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Editorial  |   June 2019
Management of Temporomandibular Disorders: New Opportunities for Osteopathic Medicine?
Author Notes
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  Address correspondence to Raymond J. Hruby, DO, MS, FAAO (Dist), Department of Neuromusculoskeletal Medicine/Osteopathic Manipulative Medicine, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific, 309 E 2nd St, Pomona, CA 91766-1854. Email: rhruby@westernu.edu
     
Article Information
Neuromusculoskeletal Disorders
Editorial   |   June 2019
Management of Temporomandibular Disorders: New Opportunities for Osteopathic Medicine?
The Journal of the American Osteopathic Association, June 2019, Vol. 119, 340-341. doi:https://doi.org/10.7556/jaoa.2019.060
The Journal of the American Osteopathic Association, June 2019, Vol. 119, 340-341. doi:https://doi.org/10.7556/jaoa.2019.060
This issue of The Journal of the American Osteopathic Association (JAOA) includes an interesting study by Saueressig et al1 titled “Evaluation of the Use of a Force Diagram in the Management of Temporomandibular Joint Sounds: A Prospective Cross-sectional Study.” In this study of patients with temporomandibular disorders (TMDs), the authors evaluated the results of management of joint sounds (clicking and crepitation) using occlusal splints combined with occlusal adjustment (OA) based on a force diagram. Patients (N=199) were examined and administered a questionnaire to determine the diagnosis of TMD and orofacial pain. Patients were then assigned to 1 of 2 splint therapies: either an anterior front-plateau–type bite plane (FP group) or a maxillary muscle relaxation appliance (MRA group). The authors used a force diagram to assist in objectively assessing the effectiveness of OA on these patients, as well as a visual analog scale for patients to self-assess the severity of TMD-related symptoms over time. The results showed a statistically significant reduction in the prevalence of symptoms in patients with clicking and crepitation.1 
The force diagram allowed the authors to evaluate the interactions of loads caused by muscular effort, which are sensed by the teeth, and the temporomandibular joints during the protrusive movement of the mandible. The force diagram describes the occlusal forces applied to the teeth. The simultaneous bilateral contact of the lower incisors in protrusion with the palatal surface of the upper incisors generates equal forces on both sides. If unilateral rather than bilateral contacts occur between the lower and upper incisors, then there are asymmetric force components that run perpendicular to the midline. 
Saueressig et al1 realized that restoring these force components to symmetry required a treatment approach that resulted in proper function between the maxillary and mandibular teeth. This approach, in turn, requires that muscles, tendons, and ligaments have normal tone; that energy expenditure of these tissues is not excessive; and that the mandible and associated support structures retain as much physiologic motion as possible. 
Osteopathic physicians (ie, DOs) have long recognized the role of somatic dysfunction and the value of using osteopathic principles in the management of certain dental and orthodontic conditions such as TMD. In fact, there is a long history of collaboration between DOs and members of the dental profession in the management of TMD. Magoun and Frymann were some of the first DOs to publish information on this important topic. Magoun,2 for example, described how the recognition of the presence of somatic dysfunction associated with some dental conditions made these problems much less mysterious and much more treatable. He also was one of the first osteopathic authors to discuss the role of osteopathic manipulative treatment (OMT) in assisting (along with dental or orthodontic treatments) with dental equilibration.3 Frymann4,5 published information specifically relating osteopathic principles and the use of OMT for the management of TMD. She emphasized the need for unimpeded physiologic motion of the mandible and associated structures, understood the role of trauma and malocclusion in TMD, and recommended that OMT be performed before each orthodontic or dental treatment so that such treatments would always be applied to structures that were maintained in the best physiologic motion possible. 
Some dental practitioners quickly recognized the value of osteopathic medicine in the collaborative treatment of TMD. In 1987, Libin6 described the dental view of osteopathic approaches to craniomandibular problems. Over time, additional clinical research has provided an evidence base for collaboration between osteopathic medicine and dentistry in the management of TMD and other dental or orthodontic conditions.7-9 
Osteopathic physicians, particularly those involved in the treatment of patients with TMD, should be interested in this article for several reasons. First, the authors provide an excellent study that demonstrates an objectively measured approach to the management of TMD. Second, the approach taken by Saueressig et al1 reflects the osteopathic concept of the interrelationship between structure and function, showing how a condition such as TMD can easily be viewed in the light of osteopathic principles and practice. Third, their approach could provide a basis for collaborative research between osteopathic medicine and dentistry. 
While the authors’ results were excellent, we, as DOs, should consider the use of these objective methods in further collaborative clinical research between DOs and dentists. This research could provide more evidence to show that a collaborative approach to TMD may be more efficacious than either dentistry or osteopathic medicine alone; in addition, such research would strengthen the growing scientific basis for osteopathic medicine. 
References
Saueressig NS, Hickert AC Saueressig, de Andrade GK, Bttencourt HR, Basso D, Saueressig NG. Evaluation of the use of a force diagram in the management of temporomandibular joint sounds: a prospective cross-sectional study. J Am Osteopath Assoc. 2019;119(6):349-356. doi: 10.7556/jaoa.2019.063
Sr Magoun HI. Osteopathic approach to dental enigmas. J Am Osteopath Assoc. 1962;62(2):110-118.
Sr Magoun HI. Dental equilibration and osteopathy. J Am Osteopath Assoc. 1975;74(10):981-991. [PubMed]
Frymann VM. Cranial osteopathy and its role in diseases of the temporomandibular joint. Dent Clin North Am. 1983;27(3):595-611. [PubMed]
Frymann VM. Why does the orthodontist need osteopathy in the cranial field? The Cranial Letter. 1988;41(9).
Libin BM. The cranial mechanism: its relationship to cranial-mandibular function. J Prosthet Dent. 1987;58(5):632-638. [CrossRef] [PubMed]
Kalamir A, Bonello R, Graham P, Vitiello AL, Pollard H. Intraoral myofascial therapy for chronic myogenous temporomandibular disorder: a randomized controlled trial. J Manipulative Physiol Ther. 2012;35(1):26-37. doi: 10.1016/j.jmpt.2011.09.004 [CrossRef] [PubMed]
Cuccia AM, Caradonna C, Caradonna D. Manual therapy of the mandibular accessory ligaments for the management of temporomandibular joint disorders. J Am Osteopath Assoc. 2011;111(2):102-112. [PubMed]
Cuccia AM, Caradonna C, Annunziata V, Caradonna D. Osteopathic manual therapy versus conventional conservative therapy in the treatment of temporomandibular disorders: a randomized controlled trial. J Bodyw Mov Ther. 2010;14(2):179-184. [CrossRef] [PubMed]