Management of temporomandibular disorders

1. PROSTHODONTIC
MANAGEMENTOF
TMD
Nishu Priya
II year PGT

2.  All the treatment methods being used for TMDs can be categorized generally into one of two types:
definitive treatment or supportive therapy.
 Definitive treatment refers to those methods that are directed toward controlling or eliminating the etiologic
factors that have created the disorder.
 Supportive therapy refers to treatment methods that are directed toward altering patient symptoms but
often do not affect the etiology.

3. Definitive
Treatment
 Definitive therapy is aimed directly toward the elimination or alteration of the
etiologic factors that are responsible for the disorder.
 Since it is directed toward the etiology, an accurate diagnosis is essential.
 It is with this rationale that the statement is made: All initial treatment
should be conservative, reversible, and noninvasive.

4. DefinitiveTherapy
Considerations for
Occlusal Factors
1. Reversible Occlusal Therapy
 It alters the patient’s occlusal condition only temporarily
 accomplished with an occlusal appliance.
 This is an acrylic device worn over the teeth of one arch that has an opposing
surface that creates and alters the mandibular position and contact pattern of
the teeth.
2. Irreversible Occlusal Therapy
 permanently alters the occlusal condition and/or mandibular position.
 selective grinding, restorative procedures, orthodontic treatment and surgical
procedures aimed at altering the occlusion and/or mandibular position.

6. Classification of occlusal appliances
According to Okeson :
1) Stabilization appliance
2) Anterior repositioning appliances (ARA)/ Mandibular orthopedic repositioning appliance (MORA)
Other types:
 a) Anterior/Posterior bite plane
 b) Pivoting appliance
 c) Soft/ resilient appliance (silicone)
Dawson classified splints as:
1. Permissive splints/ muscle deprogrammer
2. Non-permissive splints/ Directive splints

7. 1. Permissive occlusal splints
 have a smooth surface on one side  allows the muscles to move the
mandible without interference from deflective tooth inclines  the condyles can
slide back into centric relation.
2. Directive occlusal splints
 direct the lower arch into a specific occlusal relationship that in turn directs the
condyles to a predetermined position.
 They should be reserved for specific conditions involving intracapsular TMDs.
 An example of a nonpermissive splint is a repositioning splint (anterior
repositioning appliance [ARA])
PRINCIPLE
Most occlusal splints have one
primary function: to alter an
occlusion so it does not
interfere with complete seating
of the condyles in centric
relation.

8. What splints cannot do

9. Anterior deprogramming splints
(Anterior midpoint contact splints)
designed to disengage all teeth except incisors
minimizes elevator muscle clenching force
muscle clenching forces are reduced significantly
during parafunctional movements provides an immediate reduction of occlusal
forces + prevents their destructive impact on the masticatory system
prevent/minimize the effects of wear on the teeth
 It is mainly recommended in patients with acute or chronic muscle pain
 The width of the midpoint contacting platform is limited to the width of the two
lower incisors, measuring 8-10mm.

10. Examples of permissive splints include bite planes anterior jigs, Lucia jig, anterior deprogrammer and stabilization splints
https://dental.thedawsona
cademy.com/how-to-
make-a-differential-
diagnosis-using-a-lucia-jig

11. relieves the symptoms of muscle pain
confirms a diagnosis of occluso-muscle disorder
choice of treatment
The proper use of any segmental splint is to use it for diagnostic purposes
only.
correct the occlusal disharmony
directly
extend coverage of the splint to
include contact on all teeth
does not relieve pain
Pain increases
intracapsular disorder
Anterior deprogramming device
When Occlusal Splints Are Not
Necessary
No sign of TMJ tenderness or tension
+ a negative history it is not
necessary to fabricate an occlusal
splint prior to restorative dentistry,
orthodontics or equilibration

12. When a pre-treatment occlusal splint is appropriate
 If there is doubt about complete seating of the TMJs
 to test the stability of the condylar position by use of a centric relation
occlusal splint
 use of an occlusal splint can confirm that the result will be comfortable
when completed with irreversible occlusal therapy
How Long Must the Splint Be
Worn?
1. All related pain is gone.
2. The joint structure is stable.
3. The bite structure is stable.

