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Educated guesses, subjective feelings and speculation does not produce effective, reliable, lasting results. Addressing the source of the problems rather than just treating the symptoms is crucial if one desires to reach maximal dental improvement.
Depending on the dentists “philosophy” of what TMD/orofacial pain is about, you will be diagnosed, provided answers and receive treatment based on either a bio-physiologic neuromuscular perspective or a bio-psychosocial perspective. Two different paths of focus with two different outcomes will result.
What path of treatment and care will you chose?
THREE (3) Areas that are Overlooked By Most When Treating TMD/TMJ (Myofacial Pain Dysfunction):
- Structural imbalances
- Biochemical/nutritional imbalances
- Emotional/psychological imbalances
To date, there is no clear method that has been agreed upon regarding what is “TMJ” (more accurately recognized as TMD – temporomandibular joint dysfunction and its associated craniomandibular and neuro-muscular occlusal issues). Research has been promised, yet our patients who are suffering can’t wait any longer! There lives are at stake and they are looking for answers. Many of the dentists who are familiar with these conditions have discovered effective, objective means to treat the TMD patient, but researchers have not shown a willingness to work with the clinicians who actually contend with these problems daily.
Within the dental profession, there are two prominent philosophies and perspectives to addressing TMD:
- Bio-Psychosocial Perspective
- Bio-Physiologic Neuromuscular Perspective
The National Institute of Dental and Craniofacial Research (NIDCR) ignores that TMD may have not only a muscular component to this disease/dysfunction, but that it also may have an occlusal component as well is an over-site which only exemplifies its intent to ignore the bio-physiologic factors of the stomatognathic system and posture of the upper quarter of the bodies systems.
- It suggests that medicine is the solution to TMD problems.
- It suggests that TMD often resolves itself and is self-healing.
- It emphasizes that TMD is a self-limiting disease and occlusal (bite) changes are to be avoided.
- It does not acknowledge that TMD is a major component in the scope of dental practice nor does it recognize that the dentist has a major role in dealing with muscles, joints and teeth as it pertains to temporomandibular joint disorder and all the associated signs and symptoms that relate to the trigeminal system.
Taking a “wait and see” approach to disease based on unfounded, conflicting opinions that TMD is both innocuous and unaffected by preventative therapy lacks responsibility to the public. A support for pain medications that can lead to dependency and drug abuse in dealing with chronic pain rather than a philosophy of support toward prevention is irresponsible.
To improperly suggest that occlusion is not even remotely related to TMD when it has been well demonstrated that loss of posterior occlusal support and parafunction have a role, even if an indirect one, is fatuous. If the latter is an unfair criticism, why then would one support the use of flat splints presumably to avoid parafunction?
To convey that jaw joint X-rays (transcranial/tomographic radiographs) are not generally useful in diagnosing TMJ disorders is unconscionable and confused as to the understanding and appreciation of the TM joint. Not having an ability to distinguish normal from abnormal, pathologic from physiologic affords the doctor no possible way to diagnose nor render appropriate therapy. It is not customarily used as a first radiographic procedure, but rather for conditions of long-standing pain and limitation of jaw movement that have not been responsive to conservative treatment. MRI may be indicated in cases of direct trauma to the joints as an early diagnostic modality.
No mention of the American Dental Association’s granted Seal of Acceptance to three computerized measurement devices that aid in the management of TMD are mentioned in this philosophy.
BACKGROUND: Psychosocial factors have a role in the onset of chronic orofacial pain. However, current management involves invasive therapies like occlusal adjustments and splints which lack an evidence base.
OBJECTIVES: To determine the efficacy of non-pharmacologic psychosocial interventions for chronic orofacial pain.
SEARCH METHODS: The following electronic databases were searched: the Cochrane Oral Health Group Trials Register (to 25 October 2010), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 4), MEDLINE via OVID (1950 to 25 October 2010), EMBASE via OVID (1980 to 25 October 2010) and PsycINFO via OVID (1950 to 25 October 2010). There were no restrictions regarding language or date of publication.
