf, Laura Nykänen, Juan Fernando Oyarzo, Maria Pigg,
Matteo Pollis, Claudia C. Restrepo, Roberto Rongo, Marco Rossit, Ovidiu I. Saracutu, Oliver
Schierz, Nikola Stanisic, Matteo Val, Merel C. Verhoeff, Corine M. Visscher, Ulle Voog-Oras,
Linnéa Wrangstål, Steven D. Bender, Justin Durham & International Network for Orofacial
Pain and Related Disorders Methodology (03 Oct 2024): Temporomandibular disorders:
INfORM/IADR key points for good clinical practice based on standard of care, CRANIO®, DOI:
10.1080/08869634.2024.2405298

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CRANIO : THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE
https://doi.org/10.1080/08869634.2024.2405298

TMJ

Temporomandibular disorders: INfORM/IADR key points for good clinical

practice based on standard of care
Daniele Manfredini DDS, MSc, PhD a, Birgitta Häggman-Henrikson DDS, PhD b, Ahmad Al Jagshi DDSc,d,
Lene Baad-Hansen DDS, PhD e, Emma Beecroft DDS, PhDf, Tessa Bijelic DDSb, Alessandro Bracci DDS g,
Lisa Brinkmann DDSh, Rosaria Bucci DDS, MSc, PhD i, Anna Colonna DDS, MSc a, Malin Ernberg DDS, PhD j,
Nikolaos N. Giannakopoulos DDS, PhD k,l, Susanna Gillborg DDS b,m, Charles S. Greene DDS n,
Gary Heir DDSo, Michail Koutris DDS, PhD p, Axel Kutschke DDS b,q, Frank Lobbezoo DDS, PhD p,
Anna Lövgren DDS, PhD r, Ambra Michelotti DDS, MSc, PhD i, Donald R. Nixdorf DDS s, Laura Nykänen DDS,
PhDt, Juan Fernando Oyarzo DDS, PhD u, Maria Pigg DDS, PhD v,w, Matteo Pollis DDS a,
Claudia C. Restrepo DDS, PhD x, Roberto Rongo DDS, PhD i, Marco Rossit DDS, MSc a,
Ovidiu I. Saracutu DDS a, Oliver Schierz DDSh, Nikola Stanisic DDS b, Matteo Val DDS, MSc a,
Merel C. Verhoeff DDS, PhD p, Corine M. Visscher PT, PhD p, Ulle Voog-Oras DDS, PhD y,
Linnéa Wrangstål DDS b, Steven D. Bender DDS z, Justin Durham DDS, PhD f and International Network for
Orofacial Pain and Related Disorders Methodology aa
a
Orofacial Pain Section, School of Dentistry, Department of Medical Biotechnologies, University of Siena, Siena, Italy; bDepartment of Orofacial
Pain and Jaw Function, Faculty of Odontology, Malmö University, Malmö, Sweden; cCollege of Dentistry, Ajman University, Ajman, United
Arab Emirates; dDepartment of Prosthodontics, Gerodontology and Dental Materials, Greifswald University Medicine, Greifswald, Germany;
e
Section for Orofacial Pain and Jaw Function, Department of Dentistry and Oral Health, Aarhus University, Aarhus, Denmark; fSchool of Dental
Sciences, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; gSchool of Dentistry, Department of Neurosciences,
University of Padova, Padova, Italy; hDepartment of Prosthetic Dentistry and Material Sciences, Medical Faculty, University of Leipzig, Leipzig,
Germany; iDepartment of Neuroscience, Reproductive and Oral Sciences, School of Orthodontics, University of Naples Federico II, Naples, Italy;
j
Division of Oral Rehabilitation, Department of Dental Medicine, Karolinska Institutet and The Scandinavian Center for Orofacial Neurosciences
(SCON), Huddinge, Sweden; kDepartment of Prosthodontics, National & Kapodistrian University of Athens, Athens, Greece; lDepartment of
Prosthodontics, University of Würzburg, Würzburg, Germany; mDepartment of Stomatognathic Physiology, Kalmar County Hospital, Kalmar,
Sweden; nDepartment of Orthodontics, College of Dentistry, University of Illinois at Chicago, Chicago, IL, USA; oDepartment of Diagnostic
Sciences, Center for Temporomandibular Disorders and Orofacial Pain, Rutgers School of Dental Medicine, Newark, USA; pDepartment of
Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam,
Amsterdam, The Netherlands; qDepartment of Orofacial Pain and Jaw Function, Gävle County Hospital, Public Dental Health County Council of
Gävleborg, Gävle, Sweden; rDepartment of Odontology, Orofacial Pain and Jaw Function, Faculty of Medicine, Umeå University, Umeå,
Sweden; sDivision of TMD & Orofacial Pain, School of Dentistry and Departments of Radiology and Neurology, Medical School, University of
Minnesota, Minneapolis, MN, USA; tDepartment of Oral and Maxillofacial Diseases, University of Helsinki, Helsinki, Finland; uTMD and Orofacial
Pain Program, Faculty of Odontology, Universidad Andres Bello, Santiago, Chile; vDepartment of Endodontics, Faculty of Odontology, Malmö
University, Malmö, Sweden; wScandinavian Center for Orofacial Neurosciences (SCON), Malmö, Sweden; xCES-LPH Research Group,
Universidad CES, Medellin, Colombia; yInstitute of Dentistry, Tartu University, Tartu, Estonia; zDepartment of Comprehensive Dentistry, Texas
A&M College of Dentistry, Dallas, TX, USA; aaInternational Network for Orofacial Pain and Related Disorders Methodology (INfORM), a Network
within the International Association for Dental Research (IADR)