13. Fabrication of an ideal permissive
splint

14. Stabilization Appliance
This type of splint is constructed with even posterior contact in centric relation with condyles seated,
separation of posterior teeth in protrusive or lateral excursions.
Treatment Goals
• provides an occlusal relationship considered optimal for the
patient
• the condyles are in their most musculo-skeletally stable
position at the time that the teeth are contacting evenly and
simultaneously.
• Canine disocclusion of the posterior teeth during eccentric
movement

15. Indications
 generally used to treat muscle pain disorders
 It can decrease the parafunctional activity
 local myalgia or chronic centrally mediated myalgia
 retrodiscitis secondary to trauma

16. Fitting the Appliance to the Maxillary
Teeth
Locating the Musculoskeletally Stable
Position
Developing the
Occlusion

17. fabrication of a mandibular stabilization
• maxillary and mandibular appliances reduce symptoms equally.
• Advantages- affects speech minimally and improves aesthetics
• The maxillary incisors are angled labially it is impossible to develop an anterior stop on the mandibular
appliance that is perpendicular to the long axis of the maxillary incisors.

18. Instructions and Adjustments
 The patient is instructed in proper insertion and removal of the
appliance
 bruxism - nighttime use
 diurnal muscle activity - during the day
 Retrodiscitis - may need to be worn more frequently
 myogenous pain disorders respond best to part-time use (especially
nighttime use), while intracapsular disorders are better managed with
more continuous use
 Follow up 2 to 7 days- the occlusal marks on the appliance are re-
examined
As muscles relax and symptoms
resolve, a more superoanterior position
of the condyle may be assumed. This
change must be accompanied by
adjustments of the appliance to
optimum occlusal conditions.

19. Anterior
Positioning
Appliance

20. Anterior Positioning Appliance
Description and Treatment Goals
 The anterior positioning appliance is an interocclusal
device that encourages the mandible to assume a
position more anterior to the intercuspal position.
 The goal of treatment is not to alter the mandibular
position permanently but only to change the position
temporarily to enhance adaptation of the retrodiscal
tissues.
 The purpose of an anterior positioning appliance is to
temporarily bring the mandible forward in an attempt to
improve the condyle disc relationship
Indications
 used primarily to treat disc displacements with reduction
and disc displacements with intermittent locking
 patients with painful joint sounds and jaw catching
 inflammatory disorders

21. Fabricating and Fitting the
Appliance
Locating the Correct Anterior
Position

22. Adjusting the
Occlusion
Instruction and Adjustments
• instructed to wear the appliance only at night.
• During the day, the appliance should not be worn
• The maxillary appliance is best for nighttime use since the
patient can not consciously maintain the forward position. It is
likely that during sleep the mandible will retrude and the

23. Anterior Bite Plane
Description and Treatment Goals
 The anterior bite plane is a hard acrylic appliance worn over the maxillary
teeth providing contact with only the mandibular anterior teeth. It is
primarily intended to disengage the posterior teeth and thus eliminate their
influence on the function of the masticatory system.
Indications
 for the treatment of muscle disorders related to orthopedic instability or an
acute change in the occlusal condition.
 Parafunctional activity may also be treated with it but only for short periods.
complication
appliance covers only a portion of one arch
appliance is worn continuously for several
weeks or months
unopposed posterior teeth have the
potential to erupt
anterior openbite

24. Posterior Bite Plane
Description and Treatment Goals
 usually fabricated for the mandibular teeth and consists of areas of hard
acrylic located over the posterior teeth and is connected by a cast metal
lingual bar
 The treatment goals of the posterior bite plane are to achieve major
alterations in vertical dimension and mandibular positioning.
Indications
 in cases of severe loss of vertical dimension or when there is a need to
make major changes in anterior positioning of the mandible.
 may be helpful for certain disc derangement disorders
complication

25. Pivoting Appliance
Description and Treatment Goals
 hard acrylic device that covers one arch and usually provides a
single posterior contact in each quadrant
 This contact is established as far posteriorly as possible. When
superior force is applied under the chin, the tendency is to push
the anterior teeth close together and pivot the condyles
downward around the posterior pivoting point.
Indications
 painful disc displacement
 Treatment of symptoms related to osteoarthritis of the TMJ
 distract a condyle from the fossa - unilateral pivot appliance

26. Soft or Resilient Appliance
Description and Treatment Goals
 The soft appliance is a device fabricated of resilient material that is
usually adapted to the maxillary teeth.
 Treatment goals are to achieve even and simultaneous contact with
the opposing teeth.
Indications
 Protective athletic splints
 for patients who exhibit high levels of clenching and bruxism
 for patients who suffer from repeated or chronic sinusitis resulting in
extremely sensitive posterior teeth

