Understanding Diagnostic Failure in Temporomandibular Disorders: A Narrative Synthesis of Evidence and Five-Domain Framework for Iatrogenic Mismanagement.

BACKGROUND

Diagnostic errors in temporomandibular disorders (TMDs) contribute to unnecessary procedures and avoidable patient mismanagement despite advances in pain science, diagnostic classification systems, and evidence-based care.

OBJECTIVE

To conduct a narrative review and present a dynamic, five-domain framework explaining how diagnostic uncertainty interacts with educational, cognitive, systemic, and ethical factors to produce iatrogenic overtreatment.

METHODS

Searches of PubMed, Scopus, Web of Science, and Google Scholar (inception to April 2026) identified literature on TMD diagnosis, clinical reasoning, dental education, health system organization, and bioethics. Concepts were synthesized into interacting thematic domains.

RESULTS

Five dynamic, interacting domains were identified: (1) Educational Deficits, (2) Structural Reductionism, (3) Occlusal Overinterpretation, (4) System Fragmentation, and (5) Ethical Dissonance. The model demonstrates how educational gaps foster reductionist diagnostic paradigms, which are amplified by health-system silos and defensive clinical practices, increasing the likelihood of non-indicated, irreversible interventions.

CONCLUSIONS

The Five-Domain Framework offers a systemic model for understanding diagnostic breakdown in TMD management, providing a structured foundation for educational reform, integrated care pathways, and future empirical research.