Elsevier Editorial System(tm) for American Journal of Orthodontics & Dentofacial

Orthopedics
Manuscript Draft

Manuscript Number:

Title: Orthodontics and Temporomandibular Disorders: A Curriculum Proposal for Postgraduate

Programs

Article Type: Original Article

Corresponding Author: Dr. Charles S. Greene,

Corresponding Author's Institution: UIC College of Dentistry, M/C 835

First Author: Charles S Greene, DDS

Order of Authors: Charles S Greene, DDS; John Stockstill, DDS, MS; Donald Rinchuse, DMD, MS, MDS,
PhD; Sanjivan Kandasamy, BDSc, BScDent, DocClinDent, MOrthRCS, MRACDS

Abstract: ABSTRACT

In a previous paper, the authors reported the results of a survey of all American and Canadian
orthodontic postgraduate programs to determine how the topics of occlusion, temporomandibular
joint and temporomandibular disorders were currently being taught. Based on the finding of
considerable diversity among those programs, we decided to write a TMD curriculum proposal which
would be compatible with and satisfy the current curriculum guidelines for postgraduate orthodontic
programs. These guidelines arise from a combination of the ADA/CODA published requirements and
the July, 2010 American Board of Orthodontics (ABO) written guide for the Phase II examination. The
proposed curriculum, which is based on the latest scientific evidence in the TMD field, provides
program directors with a template for covering these subjects thoroughly. At the same time, they can
focus on all of the related orthodontic issues, so that their future graduates will be prepared to deal
with patients who either present with or later develop TMD problems.
*Title Page

Orthodontics and Temporomandibular Disorders:

A Curriculum Proposal for Postgraduate Programs

Charles S. Greene, DDS **

Clinical Professor, Department of Orthodontics, UIC College of Dentistry,
Chicago, IL.

John Stockstill, DDS, MS

Associate Professor and Director of Orthodontic Research, Department of
Orthodontics, MCG School of Dentistry, Augusta, GA.

Donald Rinchuse, DMD, MS, MDS, PhD

Professor and Graduate Orthodontic Program Director, Seton Hill University,
Greensburg, PA.

Sanjivan Kandasamy, BDSc, BScDent, DocClinDent, MOrthRCS, MRACDS

Clinical Senior Lecturer, Dental School, The University of Western Australia,
Nedlands, Australia and Adjunct Assistant Professor in Orthodontics, Centre for
Advanced Dental Education - St. Louis University, St. Louis, MO.

** Corresponding Author
Charles S. Greene, DDS
Department of Orthodontics
UIC College of Dentistry
801 South Paulina – M/C 841
Chicago, IL 60612-7211
Phone 312-996-7138
FAX 312-996-0873
[email protected]
*Manuscript (no author identifiers please)

Orthodontics and Temporomandibular Disorders:

A Curriculum Proposal for Postgraduate Programs

ABSTRACT

In a previous paper, the authors reported the results of a survey of all American and
Canadian orthodontic postgraduate programs to determine how the topics of occlusion,
temporomandibular joint and temporomandibular disorders were currently being taught.
Based on the finding of considerable diversity among those programs, we decided to write a
TMD curriculum proposal which would be compatible with and satisfy the current
curriculum guidelines for postgraduate orthodontic programs. These guidelines arise from
a combination of the ADA/CODA published requirements and the July, 2010 American
Board of Orthodontics (ABO) written guide for the Phase II examination. The proposed
curriculum, which is based on the latest scientific evidence in the TMD field, provides
program directors with a template for covering these subjects thoroughly. At the same
time, they can focus on all of the related orthodontic issues, so that their future graduates
will be prepared to deal with patients who either present with or later develop TMD
problems.