27. DefinitiveTherapy
Considerations for
EmotionalStress
Common Personality
Traits
perfectionists, compulsive, and
domineering; more introverted, more
neurotic with more trait anxiety; unhappy,
dissatisfied, and self-destructive
Common Emotional States
a correlation may be drawn
between increased levels of
anxiety, fear, frustration, anger
and depression
Restrictive Use
Voluntary
Avoidance
Education and Cognitive Awareness
Training

28. Relaxation Therapy
i. Substitutive relaxation: substitution for stressful events or an interposition between them in an
attempt to lessen their impact on the patient
ii. Active relaxation therapy: directly reduces muscle activity. Patient can be trained to relax the
symptomatic muscles to aid in establishment of normal function.
Jacobson’s method- patient tenses the muscles and then
relaxes them until the relaxed state can be felt and maintained.
The patient is instructed to concentrate on relaxing the
peripheral areas and to move progressively centrally.
Reverse approach- the muscles are passively stretched and
then relaxed
Other training methods also encourage relaxation but are used
to a lesser degree - Self-hypnosis, meditation, and yoga
Biofeedback- technique that assists the patient in regulating
bodily functions that are generally controlled unconsciously. It is
accomplished by monitoring EMG activity of muscles.
Negative biofeedback- The feedback unit brings parafunctional
activity to a conscious level and therefore allows it to be more
readily controlled

29. DefinitiveTherapy
Considerations for
Trauma
 Macrotrauma  supportive therapy
 Microtrauma  occlusal appliance

30. DefinitiveTherapy
Considerations for
Deep Pain Input
 Once the deep source of pain is resolved the TMD will also resolve.
 Both treatments provided at the same time will provide the best
success for the patient.

31. DefinitiveTherapy
Considerations for
Parafunctional
Activity
 Since diurnal and nocturnal parafunctional activities may be different
in character and origin, it is important that they be identified and
separated.
 Diurnal activities  Patient education about parafunctional activities
and their avoidance
 Nocturnal activities  occlusal appliance therapy

32. Supportive
Therapy
 Supportive therapy is directed toward altering the patient’s
symptoms and often has no effect on the etiology of the disorder.
 Supportive therapy is directed toward the reduction of pain and
dysfunction.

33. Pharmacologic
Therapy
 analgesics, antiinflammatories, muscle relaxants, anxiolytics, anti-
depressants, anticonvulsives, injectables, and topicals.
Injectable Medications
• management a chronic TMDs  breaking the
pain cycle
• 2% lidocaine and 3% mepivacaine.
• intracapsular injection of sodium  in
treatment of disc displacement without
reduction; post arthocentesis
Analgesics and
antiinflammatorie
s
• Paracetamol
• Salicylates
• Propionic acid
derivatives
• Cox-2
inhibitors
Muscle Relaxants
• Cyclobenzapri
ne
• Metaxalone
• Methocarbamo
l
• Baclofen
• carisoprodol
Anxiolytic
Agents
• Diazepam
• Clonazepa
m
• alprazolam
Antidepressants
• Tricyclic
• SSRI
• SNRI
Anticonvulsive
Agents
• Gabapentin
• Pregabalin

34. PhysicalTherapy
i. Thermotherapy
Heat vasodilation
provides a cutaneous peripheral
input carried by A-beta fibers
masks nociceptive input carried by the c-fiber
ii. Coolant therapy
 Cold encourages relaxation of muscles that are in spasm
 Ice; frozen vegetables
 vapor spray- ethyl chloride and fluoromethane
Vapocoolant spray is applied (1 or 2 feet for 5 seconds)
stimulation of cutaneous nerve fibers
Shut down the c-fibers
Pain relief

35. iii. Ultrasound therapy
 Produces an increase in temperature at the interface of the tissues
affects deep tissues increase the blood flow + separate
collagen fibers flexibility and extensibility of connective
tissue
iv. Phonophoresis
 to administer drugs through the skin
v. Iontophoresis
 the medication is placed in a pad on the desired tissue area and
current is passed
vi. Electrogalvanic stimulation therapy
 A rhythmic electrical impulse is applied to the muscle
repeated involuntary contractions and relaxations
break up myospasms
vii. Transcutaneous electrical nerve stimulation
 the electrical activity decreases pain perception
viii. Cold laser
 accelerate collagen synthesis, increase vascularity of healing
tissues, decrease the number of microorganisms, and decrease
pain.

