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Longitudinal Studies
LETTERS
TO
THE
E D IT O R
surrender neither his responsibilities to his patients for their general health, nor his recommendations for operative procedures. The 15 cases so ably described ini tially revolved around the discovery of the condition, coupled with good diagnostic judgment. If periodically followed up and evaluated, a more op portune time could have been arrived at, alleviating many of the sequelae. W e know w h ere w e stan d on symptomatic and pathologically in volved teeth. We should be ever alert not to fall into a pattern of surgical procedures (outstanding of which, in the early 1930s were indiscriminate removals of tonsils and adenoids in the young) un less our good judgment in diagnosis and responsibilities to our patients are considered to the utmost. I know from personal experiences, unfortunately, that some members of our profession will not be giving the third molars serious thought, but will relegate them to the wastebasket. Careful review of out p atien ts’ health and welfare will permit us to offer a true professional opinion. BENJAMIN ZACKIM, DDS MAHOPAC, NY
Longitudinal studies □ This letter is prompted by the sev eral references (November 1980) re garding indications for removal of asymptomatic third molars, and the n eed for lon g-term lo n g itu d in al studies to determine the statistical in cidence of pathological processes de veloping in patients with asymptoma tic impacted third molars. A near-ideal investigative model exists in the Navy’s “Thousand Av iator” type study at the Aerospace Medical Center, Pensacola. In the late 1940s or early 1950s, 1,000 Navy Avia tion Cadets were chosen for a longitu dinal study of various medical prob lems associated with aviation which might influence the longevity of Naval Aviators. The group is (or was) re called every four years for extensive medical, clinical, and laboratory ex amination, evaluation, and documen tation. The study was designed to con tinue through the lifetime of the group. Additional groups of 1,000 were to have been initiated as funding permit ted. m m TADA. Vol. 102. Tanuarv 1981
In the planning stages of the second group of 1,000, in 1964, an attempt was made to include the study as proposed by Drs. Bruce, Fredrickson, and Small, but there was insufficient interest, and the protocol remains in my files. Copies of this letter to the respective Commanding Officers of Naval Aeros pace and Regional Medical Center and Naval Regional Dental Center, Pen sacola, suggest that these facilities re main as one of the most appropriate sites for a longitudinal study of this na ture. H. S. SAMUELS, CAPTAIN, DC, USN (RET) MAITLAND, FLA
Federal control □ I read with great interest “A look at the issues ten years later” (October 1980). I am amused at the concern about federal mandatory enrollment requirements and their ill effect on dental schools. Let me say, if all schools had the courage of West Vir ginia University and refused money with the feds’ enrollment strings at tached, they would not be beleaguered with federal intervention. Will men ever learn that we cannot suckle the teat of federal money sepa rate from the body of federal control? R. DAVID REMALEY, DDS DECATUR, GA
Myofascial pain-dysfunction syndrome □ The article on Dr. Hillenbrand’s comments (October 1980) about the challenges facing dentistry was both tim ely and stim ulating. However, when I turned the page to the next arti cle, “ Treatment of the myofascial pain-dysfunction syndrome: psycho logical aspects,” I was made aware, again, of the tremendous challenge facing dentistry regarding the myofas cia l p ain d y sfu n ctio n syndrom e (MPD). During the 1970s, the profession of dentistry became seriously divided over the nature and causes of the MPD syndrome. On the one hand, there are those who believe that the cause is emotional stress, but, on the other hand, there are those who believe that the etiology is irregularity of the dental occlusion. H ow ever, re c e n t stu d ie s have
clearly demonstrated that the majority of patients with symptoms of MPD syndrome have internal derangement of the temporomandibular joint (TMJ). Internal derangement of the TMJ is de fined as anterior displacement of the disk associated with posterosuperior displacement of the condyle. The signs and symptoms of the MPD syndrome are the signs and symptoms of an anteriorly displaced disk. The displaced disk causes the clicking and limitation. When the opening click oc curs, the disk snaps back into place above the condyle and translation pro ceeds normally. However, when the closing click occurs, the disk snaps out of place. If the disk is out of place in the closed position, and the patient cannot produce the opening click, the dislo cated disk jams the joint, causing the limitation of movement. Actually these symptoms of recip rocal clicking and locking are only the symptoms of the early phases of inter nal derangements. When the disk is displaced anteriorly, the mandibular condyle becomes seated in the her niated or stretched posterior disk at tachments, and eventually these at ta c h m e n ts h e r n ia t e . T h e n , r a diographic and clinical evidence of degenerative arthritis becomes appar ent. In other words, early in this dys function, perhaps during the first sev eral years, the patient has the clinical symptoms of reciprocal clicking and locking. However, after the locking and clicking have ceased, there is a period in which there is neither limita tion nor clicking. Then, after several more years, the joint begins to make a grinding crepitant noise, and the clini cal and radiographic evidence of de generative arthritis becomes apparent. What we are dealing with here is of immense proportions. Perhaps 25% of the entire population have some form or degree of internal derangement of the disk and condyle, and at least 10% of the population are suffering se verely from these problems. The most severe symptom is headache. So, as we look forward to the early 1980s, we should address ourselves to the challenge presented by patients with symptoms of the MPD syndrome. As we correlate the clicking and lim- , itation to range of jaw movement studies, condylar path recordings, TMJ radiography and arthrography, we will learn how the symptoms of MPD are caused by internal derange-