Introduction

We have previously published the results of our survey of American and Canadian orthodontic
graduate programs, in which we asked the program directors about their didactic and clinical
teaching of temporomandibular joint- related topics.1 Their responses indicated that didactic and
clinical exposures to the topics of occlusion, the TMJ, and temporomandibular disorders (TMDs)
were being presented in many different ways. Some programs were devoting a lot of time to
these issues, and their teaching generally was consonant with current scientific evidence.
However, others were either insufficiently covering these topics or they were presenting outdated
concepts, especially in regard to possible relationships between orthodontic treatment and

1
TMDs. At the end of our article, we recommended that every orthodontic graduate program
should try to align their teaching in this area with the currently available scientific evidence.1

We recognize that each orthodontic postgraduate program is separate and free to control its own
curriculum, but all of them must satisfy the requirements established by official accrediting
agencies such as the ADA Council on Dental Accreditation (CODA). We also know that many
aspects of the orthodontic curriculum are based on standards established by the American
Association of Orthodontists (AAO) and/or the American Board of Orthodontics (ABO).
Therefore, we decided to present a proposal for designing a curriculum that covers the topic of
TMDs and orthodontics in a manner targeted specifically at future practicing orthodontists, in the
hope that teaching programs will find it helpful. In addition, we believe that the official
orthodontic associations may find it useful when revising or expanding present standards for
evaluating and accrediting advanced education programs in orthodontics. 2

2
I. What is currently required?

It is quite striking that the ADA-CODA guidelines for Accreditation Standards for Advanced
Specialty Education Programs in Orthodontics and Dentofacial Orthopedics 3 deal with the topic
of Occlusion/ TMD in eight words: “Manage patients with functional occlusal and
temporomandibular disorders (Standard 4-3.4g).” This is a required Proficiency rather than a
Familiarity, which means that an orthodontic graduate should somehow become proficient at
doing something clinically about these conditions, rather than simply knowing about them or
recognizing the symptoms prior to any orthodontic intervention. It is hard to imagine a less
specific directive coming from any accrediting body, and indeed this may explain a lot of the
diversity in what really is happening across various programs.

On the other hand, the World Federation of Orthodontics ** has put forth a much more specific
list of topics to be covered in dealing with these issues 4:
 Occlusion and temporomandibular disorders (TMD)
 Anatomy and function
 General TMJ concepts
 Normal occlusion and function
 Differential diagnosis of TMD
 TMD in children, adolescents and adults
 Management philosophies
However, this is a very broad and vague type of list which does not even mention orthodontics or
the real-life dilemmas of orthodontic practitioners. We believe it is possible to narrow the focus
of teaching in this area so that the issues are being discussed at a higher (graduate) level, with
special emphasis on the needs of a clinical orthodontist in terms of essential diagnostic and
management proficiency.

** The World Federation of Orthodontist Guidelines for Postgraduate Orthodontic

Education: Occlusion and TMJ. On page 165, occlusion and temporomandibular disorders
and the specific areas that need to be addressed in the curriculum are listed in Appendix 2:
Educational Topics. One more mention of occlusion and TMD in the WFO document is on
page 166, Appendix 2, Educational Topics (Continued), under Special Orthodontic
Subjects: TMD and orthodontics.

3
II. Recommended Curriculum for a TMD Course
A list of suggested topics to be covered in a one-semester TMD course is presented in Table I,
along with a brief list of issues to be discussed under each topic. This proposed course outline is
based on the collective experiences of the four authors as they have taught generations of
orthodontic residents about TMJ issues for several decades. Specific concepts and detailed
content proposals are not presented here, because we believe that program directors and faculty
should have the freedom to make such choices within the overall context of their programs.
However, we do recommend that an evidence-based and problem-based approach to this
contentious field is the best strategy to follow. As part of that approach, we believe the following
three points should be made clear throughout the didactic course as well as during the clinical
exposure in every program:
1. Orthodontic treatment will not prevent children or adult patients from developing a TMD
problem later in life 5-7;
2. Orthodontic treatment will not generally cause either children or adult patients to develop
TMD problems later in life 8-12. However, if TMD symptoms arise during orthodontic treatment,
they may be due to various forces or appliances which exceed the adaptive capacity of an
individual patient, and appropriate responses will be required 13-15;
3. Orthodontic treatment is neither a first-line nor a second-line therapy for symptomatic TMD
patients, regardless of how their occlusion appears at presentation 5, 6, 10-12, 15, 16-18.