36. Manual
Techniques
i. Soft Tissue Mobilization
 helpful in regaining normal function and mobility of injured or painful tissues
 superficial massage mild stimulation of cutaneous sensory nerves
reduces pain
 Deep massage help in mobilizing tissues increase blood flow
eliminate trigger points
ii. Joint Mobilization
 Decrease interarticular pressure + increase range of joint movement
 Distraction of the TMJ place the thumb in the patient’s mouth over the lower
second molar area on the side to be distracted  the thumb places
downward force same hand pulls up on the anterior portion

37. iii. Muscle Conditioning
 Passive muscle stretching : assist in re-establishing
normal muscle length and function
 Assisted muscle stretching: to regain muscle length
 Resistance exercises: utilize the concept of reflex
relaxation or reciprocal inhibition.
- patient attempts to open the mandibular
depressors are active keep the mandible
from dropping suddenly resistance
neurologic message sent to the antagonistic
muscles elevators relax completely
 postural training: head is in the forward position
produces elongation of the supra and infrahyoid
muscles + closes the posterior space between atlas
and axis leads to muscular and cervical
symptoms

38. Acupuncture
 uses the body’s own antinociceptive system to reduce the levels of
pain felt
stimulation of acupuncture points
release of endogenous opioids (endorphins and enkephalins)
block transmission of of noxious stimuli
reduce painful sensations

39. Physical Self-
Regulation
 The PSR approach focuses on limiting any activity that increases the sense
of discomfort or pain to promote return of pain-free function.
patients are provided with an explanation of their condition
given instructions regarding the rest positions for structures in the orofacial region
specific skills are provided for improving awareness of postural positioning
skill for relaxing upper back tension
progressive relaxation procedure involving the positioning of body structures
Diaphragmatic breathing entrainment instructions
instructions for beginning sleep in a relaxed position

40. Protective Co-Contraction (Muscle Splinting)
Definitive Treatment
 protective co-contraction is a normal CNS response
 Treatment should instead be directed toward the reason for
the co-contraction.
 Etiology – trauma: no definitive treatment
- poorly fitting restoration: altering restoration to
harmonize with occlusion
- deep pain : stress management, physical self
regulation
Supportive Therapy
 restrict use of the mandible to within painless limits
 Short-term pain medication
 PSR techniques
Treatment of Masticatory Muscle
Disorders

41. Local Myalgia (Noninflammatory Myalgia)
Definitive Treatment
 Eliminate any ongoing altered sensory or proprioceptive input
 Eliminate any ongoing source of deep pain input
 physical self-regulation- restrict mandibular use to within painless limits
 -use the jaw to stimulate the proprioceptors and mechanoceptors
 - reduce any non-functional tooth contacts
 - reduce stress and promote relaxation
 nighttime clenching or bruxing  occlusal appliance
 Cyclic muscle pain  NSAIDs every 4-6 hours for 5-7 days to break the cycle
Supportive Therapy
 passive muscle stretching
 gentle massage

43. Myospasms (Tonic Contraction Myalgia)
Definitive Treatment
 best treated by reducing the pain followed by passively lengthening or stretching the involved
muscle
 manual massage
 vapocoolant spray
 Ice
 an injection of local anesthetic
 elimination of etiologic factors- myospasms are secondary to fatigue and overuse  patient is
advised to rest the muscle
 Supportive Therapy
 Soft tissue mobilization -deep massage and passive stretching
 Once myospasm is reduced  muscle conditioning exercises and relaxation techniques
 Pharmacologic therapy  not indicated because of the acuteness of the condition

45. Myofascial Pain (Trigger Point Myalgia)
Definitive Treatment
 Eliminate source of deep pain input
 stress management techniques
 posture or work position improved
 PSR techniques
 sleep disorder low dosages of a tricyclic antidepressant before bedtime
 treatment and elimination of the trigger points:
- Spray and Stretch
- Pressure and Massage
- Ultrasound and Electrogalvanic Stimulation
- Injection and Stretch
Supportive Therapy
 soft tissue mobilization
 muscle conditioning techniques
 Pharmacologic therapy- muscle relaxant

