Clinical decision making for temporomandibular disorders

Temporomandibular Disorders (TMD) encompass a number of clinical problems that involve the masticatory musculature, the temporomandibular joint (TMJ), or both. In any given patient, there exists the possibility of several overlapping TM disorders, an orofacial pain condition mimicking a TMD, or a concomitant TMD and non-TMD disorder. Since differential diagnosis involves the determination of which diseases or disorders a patient is suffering from by systematically contrasting the clinical characteristics, differentiation from among multiple possible conditions complicates the diagnostic process, which often must be approached with a certain degree of uncertainty. In addition, the therapeutic decisions that emanate from the diagnostic process have their own predictive uncertainties. These uncertainties can be ameliorated by coupling available clinical research data with structured clinical problem solving methods during the diagnostic-therapeutic decision making process. It is within this context that this article includes a discussion of the rationale for why the clinician should use decision making methods for TMD, a review of previous attempts at developing decision models for TMD, a discussion of the diagnosis of TMD with particular emphasis on the reliability and validity of their diagnostic criteria, a summary of the efficacy of therapeutic modalities and their application to treatment decisions, a sample decision tree analysis of a TM disorder, and some general recommendations for dental education.