The literature supporting these three statements is abundant in the orthodontic field as well as in
the wider TMD field. Therefore, these statements should be regarded as fundamental knowledge
in 21st century orthodontics, and they should be discussed with graduate students by contrasting
them to older belief systems in the orthodontic profession. Readers of this article as well as all
graduate orthodontic students should especially look at the most recent review of this literature
by Michelotti and Iodice 15, which includes an outstanding Table summarizing 24 papers on
“Studies published between 1989 and November 2009 that examined the relationship between
orthodontic treatment and TMD.”

In addition, it is important to stress throughout the TMD course that, in the modern orofacial
pain community, these disorders are currently being studied and managed within a medical
orthopedic framework; this represents a significant departure from a traditional dental model 19.
In addition, TMD patients today are being managed within a biopsychosocial paradigm, and

4
 some of them (especially chronic patients) have significant psychosocial issues which must also
be dealt with 20, 21. Finally, many of the chronic TMD patients have been found to be suffering
from various co-morbid pain conditions (fibromyalgia, irritable bowel syndrome, interstitial
cystitis, etc.), and these conditions impact both the diagnosis and management of chronic TMD
problems 22, 23.

III. TMD and Orthodontics – Special Interest Topics for Orthodontists

In addition to the TMD course topics presented in Table I, it would be desirable to follow that
course with a series of focused discussions about TMD issues that arise in orthodontic practice.
These discussions should be conducted within a problem-based learning (PBL) format, so that
the residents could search for relevant materials and be prepared for an open dialogue between
themselves and their instructors. There are a number of TMD and occlusion issues that
frequently arise within most orthodontic programs as well as in outside practice, and the
residents should be prepared to deal with them when they do occur. To develop critical thinking
skills, a debate format could be used to address many of the issues related to orthodontics,
functional occlusion, condyle position, and TMD. A list of suggested topics is presented below:

A. Specific orthodontic concerns and issues

1. How has the orthodontic literature changed over the years in regard to TMD –
orthodontic relationships? The evolution of thinking about the relationship between these
topics parallels what has happened in the other disciplines that comprise the dental
profession. A review of these historical concepts within the orthodontic field will help the
new graduates appreciate the spectrum of professional opinions they will encounter as
they enter practice.
2. The topic of occlusal hyper-awareness (also known as phantom bite) has generally been
neglected in orthodontic training programs. A recently published paper 24 reported the
results of a survey of practicing U.S. orthodontists about their experiences with patients
complaining of occlusal awareness and discomfort. The responses to that survey
indicated that most orthodontists were either unaware of this condition, or they were
uncertain about how to deal with such patients. Many of these patients have either
already had orthodontic treatment, or are requesting it as a solution for their problem.

5
 Appropriate responses to these situations can be very complicated, and dealing with such
problems may produce a significant amount of anxiety in both patients and dentists.
3. The TMD course described in Table I includes the topic of screening prospective
orthodontic patients for TMD signs and symptoms. However, some additional time is
required to have in-depth discussions about how to react to positive findings from those
screenings. This should include topics such as:
a. What constitutes a minor finding vs a major TMD sign and/or symptom?
b. Who should manage the TMD problem if it requires treatment?
c. What are the cautions suggested for the orthodontic management of such patients?
4. How should orthodontists react to and deal with TMD problems which arise during their
treatment? Who is responsible for managing these situations? When is it appropriate to
resume orthodontic treatment? What if the TMD situation cannot be resolved
completely?
5. How should orthodontists react to post-treatment TMD complaints from their completed
patients? Does it matter if these complaints arise during the immediate post-treatment
period vs several years later? What is the orthodontist’s responsibility for providing or
seeking appropriate care for these patients?

B. Interactions between orthodontists and general dentists – TMD and occlusion issues
1. How should an orthodontist respond to a patient referred by a familiar referring dentist,
specifically for treatment of a TMD problem? Assume that the linkage between the
patient’s occlusion and the symptoms has already been proclaimed by the dentist.
2. Same as #1, but assume that the referring dentist is new to the practice.
3. A finished orthodontic patient is sent back to the original referring dentist. However, this
dentist does not like the occlusal result produced, and makes negative comments to the
patient (and parents, if a child) about this outcome. Possibilities include:
a. The critique was based only on personal opinion, but no specific occlusal
philosophy was cited by the dentist
b. A more specific critique was offered, based on a specific occlusal theory.
c. The criticism is based on the dentist’s recent involvement with a major occlusion
“Institute”, which has convinced him that only certain very specific occlusal

6
 outcomes are acceptable, and that only special occlusally-aware orthodontists can
render a successful outcome.
d. The patient is told that future TMJ/occlusal problems will occur if this situation is
not corrected.
e. The patient is advised to seek a second opinion from a different orthodontist,
rather than returning to you.
4. Same as #3, except the patient is seeing a new dentist who did not make the initial
orthodontic referral.

