Appropriate Management of Temporomandibular Disorders in the Elderly
the retrodiscal tissue of older individuals.
The articular surface of the mandibular condyle also undergoes age-related changes that are similar to other load-bearing articular surfaces. Radiographic cortical plate irregularities and flattening of the condylar head are frequently noted with advancing age. Macroscopically, surface erosions and cartilage denudation is repeatedly seen.
Incidence
It has been estimated that 13% of the population will, at some point, experience pain at rest or during function in the craniomandibular complex.7 The exact prevalence of TMDs in the elderly is unknown, but one study suggested a low incidence of TMJ problems in an older institutionalized population.8 TMDs seem to be at least twice as prevalent in women, who are also more likely to seek treatment. Pain onset tends to occur after puberty and peaks during the reproductive years, with the highest prevalence in the 20-40 year age group and the lowest prevalence being among children, adolescents and the elderly.9
The societal costs of TMDs are significant. MacFarlane, et al. demonstrated that up to 17% of individuals with orofacial pain in a U.K. community missed work.10 Patients suffering from a TMD have been shown to use significantly more health care services and have mean costs up to 1.6 times higher for all services, with outpatient visits accounting for about 40% of the difference in mean costs.11 A relationship between clinical evidence and subjective complaints of TMJ pain and dysfunction and high rates of depressive symptoms also has been determined.12
The radiographic incidence of TMJ abnormalities is significantly greater than the incidence of patients presenting with TMD. Disc displacement, often clinically present as "clicking", has been found on magnetic resonance imaging (MRI) examination in at least 33% of asymptomatic patients.13 Studies also have concluded that it is not possible to predict the development of orofacial pain based solely on the radiological signs of TMJ osteoarthritis.14 However, Emshoff, et al. have demonstrated a fair diagnostic agreement between the presence of clinically evident TMJ pain with limited mouth opening and the MRI diagnosis of disc displacement without reduction and osteoarthrosis.15,16
Management of Temporomandibular Disorders
Numerous conditions, some life threatening, can mimic the common signs and symptoms of a TMD. A thorough history and clinical examination of the entire maxillofacial region by a health care provider experienced in facial pain diagnosis and management is therefore of paramount importance. Initial plain film imaging of the mandibular condyles and glenoid fossa is required. More advanced imaging with computed tomography or MRI is required in select cases.
Most TMDs follow a natural course of decreasing pain and improving function independent of the treatment provided. As a result, the primary role of the clinician should be to provide pain management and supportive care. The identification and, where possible, elimination of etiological factors is essential, including gross malocclusions, ill-fitting dentures, loss of intra-arch vertical dimension, life "stressors", parafunctional habits and/or ongoing trauma.
Initial conservative management usually involves the initiation of a soft diet, physiotherapy, bite plane therapy, stress reduction and pharmacotherapy. Non-steroidal anti-inflammatories, muscle relaxants, analgesics and, when required, antidepressants are routinely prescribed. Close follow-up is necessary.
Surgical Interventions
The majority of patients will improve with conservative measures, but roughly 5% will eventually require surgical intervention. Improvements in diagnosis and surgical techniques have enabled us to better define the role of surgery in managing TMJ disorders. However, due to the persistent limitation in our understanding of the precise pathological processes causing joint pain and dysfunction, there is still debate over the exact role of surgery in the management TMD.17 The procedures presently performed include arthrocentesis, arthroscopy, vertical