From the Guidelines
For a patient with degenerative left TMJ, small joint effusion, severely torn fragmented anterior displaced disc, and dislocated right temporomandibular disc who has been in physical therapy for 3 months, I strongly recommend referral to a therapist who can provide cognitive behavioural therapy (CBT) with or without biofeedback or relaxation therapy, as this approach has been shown to be effective in managing chronic pain associated with temporomandibular disorders 1. Given the patient's ongoing physical therapy, it is essential to consider additional interventions that can address the chronic pain aspect of their condition.
- The patient may benefit from therapist-assisted mobilisation, manual trigger point therapy, supervised postural exercise, or supervised jaw exercise and stretching with or without manual trigger point therapy, as these interventions have been issued strong recommendations in favour by the guideline panel 1.
- A pain management specialist may also be considered for targeted treatments, although it is crucial to note that certain interventions like botulinum toxin injection, trigger point injection, and corticosteroid injection have conditional recommendations against them 1.
- An oral and maxillofacial surgeon who specializes in TMJ disorders may be necessary for evaluating the need for more invasive interventions, but this should be considered after exploring less invasive options that have stronger recommendations.
- Before any surgical intervention, updated advanced imaging (MRI and/or CT) should be performed to assess the current joint status. The multidisciplinary approach is necessary because the bilateral nature of the disorder with significant disc displacement and effusion suggests that physical therapy alone may be insufficient for this complex case, requiring specialized interventions to address both pain management and structural abnormalities.
From the Research
Referral Options for the Patient
The patient has been undergoing physical therapy for 3 months, and considering the severity of the condition, including degenerative left TMJ with small joint effusion, severely torn fragmented anterior displaced disc, and dislocated right temporomandibular disc, referral to other specialists may be necessary.
- The patient may benefit from a referral to an oral and maxillofacial surgeon 2, as they can provide advanced treatment options such as temporomandibular joint total joint replacement (TJR) 3 or arthroscopic disc repositioning techniques 4, 5.
- An orthodontist may also be considered for referral, as they can provide additional treatment options and work in conjunction with the oral and maxillofacial surgeon 2.
- Additionally, a pain management specialist may be referred to, as they can provide guidance on managing acute pain 6 and developing a multimodal pain control plan.
Considerations for Referral
When referring the patient to other specialists, it is essential to consider the importance of personal and professional relationships between the referring doctor and the specialist 2. This can promote trust and open communication, leading to better patient care.
- The patient's specific needs and condition should be taken into account when selecting a specialist for referral.
- The referring doctor should consider the various treatment options available, including arthroscopic and open disc repositioning procedures 5, and choose the specialist who can provide the most appropriate care.