All of the above negative scenarios could be discussed under three different assumptions:
1) The general dentist is the one who makes the negative phone call to the orthodontist.
2) The patients (or parents) make the negative phone call to the dentist.
3) The “special occlusally-aware orthodontist” makes the phone call to the treating or
original orthodontist to discuss the “inappropriately finished” case.

IV. How does the proposed TMD course fit into current curriculum requirements?
The TMD course outline presented in this article, as well as the suggested discussion topics,
would appear to be very timely in terms of current curriculum guidelines for postgraduate
orthodontic programs. These guidelines arise from a combination of the ADA/CODA published
requirements and the July, 2010 American Board of Orthodontics (ABO) written guide for the
Phase II examination 3,4. While there is a fair amount of flexibility among postgraduate
programs for designing their specific curricula, those guidelines have a major impact on what
needs to be covered in every program. The pertinent sections of the ABO written guidelines are
as follows:
o There are a total of 27 subject areas that are listed for study. Specifically, topic
#19 - Principles of Occlusion, and topic #26 - Temporomandibular Disorders,
are found on page 3.
o Under the section on “Test Specifications” that lists the percentage of questions
taken from each discipline, 5% of the questions are on the topic of “Occlusion”
and 4% of the questions are on the topic of “Temporomandibular Disorders.”

7
 o There are 86 required reading articles (primary sources), with five being related to
occlusion/TMD issues:
 Huang G. Occlusal adjustment for treating and preventing
temporomandibular disorders. Am J Orthod Dentofacial Orthop
2004;126(2):138-9.
 Kim MR, Graber TM, Viana MA. Orthodontic and temporomandibular
disorder: a meta-analysis. Am J Orthod Dentofacial Orthop
2002;121:438-46.
 Andrews LF. The six keys to normal occlusion. AJO 1972;62:296-309.
 English JD, Buschang PH, Throckmorton GS. Does malocclusion affect
masticatory performance? Angle Orthod Feb 2002;72(1):21-7.
 McNamara JA, Seligman DA, Okeson JA. Occlusion, orthodontic
treatment and temporomandibular disorders: a review. J Orofacial Pain
1995;9(1):73-115.
In addition, the ABO recommends 23 textbooks related to different areas of orthodontics; book
#6 in the listing is the only one focusing primarily on the topic of temporomandibular disorders
(Okeson J. “Management of Temporomandibular Disorders and Occlusion” 6th ed., Mosby,
2008).

CONCLUSION
The main intention of the authors in writing this paper was to fill a gap in postgraduate
orthodontic programs, as revealed in our recent survey that was published in this journal 1.
Clearly, when over half of the programs in the USA are found to either not cover TMD topics
very well or to present somewhat outdated and even questionable material, there is a need for
improvement. It is in the best interests of the new graduates and their future patients, and thus for
the orthodontic specialty as a whole, if there are evidence-based guidelines for those involved in
the teaching of these subjects. Also, because the topics of TMD and occlusion continue to be a
source of controversy in the orthodontic profession, there is a need for new graduates to
understand the historical and present elements of that controversy in order to communicate with
all their colleagues. Finally, while the main focus of orthodontic practice remains the diagnosis
and management of malocclusions, modern orthodontists must deal with the inevitable fact that

8
TMD issues will arise in their practices; will they be properly prepared to provide appropriate
evidence-based care for those patients?

