The National Institutes of Health (NIH) and the National Institute of Dental and Craniofacial Research (NIDCR) estimate that $4 billion is spent every year on the diagnosis and treatment of temporomandibular joint dysfunction (TMJD), also known as temporomandibular joint disorders (TMD). A subclassification of musculoskeletal conditions, research into the etiology, pathomechanics and pathophysiology of TMD has been extensive.1-10 It's interesting to note that research into TMD closely parallels investigation of the dysfunctional and symptomatic intervertebral joint motion segment. The curious thing is that while chiropractors are extensively trained in the diagnosis and treatment of musculoskeletal conditions, chiropractic management of TMD amounts to a very small percentage of that $4 billion. That is a shame.
Here is a quote taken directly from the TMD awareness brochure put out by the NIH: "Because there is no certified specialty for TMJ disorders in either dentistry or medicine, finding the right care can be difficult. Look for a health care provider who understands musculoskeletal disorders (affecting muscle, bone and joints) and who is trained in treating pain conditions. Pain clinics in hospitals and universities are often a good source of advice, particularly when pain continues over time and interferes with daily life. Complex cases, often marked by prolonged, persistent and severe pain; jaw dysfunction; co-existing conditions; and diminished quality of life, likely require a team of experts from various fields, such as neurology, rheumatology, pain management and others, to diagnose and treat this condition."
There are any number of reasons why chiropractors are not mentioned in this brochure when they should be featured in any or all of these capacities: diagnosticians, treating physicians and, with appropriate training, treatment team members or even case managers for complex cases. This situation can be rectified.
TMD Second Only to Low Back Pain
Dentists recognized long ago that TMD patients are plentiful (5-15 percent of the U.S. population, according to NIDCR studies) and seek treatment frequently. The aggressive movement by dentists into this field has led to the misconception that TMD is a dental disorder. Over time it has actually come to be assumed that TMD originates from malocclusion and/or stress-mediated parafunctional habits (e.g., bruxism). While this theory has been disproved numerous times, the bulk of the money is spent on dental treatments for TMD, despite the fact that dental alteration of the occlusion and/or orthodontic treatment have proven to be ineffective treatments.11-15
This is not to say that dentists do not have an important place on the treatment team. They can function as point-of-entry diagnosticians and providers of initial home-care instructions. Dentists with specialized training can also provide oral orthotic therapy and chronic pain/medication management to complement the physiotherapy, hands-on therapy and nutritional advice given by the chiropractor. As it stands today however, chiropractic is glaringly absent in this equation. As a result, patients don't get the best care and chiropractors miss out on this market.
This unfortunate situation will only change if chiropractors learn to look for, accurately diagnose, refer and, if they choose, treat TMD. This would result in a huge increase in chiropractic patient visits and more effective treatment (e.g., home care, manipulation, spinal care, pathology-/location-specific physiotherapy, trigger-point and cranial therapy, nutritional counseling).8, 16
Accurate TMD diagnosis will also result in more effective treatment for patients who suffer from resistant neck pain and headache, as these symptoms and signs (e.g., cervical muscle hypertonicity) can be misdiagnosed as cervicogenic. They can, in fact, be driven by inflammation and/or disturbed biomechanics of the temporomandibular joints (TMJ). Symptoms frequently produced by an inflamed/dysfunctional TMJ include neck and upper shoulder muscle pain/hypertonicity (this is not referred pain), headaches, ear pain, dizziness and tinnitus.7, 17 As these symptoms are not included in the NIH cost estimate (which only factored in local TMJ and orofacial pain/dysfunction), the societal impact of TMD is clearly more than the $4 billion estimate.
TMD and the Chiropractic Paradigm
The reason that TMD frequently produces such wide-ranging symptoms is quite straightforward. TMJ are paired synovial joints containing a rich neurology that profoundly impacts the trigeminal-cervical complex.18-21 Inflammation, tissue damage and/or biomechanical disturbance can lead to aberrant neural discharge and CNS facilitation.20, 22 The symptoms of this neural activity frequently express themselves far from their origin in these joints.
There is no paradigm shift here. This is basic chiropractic theory: Disturbed joint function results in disturbed neural function, which results in both local and peripheral symptoms.23 The temporomandibular joints happen to be unique in that their neurology is far richer in mechanoreceptors than nociceptors, and mechanoreceptor sensitization can lead to CNS facilitation.21, 24 As a result, the predominant symptoms of many problematic TMD cases are peripheral to TMJ and the orofacial region.7, 22, 25
Head posture influences TMJ biomechanics, and whiplash injuries are known to alter head posture via cervical/spinal injury and to simultaneously damage the TMJ.26-35 Chiropractors who serve as primary care physicians for whiplash patients should include a rule-out examination protocol for temporomandibular joint disorders. Direct participation in the specific care of any diagnosed TMD is also an excellent option.
In any case, all health care professionals should be encouraged to refer whiplash patients to chiropractors trained in TMD. Just think what it could mean to your practice if TMD referrals from other health professionals opened the door for you to show these doctors and their patients the benefits of chiropractic care!
Positioning Your Practice
There are a few simple tests that need to be added to the clinical work-up if chiropractors want to expand their reach into the world of TMD diagnosis and treatment. These tests include: TMJ range of motion; palpation of the TMJ and masticatory muscles; tracking of mandibular movement; and ascultation of the TMJ during mandibular movement. While TMD specialists may also include joint/muscle challenges, radiographic studies and special tests (e.g., MRI), almost any dentist suspecting a TMD will perform and record the results of these tests. Chiropractors should perform these tests routinely as well.
These tests will add no more than five minutes to your examination. The time spent learning the language, examination procedures and diagnostic workup will pay for itself many times over. Here's why: Satisfied patients refer, you can advertise a new service, and professional referrals from dentists and others are available to those who speak the TMD language. The door to this huge ($4 billion) market is open, and our profession should walk in and make a difference.
References
When I graduated from chiropractic college in 1981 and started practice, I heard it all, and very little was positive. “You are a quack; you do not know what a subluxation is; you couldn’t get into a real health care program, so you chose the one that is slightly above a mail-order degree; you have no proof that chiropractic works; Are you really licensed?”, and so much more.
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A central challenge in creating our identity is that chiropractic is a method of care, not a technique or procedure. This is an important concept for us to promote. Our patients are treated with lifestyle modification, exercise, nutritional supplements, diet and a whole-body approach to accelerate the natural healing process. We are not simply CMT providers.
The results of a global survey released late last year (2023) unveiled some startling findings among medical and nursing students. The “Clinician of the Future: 2023 Education Edition” surveyed 2,212 students, of which 446 were in the United States, from 91 countries.
