Mattias Billing outlines how general dentists can better support patients with TMD and related conditions – without overstepping into specialist territory.
Temporomandibular disorders (TMD), bruxism and related jaw joint issues are increasingly common concerns in general dental practice. Yet, many clinicians still find these conditions complex and challenging to manage.
With growing awareness of the links between oral health, sleep, stress and systemic wellbeing, it is more important than ever for dentists to adopt a holistic, evidence-based approach. Here, Dr Mattias Billing explores how digital tools, interdisciplinary collaboration, and conservative care strategies can empower general dentists to better support patients with TMD and related conditions – without overstepping into specialist territory.
Mattias works in a referral practice at the Lister House Dental & Specialist Centre, part of Bupa, and with Cromwell Hospital, in collaboration with their Sleep Medicine Unit.
Simple principles
In the first ten years running my own practice, I used to mount every case with a facebow onto articulators. Later, I upgraded to Cadiax Compact, which had a built-in failsafe to identify patients who were off the disc.
Despite this accuracy, most of my dentistry at the time was still conformative, as the consensus was that reorganised treatment was specialist territory. Recent developments in digital technology, such as Modjaw and Align Technology, have shown that digitalisation of articulators can help dentists create more predictable digital workflows.
As aligner orthodontics involve some level of bite reorganisation – leading to horizontal and vertical changes – these changes can now be visualised, planned and clearly explained to patients in advance. With the recent boom in scanning, most dentists can now also accurately diagnose tooth surface loss and monitor erosion and wear, which can also impact these movements over time.
For newly-qualified dentists or those early in their careers, these concepts can be challenging. However, the sooner you integrate simple principles for avoiding TMD and managing it effectively when it occurs, the fewer long-term issues you’ll encounter. By understanding the etiology of various diagnoses – such as bruxism (recently reclassified as a movement disorder linked to sleep and breathing) and the impact of rheumatological changes in jaw joints, we can refer more accurately.
Tooth wear and OSA
Tooth wear may also reflect psychological wellbeing and be linked to parafunctional habits, such as nail and hair biting, or involuntary jaw movements like lip, tongue and cheek biting. Identifying these signs during checkups allows for timely intervention.
Other bite-related changes are emerging in the overlap between medicine and dentistry, particularly in the treatment of obstructive sleep apnoea (OSA). Studies show that some mandibular advancement devices (MADs) can cause occlusal changes over time. These changes may be acceptable in patients with underlying medical conditions, but are less justifiable in those presenting only with snoring.
In a Swedish study, researchers observed a 1mm vertical and 1mm anterior movement of the lower jaw over a ten-year period in patients with a neutral class I bite – changes that were irreversible. For patients with an overjet or class II bite, the shift was 2mm in both directions and continued to progress over the next decade.
Practical advice for general dentists
As a guide for general dentists managing TMD patients, I recommend three recent publications:
- Management of painful Temporomandibular disorder in adults: NHS England Getting It Right First Time (GIRFT) and Royal College of Surgeons’Faculty of Dental Surgery: the first paper evaluates the evidence base for various treatments, helping patients make informed decisions and avoid costly, ineffective options. It also outlines an evidence-based TMD care pathway useful for dental teams
- Management of chronic pain associated with temporomandibular disorders: a clinical practice guideline: the second paper addresses patients with mild to moderate chronic TMD (lasting over three months). It recommends jaw and posture exercises and cognitive behavioural therapy (CBT) as first-line treatments. Involving the patient’s GP for pain relief or further referral may be necessary for prolonged or complex cases
- Temporomandibular disorders: INfORM/IADR key points for good clinical practice based on standard of care: the third article presents a ten-point program focused on patient-centred decision-making. It emphasises thorough clinical diagnosis and history-taking before initiating treatment. Initial management should focus on reducing exacerbations and improving quality of life through self-management and conservative approaches such as CBT. Oral appliances like Michigan splints may be used, but only for a limited time and with follow-up. Changing the occlusion or reorganising the bite is not recommended unless under specialist care.
The general recommendation is to establish a non-invasive pathway to identify TMD early and refer patients for physiotherapy or CBT before it affects their teeth or your dental work. This may include TMD exercise apps, jaw relaxation aids, mindfulness tools, and sleep improvement strategies.
As we are moving into an era of minimally invasive dentistry, I believe this has become the next major development in general dental practice.
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This article is sponsored by Bupa Dental Care.