9
 REFERENCES

1. Stockstill, J., Greene, C., Kandasamy, S., Campbell, D., and Rinchuse, D.: Survey or
orthodontic residency programs: Teaching about occlusion, temporomandibular
joints, and temporomandibular disorders in postgraduate curricula. Am J Orthod
Dentofacial Orthop, 2011;139:17-23.
2. Owens, S., Dykhouse, V., Moffitt, A., Grubb, J., Greco, P., English, J. Briss, B.,
Jamieson, S., and Riolo, M.: The new American Board of Orthodontics certification
process: further clarification. Am J Orthod Dentofacial Orthop, 2005;128(4):541-544.
3. Accreditation Standards for Advanced Specialty Education Programs in Orthodontics
and Dentofacial Orthopedics. Commission on Dental Accreditation, American Dental
Association, 2008. ADA - CODA Standard 4, under Clinical Sciences, Exhibit 11.1,
Clinical Proficiencies, 54g.
4. The American Board of Orthodontic Written Examination Guide; Edition- July 2010;
www.americanboardortho.com
5. McNamara JA, Seligman DA, Okeson JA. Occlusion, orthodontic treatment, and
temporomandibular disorders: a review. J Orofacial Pain 1995;9:73-90.
6. McNamara JA Jr, Turp JC. Orthodontic treatment and temporomandibular disorders:
is there a relationship? Part 1: clinical studies. J Orofac Orthop 1997;58:74–89.
7. Reynders RM. Orthodontics and temporomandibular disorders: a review of the
literature (1966–1988). Am J Orthod Dentofacial Orthop 1990;97:463–471.
8. Dibbets JM, van der Weele LT. Long-term effects of orthodontic treatment, including
extraction, on signs and symptoms attributed to CMD. Eur J Orthod 1992;14:16–20.
9. Rinchuse DJ. Does orthodontics cause TMJ disorders? Orthod Rev 1987;1:11.
10. Luther F. TMD and occlusion part I. Damned if we do? Occlusion: the interface of
dentistry and orthodontics. Br Dent J 2007;13:202–209.
11. Luther F. TMD and occlusion part II. Damned if we don’t? Functional occlusal
problems: TMD epidemiology in a wider context. Br Dent J 2007;13:210–216.
12. Kim MR, Graber TM, Viana MA. Orthodontics and temporomandibular disorder: a
meta-analysis. Am J Orthod Dentofacial Orthop 2002;121:438–446.
13. Okeson, J. Orthodontic therapy and the patient with temporomandibular disorder, in
Orthodontics: Current Principle and Techniques, Graber, T. (editor), 4th edition, pp.
331-344, 2005 Elsevier, Inc.
14. Greene CS. Etiology of temporomandibular disorders. Semin Orthod 1995;1:222–228
15. Michelotti A, Iodice G. Review Article: The role of orthodontics in
temporomandibular disorders. Journal of Oral Rehabilitation 2010 37; 411–429.
[NOTE: See Table 1].