ABSTRACT KEYWORDS
Objective: To present a list of key points for good Temporomandibular Disorders (TMDs) clinical Bruxism; good practice;
practice on behalf of the International Network for Orofacial Pain and Related Disorders guidelines; orofacial pain;
Methodology (INfORM) group of the International Association for Dental, Oral and Craniofacial standard of care;
temporomandibular
Research (IADR).
disorders; TMJ
Methods: An open working group discussion was held at the IADR General Session in New Orleans
(March 2024), where members of the INfORM group finalized the proposal of a list of 10 key points.
Results: The key points covered knowledge on the etiology, diagnosis, and treatment. They
represent a summary of the current standard of care for management of TMD patients. They are
in line with the current need to assist general dental practitioners advance their understanding and
prevent inappropriate treatment.
Conclusions: The key points can be viewed as a guiding template for other national and interna­
tional associations to prepare guidelines and recommendations on management of TMDs adapted
to the different cultural, social, educational, and healthcare requirements.

CONTACT Daniele Manfredini [email protected] Orofacial Pain Section, School of Dentistry, Department of Medical Biotechnologies,
University of Siena, Siena, Viale Bracci 53100, Italy
© 2024 Taylor & Francis Group, LLC
2 D. MANFREDINI ET AL.

Introduction treatment, and thereby the risk of iatrogenic chron­

ification [13]. Despite the evidence-based knowledge
Temporomandibular disorders (TMDs) are a heteroge­
of the above issues that has developed during the last
neous group of conditions affecting the temporoman­
few decades, these general principles have never been
dibular joints (TMJs), the jaw muscles, and the related
summarized with the goal of providing a short
structures. TMDs are associated with clinical signs and
synopsis and a list of key points for all health practi­
symptoms, such as functional limitation and joint
tioners in search of a “white paper” document on
sounds, muscle and/or joint pain upon palpation and
good clinical practice. The only previous attempt
during function, amongst others [1,2].
with a similar goal as this paper was published by
Historically, the etiology of TMDs has been linked to
the American Association for Dental Research sum­
imperfections of the dental occlusion, TMJ condyle
mary statement almost a decade ago [14].
position, and/or muscle imbalance, which have thus
been viewed as therapeutic targets by generations of
dental professionals. This gave life to many theories,
Material and methods
born under the precepts of the so-called “gnathology”,
which were never validated. The benign and positive An open workshop was organized as a satellite sympo­
natural evolution of most symptoms related to TMD sium on behalf of the International Network for
over time, common to many other musculoskeletal pain Orofacial Pain and Related Disorders Methodology
conditions, led to confirmation bias within some parts (INfORM) group of the International Association for
of the dental profession and created the risk of adopting Dental, Oral and Craniofacial Research (IADR) during
irreversible dentally based approaches [3,4]. the IADR General Session in New Orleans that was held
Research has shown that the etiology of TMDs is in March 2024. Before the event, the coordinators of the
actually linked to a combination of biopsychosocial project (D.M., J. D., B.H.H., S.D.B.) drafted a bulleted
factors [5]. A careful standardized approach based on list of 10 points to summarize the main aspects of TMD
history taking, a clinical examination performed by etiology, diagnosis, and treatment. The draft was circu­
a trained examiner, and psychosocial evaluation repre­ lated via email between the four of them in the weeks
sents the basis for a differential diagnosis [6]. The diag­ preceding the event.
nostic process can selectively be implemented with The workshop was divided in three parts: initially,
effective imaging prescription, that is, reserved for situa­ the draft was read aloud for the participants’ conveni­
tions where the imaging may influence diagnosis or ence; then, participants were split in three working
treatment [7]. There is a lack of evidence supporting groups of 10–12 individuals who, under the supervision
the use of electronic and/or mechanical devices in either of one of the project coordinators (J.D., B.H.H., S.D.B.),
the diagnostic or treatment phase [8]. debated on if and how the summary sentences might be
Patient management should embrace a biopsychoso­ adjusted. The chairman of the event (D.M.) provided
cial approach in such a way that practitioners providing assistance to all groups throughout the discussion phase.
care to TMD patients should use a combination of As an instruction, the workshop participants were told
orthopedic, neurological, and psychological strategies that the final by-product of their work should contain 10
[9–12]. Cognitive-behavioral and supported self- key points, which were divided as follows: one statement
management recommendations are key principles and on general principles, two statements on etiology, three
must be part of any treatment regimen alongside phy­ statements on diagnosis, three statements on treatment,
siotherapy. Second-line interventions include a trial of one statement on TMDs within the broader aspects of
medications that exert their therapeutic effect through orofacial pain. Each group had 60 min for discussion.
neuromodulation, for example decreasing excitatory After that, the supervisors of the groups summarized the
neurotransmitter release or action, or by changing the proposals of their group. As the final step, the original
properties of nociceptive neurons or pathways. The draft was adjusted under the supervision of an English
temporary use of an oral appliance over a 24-h day can mother-tongue project coordinator (J.D.) by reading it
also be considered, such as nighttime use. Only very aloud and fine tuning it by consensus with all the parti­
infrequently, and in very selected cases, are surgical cipants. A definitive list of 10 key points was then pre­
interventions indicated. pared and approved.
Proper training is thus required for dental profes­ In the weeks following the IADR General Session, the
sionals to avoid focusing TMD practice on outdated, leading supervisor drafted this paper, which was circu­
unproven, or refuted concepts. This will then help lated among all the authors for a final check before
reduce the chance of diagnostic delay, inappropriate definitive approval.
 CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE 3