TO
THE
E D IT O R
surrender neither his responsibilities to his patients for their general health, nor his recommendations for operative procedures. The 15 cases so ably described ini tially revolved around the discovery of the condition, coupled with good diagnostic judgment. If periodically followed up and evaluated, a more op portune time could have been arrived at, alleviating many of the sequelae. W e know w h ere w e stan d on symptomatic and pathologically in volved teeth. We should be ever alert not to fall into a pattern of surgical procedures (outstanding of which, in the early 1930s were indiscriminate removals of tonsils and adenoids in the young) un less our good judgment in diagnosis and responsibilities to our patients are considered to the utmost. I know from personal experiences, unfortunately, that some members of our profession will not be giving the third molars serious thought, but will relegate them to the wastebasket. Careful review of out p atien ts’ health and welfare will permit us to offer a true professional opinion. BENJAMIN ZACKIM, DDS MAHOPAC, NY
Longitudinal studies □ This letter is prompted by the sev eral references (November 1980) re garding indications for removal of asymptomatic third molars, and the n eed for lon g-term lo n g itu d in al studies to determine the statistical in cidence of pathological processes de veloping in patients with asymptoma tic impacted third molars. A near-ideal investigative model exists in the Navy’s “Thousand Av iator” type study at the Aerospace Medical Center, Pensacola. In the late 1940s or early 1950s, 1,000 Navy Avia tion Cadets were chosen for a longitu dinal study of various medical prob lems associated with aviation which might influence the longevity of Naval Aviators. The group is (or was) re called every four years for extensive medical, clinical, and laboratory ex amination, evaluation, and documen tation. The study was designed to con tinue through the lifetime of the group. Additional groups of 1,000 were to have been initiated as funding permit ted. m m TADA. Vol. 102. Tanuarv 1981
In the planning stages of the second group of 1,000, in 1964, an attempt was made to include the study as proposed by Drs. Bruce, Fredrickson, and Small, but there was insufficient interest, and the protocol remains in my files. Copies of this letter to the respective Commanding Officers of Naval Aeros pace and Regional Medical Center and Naval Regional Dental Center, Pen sacola, suggest that these facilities re main as one of the most appropriate sites for a longitudinal study of this na ture. H. S. SAMUELS, CAPTAIN, DC, USN (RET) MAITLAND, FLA
Federal control □ I read with great interest “A look at the issues ten years later” (October 1980). I am amused at the concern about federal mandatory enrollment requirements and their ill effect on dental schools. Let me say, if all schools had the courage of West Vir ginia University and refused money with the feds’ enrollment strings at tached, they would not be beleaguered with federal intervention. Will men ever learn that we cannot suckle the teat of federal money sepa rate from the body of federal control? R. DAVID REMALEY, DDS DECATUR, GA
Myofascial pain-dysfunction syndrome □ The article on Dr. Hillenbrand’s comments (October 1980) about the challenges facing dentistry was both tim ely and stim ulating. However, when I turned the page to the next arti cle, “ Treatment of the myofascial pain-dysfunction syndrome: psycho logical aspects,” I was made aware, again, of the tremendous challenge facing dentistry regarding the myofas cia l p ain d y sfu n ctio n syndrom e (MPD). During the 1970s, the profession of dentistry became seriously divided over the nature and causes of the MPD syndrome. On the one hand, there are those who believe that the cause is emotional stress, but, on the other hand, there are those who believe that the etiology is irregularity of the dental occlusion. H ow ever, re c e n t stu d ie s have
clearly demonstrated that the majority of patients with symptoms of MPD syndrome have internal derangement of the temporomandibular joint (TMJ). Internal derangement of the TMJ is de fined as anterior displacement of the disk associated with posterosuperior displacement of the condyle. The signs and symptoms of the MPD syndrome are the signs and symptoms of an anteriorly displaced disk. The displaced disk causes the clicking and limitation. When the opening click oc curs, the disk snaps back into place above the condyle and translation pro ceeds normally. However, when the closing click occurs, the disk snaps out of place. If the disk is out of place in the closed position, and the patient cannot produce the opening click, the dislo cated disk jams the joint, causing the limitation of movement. Actually these symptoms of recip rocal clicking and locking are only the symptoms of the early phases of inter nal derangements. When the disk is displaced anteriorly, the mandibular condyle becomes seated in the her niated or stretched posterior disk at tachments, and eventually these at ta c h m e n ts h e r n ia t e . T h e n , r a diographic and clinical evidence of degenerative arthritis becomes appar ent. In other words, early in this dys function, perhaps during the first sev eral years, the patient has the clinical symptoms of reciprocal clicking and locking. However, after the locking and clicking have ceased, there is a period in which there is neither limita tion nor clicking. Then, after several more years, the joint begins to make a grinding crepitant noise, and the clini cal and radiographic evidence of de generative arthritis becomes apparent. What we are dealing with here is of immense proportions. Perhaps 25% of the entire population have some form or degree of internal derangement of the disk and condyle, and at least 10% of the population are suffering se verely from these problems. The most severe symptom is headache. So, as we look forward to the early 1980s, we should address ourselves to the challenge presented by patients with symptoms of the MPD syndrome. As we correlate the clicking and lim- , itation to range of jaw movement studies, condylar path recordings, TMJ radiography and arthrography, we will learn how the symptoms of MPD are caused by internal derange-