10
16. National Institutes of Health Technology Assessment Conference Statement.
Management of temporomandibular disorders. J Am Dent Assoc 1996;127:1595-606.
17. Macfarlane T, Kenealy P, Kingdon A, Mohlin B, Pilley R, Richmond S et al. Twenty-
year cohort study of health gain from orthodontic treatment: temporomandibular
disorders. Am J Orthod Dentofacial Orthop 2009;135:692.
18. List T, Axelsson S. Management of TMD: evidence from systematic reviews and
meta-analyses. J Oral Rehabil 2010;37:430–451.
19. Greene CS, Laskin DM. Temporomandibular disorders: moving from a dentally
based to a medically based model. J Dent Res 79: 1736-1739, 2000.
20. Velly AM, Look JO, Carlson C, Lenton PA, Kang W, Holcroft CA, Fricton JR. The
effect of catastrophizing and depression on chronic pain--a prospective cohort study
of temporomandibular muscle and joint pain disorders. Pain 2011 Oct;152:2377-83.
21. Dworkin SF, Sherman J, Ohrbach R, et al. Reliability, validity and clinical utility of
RDC/TMD Axis II scales: Depression, non-specific physical symptoms and graded
chronic pain. J Orofac Pain 2002;16:207–220.
22. Plesh O, Adams SH, Gansky SA. Temporomandibular Joint and muscle disorder-type
pain and comorbid pains in a national US sample. J Orofac Pain. 2011;25(3):190-8.
23. Diatchenko L, Slade GD, Nackley AG, Bhalang K, Sigurdsson A, Belfer I, et al.
Genetic basis for individual variations in pain perception and the development of a
chronic pain condition. Hum Mol Genet 2005;14:135–143.
24. Ligas BB, Galang MTS, BeGole EA, Evans CA, Klasser GD, Greene CS. Phantom
bite: a survey of US orthodontists. Orthodontics 2011; 12: 38-47.
25. The President’s Conference on the Examination, Diagnosis and Management of
Temporomandibular Disorders. (Laskin, D. et al eds.), Chicago, American Dental
Association, 1983.
26. Roistacher, S., Olsen, F., and Tanenbaum, D.: Teaching the Management of Chronic
Face Pain. J Dent Educ 1986; 50(12):734-735.
27. Gonty, A.: Teaching a Comprehensive Orofacial pain Course in the Dental
Curriculum. J Dent Educ 1990; 54(6):319-322.
28. Mohl, N. et al: Curriculum Guidelines for the Development of Predoctoral Programs
in Temporomandibular Disorders and Orofacial Pain. J Dent Educ 1992; 56(9): 646-
649.
29. Mohl, N. et al: Curriculum Guidelines for the Development of Postdoctoral Programs
in Temporomandibular Disorders and Orofacial Pain. J Den Educ 1992;56(9): 650-
658.
30. Curriculum guidelines for occlusion. Section on Dental Anatomy and Occlusion of
the American Association of Dental Schools. J Dent Educ 1993; 57(5):384-387.
31. Curriculum guidelines for orthodontics. AADS Section on Orthodontics and the
Council on Orthodontic Education of the American Association of Orthodontists. J
Dent Educ September 1993; 57(9):707-710.

11
32. Mohl, N. et al: The Third Educational Conference to Develop the Curriculum in
Temporomandibular Disorders and Orofacial Pain: Introduction. J Orofac Pain, 2002;
16(3):173-175.
33. Glaros, A.: Teaching evidence-based approaches to orofacial pain. J Orofac Pain,
2002; 16(2):89.
34. Sessle, B.: Orofacial pain: an educational focus. J Orofac Pain 2002; 16(3): 169.
35. Fricton, J.: Development of orofacial pain programs in dental schools. J Orofac Pain,
2002; 16(3):191-197.
36. Gonzalez, Y. and Mohl, N.: Care of patients with temporomandibular disorders: an
educational challenge. J Orofac Pain, 2002; 16(3):200-206.
37. Nilner, M.: Educational Committee, European Academy of Craniomandibular
Disorders. Curriculum guidelines for orofacial pain and temporomandibular
disorders. Eur J Dent Educ 2001; 5(3):136-138.
38. Nilner, M., Steenks, M., DeBoever, J., Ciancaglini, R., Kononen, M., and Orthlieb, J.:
Guidelines for curriculum of undergraduate and postgraduate education in orofacial
pain and temporomandibular disorders in Europe. J Orofac Pain 2003; 17(4):359-362.

12
Table

TABLE I – Proposed Curriculum Topics for TMD Course

SUBJECT TITLES TOPICS TO BE COVERED

Anatomy, physiology and pathophysiology Structural and functional anatomy of TMJ
of the TMJ complex components
Ideal vs functional condyle / fossa / disk
relationships
Internal derangements of the TMJ disk
Mandibular movements and chewing
kinematics
Neurophysiology of Pain Normal pain conduction
-Nociceptive
-Inflammatory
-Neuropathic
-Musculoskeletal
Neuroplasticity
Referred and heterotopic pain
Chronic pain
History and Examination Procedures How to examine an orofacial pain patient
For Orofacial Pain and TMD Symptoms How to take a pain history
How to carry out a TMJ and masticatory
muscle history and examination including
palpation
How to carry out a static and functional
occlusal examination
How to establish correct differential diagnosis
Etiology of TM Disorders Arthrogenous vs muscular disorders
Specific vs non-specific onset history
Multi-factorial and biopsychosocial concepts
Idiopathic etiology – impact on treatment
Occlusion, condyle position (CR), and TM Theories and concepts of functional occlusion:
Disorders historical review and current status
Is there a relationship between occlusion and
TMD?
Is there a relationship between condyle
position and TMD?
Masticatory Muscle Disorders – Diagnosis and Myofascial pain
Pathophysiology Myositis
Myospasm
Local and centrally maintained myalgias
Myofibrotic contracture
Cervicogenic pain
 SUBJECT TITLES TOPICS TO BE COVERED
TM Joint Disorders – Diagnosis and TMJ disk derangements
Pathophysiology Inflammatory TMJ disorders
Non-inflammatory TMJ disorders
Traumatic joint injuries
Growth disorders ( hyperplastic and deficiency
problems)