Results Second-line treatment to support self-

management includes provisional, interim, and
As a result of the above procedures, the INfORM
time-limited use of oral appliances. Only very
group of the IADR proposes this list of 10 key points
infrequently, and in very selected cases, are sur­
for good practice in the field of TMDs, which repre­
gical interventions indicated.
sents a summary of the current standard of care for
(9) Irreversible restorative treatment or adjustments
TMD management and patients’ needs [15–23]:
to the occlusion or condylar position are not
indicated in management of the majority of
(1) Patient-centered decision-making alongside
TMDs. The exception to this may be an acute
patient engagement and perspective is critical
change in the occlusion, such as in the instance
to manage TMDs, with management being the
of a high filling or crown with TMD-like symp­
process from history through examination into
toms developing immediately following these
diagnosis and then treatment. Expectations
procedures or a slowly progressing change in
should focus on learning to control and manage
dental occlusion due to condylar diseases.
the symptoms and decrease their impact on the
(10) The presence of complex clinical presenta­
individual’s everyday life.
tions with uncertain prognosis, such as in
(2) TMDs are a group of conditions that may cause the case of concurrent widespread pain or
signs and symptoms, such as orofacial pain and comorbidities, elements of central sensitiza­
dysfunction of a musculoskeletal origin. tion, long-lasting pain, or history of previous
(3) The etiology of TMDs is biopsychosocial and failed interventions, should lead to the suspi­
multifactorial. cion of chronification of TMDs or non-TMD
(4) Diagnosis of TMDs is based on standardized pain. Referral to an appropriate specialist is
and validated history taking and clinical assess­ thus recommended; the specialty will be geo­
ment performed by a trained examiner and led graphic-specific as not all countries have
by the patient perspective. a specialty of orofacial pain.
(5) Imaging has been proven to have utility in
selected cases but does not replace the need for
careful execution of history taking and clinical Conclusions
examination. Magnetic Resonance Imaging is
the current standard of care for soft tissues The key points for good clinical TMD practice based
and Cone Beam Computerized Tomography on standard of care proposed as an official document
for bone. Imaging should only be performed by the INfORM group of the IADR cover knowledge
when it has the potential to impact the diagnosis on the etiology, diagnosis, and treatment of TMDs.
or treatment. Timing of imaging is important They represent a summary of the current standard of
and so is the cost:benefit:risk balance. care for management of TMDs and are in line with
(6) The evidence base for all interventions or devices the current need to assist general dental practitioners
should be carefully considered before their advance their understanding and prevent inappropri­
implementation over and above normal standard ate treatment. The key points can be viewed as
of care. Knowledge on developments in the field a guiding template for other national and interna­
should be kept up to date. Currently, technologi­ tional associations to prepare guidelines and recom­
cal devices to measure electromyographic activity mendations adapted to the different cultural, social,
at chairside, to track jaw motion, or to assess educational, and healthcare requirements around the
body sway, amongst others, are not supported. world.
(7) TMD treatment should aim to reduce the
impact of pain and decrease functional limita­
Disclosure statement
tion. Outcomes should be evaluated also in rela­
tion with the reduction of exacerbations, No potential conflict of interest was reported by the
education in how to manage exacerbations, author(s).
and improvement in quality of life.
(8) TMD treatment should primarily be based on
encouraging supported self-management and Funding
conservative approaches, such as cognitive- The author(s) reported that there is no funding associated
behavioral treatments and physiotherapy. with the work featured in this article.
4 D. MANFREDINI ET AL.

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