47. Centrally Mediated Myalgia (Chronic Myositis)
Definitive Treatment
 Restrict mandibular use to within painless limits
 Avoid exercise and/or injections
 Disengage the teeth- PSR techniques or stabilization appliance
 antiinflammatory medication- break cyclic muscle pain
 management of sleep antidepressants at bed time
 reducing this central sensitization anticonvulsants
Supportive Therapy
 moist heat / ice
 As the symptoms begin to resolve ultrasound therapy and gentle stretching

49. Derangements of the Condyle-Disc Complex
Disc Displacements With Reduction and Disc Displacements With
Intermittent Locking
Definitive Treatment
 Anterior positioning appliance mandible is maintained in a forward
position condyle functions on a newly adapted retrodiscal tissue
reposition condyle back on the disc
 If etiology is microtrauma, appliance therapy is delayed till the injury is a
month old
 Stabilization appliance – used if it is able to reduce symptoms
 disc is not in its original position still displaced
 musculoskeletally stable position is determined by the muscle function,
not disc position
Supportive Therapy
 decrease loading of the joint whenever possible
 Inflammation NSAID
 physical self-regulation techniques
Treatment of Temporomandibular Joint
Disorders

51. Disc Displacement Without Reduction
Definitive Treatment
 anterior positioning appliance is contraindicated aggravate the condition by
forcing the disc even more forward
 to reduce or recapture the disc by manual manipulation for acute dislocations
 acute disc displacement without reduction has been reduced,  anterior
positioning appliance continuously before beginning only night time use
 Failure to reduce the disc may indicate a dysfunctional superior retrodiscal lamina
or a loss of disc morphology
 Permanent disc displacement without reduction  given a stabilization appliance
reduce forces to the retrodiscal tissues
 Surgical considerations arthrocentesis, arthroscopy, arthrotomy
Supportive Therapy
 Patients should be encouraged not to open too wide
 Gentle, controlled jaw exercise
 Pain heat or ice, NSAIDs
 PSR for the recovery phase

53. Structural Incompatibility of the Articular Surfaces
Deviation in Form
Definitive Treatment
 Arthroplasty bony incompatibility
 Discoplasty disc is perforated or misshaped
 Supportive Therapy
 minimize the dysfunction
 stabilization appliance bruxism can accentuate the dysfunction
 If pain is associated  analgesics  prevent secondary central
excitatory effects

54. Adherences/Adhesions
Definitive Treatment
 directed toward decreasing loading of articular surfaces
 Diurnal clenching  patient awareness and PSR techniques
 nocturnal clenching or bruxism  stabilization appliance
 Adhesions arthroscopic surgery breaking the fibrous attachment
 Supportive Therapy
 passive stretching, ultrasound, and distraction of the joint more
freedom for movement
 pain and dysfunction are minimal  patient education

56. Subluxation
Definitive Treatment
 Eminectomy  reduces the steepness of the articular eminence  decreases the amount
of posterior rotation of the disc on the condyle during full translation
Supportive Therapy
 Patient must learn to restrict opening
 an intraoral device to restrict movement  attempts to develop a myostatic contracture of
the elevator muscles  eventually limiting opening to the point of subluxation
Luxation
Definitive Treatment
 directed toward increasing the disc space, which allows the superior retrodiscal lamina to
retract the disc
 Patient asked to open mouth as wide as possible activate depressors + inhibit elevators
 posterior pressure to chin or downward pressure on molars reduces dislocation by
capturing disc
 Eminectomy chronic or recurrent dislocation due to anatomic variation
 oromandibular dystonia  Botulinum toxin injected into the inferior lateral pterygoid
muscles, bilaterally using EMG guidance
Supportive Therapy
 The most effective method of treating luxation is prevention

58.  Inflammatory Disorders of the Temporomandibular Joint
 Synovitis and Capsulitis
 macrotrauma  condition is self-limiting
 synovitis is present secondary to microtrauma associated with a disc
derangement, the disc derangement should be treated.
 Supportive Therapy
 patient is instructed to restrict all mandibular movement within painless
limits
 constant pain  NSAID
 Thermotherapy  apply moist heat for 10 to 15 minutes 4 or 5 times
throughout the day
 Ultrasound therapy  two to four times per week
 acute traumatic injury  single injection of corticosteroid to the capsular
tissues. Repeated injections are contraindicated
 appropriate therapy for associated muscle hyperactivity