Psychosocial Issues in TMD/OFP Stress as an etiologic factor

Anxiety and depression
Chronic pain issues
The biopsychosocial model – impact on TX

Bruxism – Current Concepts Old theories

-Occlusal interferences
-Psychological stress
Current concepts
-Sleep parasomnias
-Minor correlation with muscular pain
Management with oral appliances
Oral Appliance Therapy Types of oral appliances
What oral appliances can and cannot do
History of OA therapy relative to failed and
successful outcomes
Evolution of OA therapy – current concepts
When/When not to use OA’s in TMD
treatment
Orthodontics and TMD History of orthodontics as related to concepts
of static / functional occlusion and TMD
Does orthodontics cause TMD?
Does orthodontics prevent TMD?
Does orthodontics cure or mitigate TMD?
Screening Orthodontic Patients for TMDs Standardized Screening questionnaire
Standardized Psychosocial evaluation
Standardized Clinical exam including history
and physical examination
Comprehensive examination (imaging as
needed) -DDS/PT/MD referrals as needed
 SUBJECT TITLES TOPICS TO BE COVERED
Treatment of TM Joint/ Disk Disorders Patient education and self-management
Pharmacological therapy
AND -Analgesics
-NSAIDS
-Corticosteroids
-Muscle relaxants
-Antidepressants
Cognitive behavioral intervention
Treatment of Myogenous TMD Problems Physical therapy
-Physical exercise and manipulation
-Physical agents and modalities
-Home care exercises
Orthopedic appliance therapy (see above)
Occlusal management
Surgical interventions
-Arthrocentesis
-Arthroscopy
-Discectomy
-Total joint replacement
CASE DISCUSSIONS Your patient presents with TMD prior to
Problem-based format with preliminary orthodontic treatment
diagnosis, treatment recommendations, and Your patient develops TMD during
eventual final outcome orthodontic treatment
Your patient develops TMD post-orthodontic
treatment
New patient presents with TMD and specific
referral for orthodontic TX as solution
New patient presents after splint TX by
dentist, now needs permanent occlusal change
to maintain new jaw relationships

LEGEND: This Table is based on TMD curriculum concepts and guidelines

published in a large number of papers over the past 20 years. 25-38
*Copyright Release Form

Copyright Statement
Must be signed by ALL authors
The undersigned author(s) transfers all copyright ownership of the manuscript
to the American Association of Orthodontists in the event the work is published. The
undersigned author(s) warrants that the article is original, does not infringe upon any copyright
or other proprietary right of any third party, is not under consideration by another journal, has
not been published previously, and includes any product that may derive from the published
journal, whether print or electronic media. The author(s) confirm that they have reviewed and
approved the final version of the manuscript. I (we) sign for and accept responsibility for
releasing this material.
The corresponding author must be named___Charles S. Greene (see below)**___
__________________________________________________________________(Signature)
Each author’s name must be typed (printed) with the signature.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Date:______________________
Return to:
American Journal of Orthodontics and Dentofacial Orthopedics
Orthodontics, School of Dentistry
D-569, Health Sciences Box 357446
Seattle, WA 98195
206-221-5413, phone

** I am sending this document without signatures, in order to complete the

submission process. As noted in my Comments to the Editorial Staff, we are
circulating this form among the four authors, one of whom is in Australia. I could
not figure out how to choose “Submit Offline” for this form, so I decided to use
this method – hope it is OK.

CS Greene
*Conflict of Interest Disclosure Form
Click here to download Conflict of Interest Disclosure Form: conflict of iinterest_disclosure form AJODO.pdf