SELECTION CRITERIA: Randomised controlled trials which included non-pharmacological psychosocial interventions for adults with chronic orofacial pain compared with any other form of treatment (e.g. usual care like intraoral splints, pharmacological treatment and/or physiotherapy).
DATA COLLECTION AND ANALYSIS: Data were independently extracted in duplicate. Trial authors were contacted for details of randomisation and loss to follow-up, and also to provide means and standard deviations for outcome measures where these were not available. Risk of bias was assessed and disagreements between review authors were discussed and another review author involved where necessary.
MAIN RESULTS: Seventeen trials were eligible for inclusion into the review. Psychosocial interventions improved long-term pain intensity (standardised mean difference (SMD) -0.34, 95% confidence interval (CI) -0.50 to -0.18) and depression (SMD -0.35, 95% CI -0.54 to -0.16). However, the risk of bias was high for almost all studies. A subgroup analysis revealed that cognitive behavioural therapy (CBT) either alone or in combination with biofeedback improved long-term pain intensity, activity interference and depression. However the studies pooled had high risk of bias and were few in number. The pooled trials were all related to temporomandibular disorder (TMD).
AUTHORS’ CONCLUSIONS: There is weak evidence to support the use of psychosocial interventions for chronic orofacial pain. Although significant effects were observed for outcome measures where pooling was possible, the studies were few in number and had high risk of bias. However, given the non-invasive nature of such interventions they should be used in preference to other invasive and irreversible treatments which also have limited or no efficacy. Further high quality trials are needed to explore the effects of psychosocial interventions on chronic orofacial pain.
DATA SOURCES: Cochrane Oral Health Group’s Trials Register, Central, Medline, Embase, PsycINFO.
STUDY SELECTION: Randomised controlled trials of psychosocial interventions for chronic orofacial pain were included. Psychosocial interventions targeted towards changing thoughts, behaviours and/or feelings that may exacerbate pain symptoms through a vicious cycle were eligible. Primary outcomes were pain intensity/severity, satisfaction with pain relief and quality of life.
DATA EXTRACTION AND SYNTHESIS: Two reviewers independently screened studies, extracted data and assessed risk of bias. Dichotomous outcomes, were expressed as risk ratios with 95% confidence intervals, continuous outcomes as mean differences with 95% confidence intervals. Heterogeneity was assessed using the Cochrane test for heterogeneity and the I2 test. Meta-analyses were conducted using the random-effect or the fixed-effect models.
RESULTS: Fifteen of the 17 eligible studies were on temporomandibular disorders (TMDs), two on burning mouth syndrome. Psychosocial interventions improved long-term pain intensity (standardised mean difference (SMD) -0.34, 95% confidence interval (CI) -0.50 to -0.18) and depression (SMD -0.35, 95% CI -0.54 to -0.16). However, the risk of bias in these studies was high.
CONCLUSIONS: There is weak evidence to support the use of psychosocial interventions for chronic orofacial pain.
Bio-Physiologic Neuromuscular Perspective
This approach focuses on not only the subjective patient complaints, but also on objective assessment of the musculoskeletal occlusal signs and symptoms of TMD.
- Measuring technology and instrumentation are used and include: 1) computerized mandibular tracking, 2) surface electromyography and 3) electrosonography of the TMJ.
- The US Food and Drug Administration (FDA) approved the sale of these devices for the purposes of measuring activity that directly relates to the TMJ. The medical necessity of their use for each patient must be documented by the treating dentist and certainly are non-invasive approaches to document medical necessity.
- These devices have been found to be extremely useful in aiding the clinician to arrive at a diagnosis for conservative treatment. NIDCR fails to even recognize such.
- The use of objective quantifiable diagnostic procedures should be implemented to quantify and qualify a patient’s dysfunction. This certainly adds essential, accurate information in the effective diagnostic and treatment process especially for patients with trauma episodes to the head and cervical regions.