59. Retrodiscitis
Definitive Treatment for Retrodiscitis From Extrinsic Trauma
 macrotrauma no longer present  no definitive treatment indicated
Supportive Therapy for Retrodiscitis From Extrinsic Trauma
 Restrict movement to within painless limits
 Pain  Ultrasound and thermotherapy
 If pain persists  a single intracapsular injection of corticosteroids. Repeated
injections are contraindicated
 acute malocclusion exists  stabilization appliance
Definitive Treatment for Retrodiscitis From Intrinsic Trauma
 trauma often remains and continues to cause injury to the tissues
 When due to anterior disc displacement with reduction anterior positioning
appliance
 Supportive Therapy for Retrodiscitis From Intrinsic Trauma
 Restrict movement to within painless limits
 Pain  Ultrasound and thermotherapy
 Chronic inflammation  corticosteroid injections not indicated

61. Osteoarthritis
Definitive Treatment
 When due to anterior disc displacement with reduction anterior
positioning appliance
 muscle hyperactivity  stabilization appliance
 oral habits must be identified and discouraged
 PSR techniques
Supportive Therapy
 osteoarthritis is a self-limiting disorder
 Conservative, supportive therapy is all that is indicated for most patients to
speed up adaptive process
 Reassurance is given that the condition normally runs a course of
degeneration and then repair.
 pain medication and anti-inflammatory
 Thermotherapy
 Passive muscle exercises within painless limits
 inflammatory condition is chronic, intracapsular injections of corticosteroids
are contraindicated
 Orthopedic instability  dental therapy

63. Inflammatory Disorders of Associated Structures
Definitive Treatment
 directed toward resting the muscle
 stabilization appliance  clenching or bruxism
 PSR techniques
Supportive Therapy
 Painful symptoms managed with analgesics
 Antiinflammatory medications
 Physical therapy – ultrasound
 an injection of corticosteroid into the tendon- Temporal tendonitis
 into the attachment of the ligament at the angle of the mandible- stylomandibular
ligament inflammation

64. Occlusal
Therapy
Treatment Goals for Occlusal Therapy
 The treatment goals of permanent occlusal therapy are to establish orthopedic
stability in this position.
1. The condyles are resting in their most superoanterior position against the
posterior slopes of the articular eminences.
2. The articular discs are properly interposed between the condyles and the
fossae.
3. When the mandible is brought into closure in the musculoskeletally stable
position, the posterior teeth contact evenly and simultaneously.
4. When the mandible moves eccentrically, the anterior teeth contact and
disocclude the posterior teeth.
5. In the upright head position, the posterior tooth contacts are more prominent
than the anterior tooth contacts.
“If occlusion is found to significantly contribute to a TMD, dentistry is the only health profession that can provide lasting effect. If
occlusion is not related to the TMD, it should not be altered other than for restorative or aesthetic reasons.”

65. Treatment Planning for Occlusal Therapy
 minor changes selective grinding or occlusal adjustment or
occlusal equilibration
 Posterior crowns must be fabricated such that occlusal forces are
directed through the long axes of the roots  cannot always be
accomplished orthodontic procedures
If selective grinding procedures cannot be
successfully performed within the confines of
the enamel  restorations – Crowns and fixed
prosthetic procedures

66. Rule of Thirds
 choice must be made among selective grinding, crown and fixed prosthodontic procedures, and
orthodontics.
 The extent of buccolingual arch discrepancy of the maxillary and mandibular posterior teeth establishes
which treatment will be appropriate.
Initial tooth contact centric cusps are located near the opposing central fossae slight alterations
greater distance more extensive treatment
 The rule of thirds has been developed to aid in determining the appropriate treatment.
selective grinding fixed prosthetic procedures orthodontics

67. Conclusion
The diagnosis and management of the most common cause of non-
dental pain in the maxillofacial region, namely temporomandibular
disorders (TMD), remains a challenge for clinicians to this day, despite
extensive clinical research into the topic. The etiology of TMD is often
multi-factorial, and precise causes for the symptoms may be difficult to
pinpoint. In the past, focus has been placed on the physical origins of
TMD, but an at least equally significant psychosocial factor is now
well-recognized.
Consequently, a multimodal approach, which might include
counselling and psychological therapy, is being increasingly
advocated.