How should dentists collaborate with Ear, Nose, and Throat (ENT) specialists on Temporomandibular Joint (TMJ) disorders?

Dentist-ENT Collaboration on TMJ Disorders: A Structured Approach

Dentists should primarily refer TMJ disorder patients to oral/maxillofacial surgeons rather than ENT specialists, as oral surgeons possess specific expertise in both surgical and non-surgical TMJ management. 1

Primary Referral Pathway

Oral and maxillofacial surgeons should be the first specialist referral for patients with persistent TMJ symptoms, as they have dedicated training in temporomandibular joint pathology and treatment. 1 ENT specialists are not the appropriate primary referral for TMJ disorders, as these conditions fall outside their core expertise in ear, nose, and throat pathology.

When Dentists Should Refer

Dentists should initiate specialist referral when: 1

• Symptoms persist despite 4-6 weeks of conservative management (patient education, simple analgesics, basic jaw exercises)
• Pain significantly impacts quality of life despite first-line interventions
• Progressive limitation in jaw function develops
• Diagnostic uncertainty exists regarding the underlying pathology

Multidisciplinary Team Composition

For complex or refractory cases, a multidisciplinary TMJ clinic provides superior outcomes in pain scores, mouth opening, and quality of life measures compared to sequential single-specialty consultations. 1 The optimal team includes: 1

• Oral and maxillofacial surgeon (team leader)
• Dentist specializing in TMJ disorders (for intraoral appliances and occlusal evaluation)
• Physiotherapist with TMJ expertise (for jaw mobilization and manual therapy)
• Pain management specialist (when pain control remains the predominant issue)
• Psychiatrist or psychologist (for cognitive behavioral therapy and addressing psychological comorbidities)

Role Delineation

Dentist Responsibilities

• Screen patients with snoring or TMJ symptoms and establish initial diagnosis in collaboration with appropriate specialists 2
• Perform comprehensive dental examination including soft tissue, periodontal, and TMJ assessment before initiating treatment 2
• Provide conservative management including patient education, jaw exercises, and occlusal splint therapy when appropriate 3
• Monitor treatment response every six months for the first year, then annually 2
• Communicate objective and subjective status of the condition to the medical team 2

Oral/Maxillofacial Surgeon Responsibilities

• Evaluate persistent or complex TMJ disorders that fail conservative management 1
• Interpret advanced imaging (MRI, CT/CBCT) for diagnostic clarification 1
• Perform surgical interventions when indicated for dentofacial deformities or joint reconstruction 2
• Coordinate multidisciplinary care for complex presentations 1

When Other Specialists Are Needed

• Rheumatologists should be consulted when TMJ symptoms are suspected to be part of systemic inflammatory conditions such as rheumatoid arthritis or juvenile idiopathic arthritis 1
• Pain management specialists are appropriate when pain control is the predominant issue despite conservative measures 1
• Physiotherapists should be integrated early for jaw mobilization, therapeutic exercises, and trigger point treatment 1

Urgent Referral Criteria to Oral/Maxillofacial Surgeon

Immediate specialist evaluation is required for: 1

• Acute limitation in mouth opening significantly impacting eating or speaking
• Progressive dentofacial deformity or mandibular asymmetry
• Suspected osteonecrosis of the jaw (swelling, pain, exposed bone)
• Joint sounds with progressive worsening despite conservative management

Communication Protocol

Establish clear communication channels between the dentist and specialist team to ensure: 2

• Shared treatment goals are established before initiating therapy
• Regular updates on treatment response and complications
• Coordinated decision-making regarding treatment modifications or escalation
• Patient education consistency across all providers to avoid confusion 2

Common Pitfalls to Avoid

• Delayed referral leads to disease progression and more difficult management 1
• Inappropriate surgical referral before exhausting conservative options 1
• Overlooking psychological factors (depression, catastrophizing) increases risk of chronicity, as up to 30% of acute TMD cases progress to chronic pain 1
• Sequential single-specialty consultations rather than coordinated multidisciplinary care results in inferior outcomes 1
• Referring to ENT specialists instead of oral/maxillofacial surgeons creates confusion and delays appropriate care 1

Conservative Management Before Referral

First-line approaches that dentists should attempt include: 1, 3

• Patient education about self-management, jaw rest, avoiding wide mouth opening, and soft diet
• Simple analgesics (NSAIDs, acetaminophen) for pain control
• Basic jaw exercises and self-massage techniques
• Supervised jaw exercises and stretching provide significant pain relief (approximately 1.5 times the minimally important difference)
• Manual trigger point therapy provides substantial pain reduction (approaching twice the minimally important difference)

Cognitive behavioral therapy should be considered early, as it provides substantial pain reduction and addresses psychological factors that predict chronicity. 3