Subjective feelings and educated guesses when treating the mandible, masticatory muscles of the head and neck and the temporomandibular joints will not produce cost effective results nor appropriate treatment times!
A Word of Caution:
Total agreement as to conservative treatment and/or no surgery is to be applauded, but to exclude or limit proper and needful data gathering is certainly going to result in inaccuracies of treatment, diagnosis, increased treatment time, frustration and greater costs.
How can any qualified treating clinician (when treating TM Joint degeneration) be limited to diagnosing a joint disease condition from only a panoramic X-ray, which is merely a surveying film and not specific for the TM Joints? Obscure data and documentation will result in obscure and unpredicatable results!
- Note: The NIDCR statement says not to use splints long-term, but criticizes the lack of long-term studies on effectiveness. These are contradictory statements.
Their position states one-sidedly “Research has disproved the popular belief that a bad bite or orthodontic braces and headgear can trigger TMJ”. To the contrary, research and documented clinical evidence has shown the opposite is true. Bad bites that are poorly misaligned can be contributory to masticatory dysfunction leading to intolerable muscle pain and discomfort which are components of TMD. Retractive orthodontics has been shown to lead to numerous signs and symptoms of TMD. These very same conditions have also been shown to be resolved with reversible splint therapy, as documented with tomography and ADA/FDA approved devices that objectively measure such conditions, before and after treatment.
The NIDCR publications states, “Irreversible treatments are of no proven value and may make the problem worse”. This is absolutely false and misleading. It causes the reader to believe that orthodontics to improve the bite or restorative dentistry using crown and bridge work to enhance the bite or occlusal adjustment (re-shaping teeth to bring the bite into balance) is impossible which totally undermines professional ethics.
- Their perspective on intraoral splints is contradictory.
Many clinicians nationally who are well versed in treating TMD patients with either acute or chronic conditions have found orthodontic treatment, restorative therapy and/or occlusal adjustments to balance the bite excellent remedies after a thorough investigation and a reversible approach has been taken first. Only after all other conservative means have been exhausted, may the clinician implement these later methods for final stabilization of the TMD patient.
This is totally contrary to the pharmacological approach which seems to be endorsed in NIDCR publications. This supposed “quick-fix” approach fails to recognize the long-term, irreversible, pathologic state medications and drug addiction leaves a chronic, paining, TMD-suffering patient with no final resolution, but rather long term drug/ medication dependency and pain.
For the NIDCR publication to make a blanket statement such as, “Avoid treatments that cause permanent changes in the bite or jaw”… most certainly is an inflammatory statement that undermines doctor/patient relationships. These types of treatments should only be performed by the clinician after need has been demonstrated.
Because there is no American Dental Association (ADA) recognized specialty for TMD and none in medicine, finding the right care can be difficult. Look for a health care provider who understands musculoskeletal disorders (affecting muscle, bone and joints) and who is trained in treating pain conditions should be the focus of the NIDCR in assisting the TMD to find help. Specially trained dentists with expertise in this field can be helpful in diagnosing and treating TMD.
If the National Institute of Dental and Craniofacial Research (NIDCR), supports an active research program on TMD and is truly interested in learning more about the cause, symptoms, process and etiology of this disorder, it would seem quite reasonable that they should listen to the numerous dentists treating in this country – doctors who are in the trenches treating their TMD patients with first-hand knowledge and experience diagnosing and rendering care to patients with TMD. These very same doctors employ these modalities in order to pinpoint the factors that lead to chronic or persistent temporomandibular pain. Identifying medications is only one avenue out of many others that should to be thoroughly investigated for conservative and effective long-term help. Research performed by experts in the field should be acknowledged and further investigated when trying to understand the etiology of TMD.
Clinical research using dental practitioners who actually treat the overwhelming majority of TMD patients must be encouraged, mentored and supported by NIDCR.
Patients suffering from TMD should not be denied their illness, but rather they should understand the nature of the illness and the available remedies for it.
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