There have been a few common phrases around recently that would not have been heard some years ago.
‘You’re on mute!’ in the first year of lockdown and ‘Have you had your jab yet?’ in 2021.
This year it is ‘Have you heard about Wordle?’
Wordle for those who have yet to discover it, is a web-based word game, with a 5x6 grid of boxes. Participants enter a five-letter word into the top line and are then informed, by the highlighting the relevant letters, whether the choices are either in the correct place for the word to be guessed (green) or present in that word but in the wrong place (a shade of sickly khaki). Using that information, the process is repeated on the descending lines until either the correct word is found or the 6th guess is incorrect. A new game is set each day.
Diagnosing tempero-mandibular joint disorder (TMD) strikes me as similar to playing Wordle, but without ever getting to line 6 with the correct answer. All responses to questions are about as helpful as those squares of sickly khaki.
‘Does it hurt when you open your mouth?’
‘Does it click when you open wide?’
‘Oh yes, listen …… and it drives my partner mad at meal times.’
‘Do you grind your teeth in your sleep?’
‘Oh yes, and it drives my partner mad to 2 in the morning.’
‘Do you clench your teeth at all?’
‘Occasionally, when my partner’s mad at me.’
‘Do you get headaches?’
‘Well, my partner and I aren’t getting on too well at the moment, so yeah, I guess I do.’
‘Have you had any knocks to the head recently?’
‘Look, I said we’re not getting on too well but its not as bad as all that!’
And so it goes on, checking for tenderness to palpation and whether the occlusion looks OK and writing ‘TMD?’ in the notes and offering generic advice about self-care, all of which is available on the NHS website, such as don’t chew pen tops, eat soft food, take some analgesics and if it doesn’t get better, see you GP, who might refer you to a dentist (who might make you a soft bite guard).
According to a recent paper in the Journal of the American Dental Association (JADA), dentists in the USA offer similar advice. One hundred and eighty five dentists were recruited to record details of a sequence of patients attending with TMD. They recruited 1,901 subjects who fulfilled their criteria for entry to the study. Almost half of these had had painful TMD for at least 3 years and diagnoses included combinations of myalgia, arthralgia and headache. A quarter had only muscle pain and 10% only joint pain.
Treatments offered were mostly non-invasive and reversible:
Three quarters of dentists in the study recommended an intra oral appliance of some sort and two thirds recommended referral to ‘allied care providers.’
And there’s the rub. To whom does one refer? Who are the allies in the management of TMD? Outside of a large conurbation with a dental hospital, I suspect most end up with the local maxillo-facial surgeon. But how often is surgery required? Orthopaedics, maybe – that speciality which diagnoses and treats ‘a wide range of conditions of the musculoskeletal system, (including) bones and joints and their associated structures that enable movement - ligaments, tendons, muscles and nerves?’ I’m not sure their interest stretches superior the hyoid and anterior to the atlas and axis. Oral medicine? Physiotherapy? Osteopathy? Aromatherapy?
It is perhaps not surprising that a further paper in JADA found that TMD is linked with other chronic conditions such as chronic back pain, myofacial syndrome, chronic stomach pains, migraine, irritable bowel syndrome, fibromyalgia and depression. They conclude that their review ‘supports the idea that clinicians, including dentists, treating patients who had received diagnoses of TMD should be attentive to the presence of signs and symptoms of other chronic pain conditions that could require collaborative care across medical specialities (for example, neurology, rheumatology and psychiatry.’
The temporomandibular joint is the Cinderella of all joints, falling between the specialities which may be able to help. Since 1892, it has clearly failed to be recognised as part of the ‘anatomical arrangements of the human body.’ Yet 80% of dentists report treating up 3 patients a month with TMD.
TMD therefore is not uncommon and these papers show that its diagnosis and treatment is a complex, multi-disciplinary exercise and not one to be passed down like the rows of a Wordle puzzle, eliciting sickly khaki responses in the hope of finding a successful result of 5 green squares.
Paul Hellyer BDS MSc
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