- Email: [email protected]
JAW PAIN: Authors' response
L E T T E R S
Mark H. Friedman, DDS Clinical Associate Professor of Medicine Clinical Associate Professor of Anatomy New York Medical College Valhalla, N.Y. 1. Friedman MH. Closed lock: a survey of 400 cases. Oral Surg Oral Med Oral Pathol 1993;75(4):422-427. 2. Friedman MH, Weisberg J. Pitfalls of muscle palpation in TMJ diagnosis. J Prosthet Dent 1982;48(3):331. 3. Friedman MH, Weisberg J. Screening procedures for temporomandibular joint dysfunction. Am Fam Physician 1982;25(6):157160. 4. Friedman MH, Agus B, Weisberg J. Neglected conditions producing preauricular and referred pain. J Neurol Neurosurg Psychiatry 1983;46(12):1067-1072. 5. Friedman MH, Weisberg J. Temporomandibular Joint Disorders: Diagnosis and Treatment. Hanover Park. Ill.: Quintessence; 1985.
Authors’ response: We thank Dr. Friedman for his interest in our article. However, we disagree with his comment that masticatory myospasm is common. This is a long-held belief not supported by the literature. Myospasm is an acute disorder characterized by sudden, involuntary, tonic contraction of the muscle.1 During a spasm, the muscle is acutely shortened, painful and with limitation in range of movement. It is diagnosed by use of needle electromyography (EMG), which will reveal sustained involuntary muscle contraction even at rest.1 A simple analogy is a cramp of the toe or calf. Moreover, based on the “pain adaptation model,” muscle pain is rarely a continuous negative phenomenon as seen in orofacial movement disorders; rather, it has an adaptive protective value to prevent further pain and dysfunction.2,3 Also, although the etiology of myospasm remains an enigma, it is likely centrally mediated rather than the result of a local temporomandibular joint disorder. 1584
JADA, Vol. 139
http://jada.ada.org
As for the myospasm’s being confused with other orofacial pains, a thorough history and examination should lead to the correct diagnosis. The secondary muscular condition that Dr. Friedman points to, which may occur in the presence of a constant deep pain input such as temporomandibular joint inflammation, dental trauma or persistent idiopathic facial pain (atypical facial pain), is likely masticatory muscle cocontraction and not myospasm. With regard to the study Dr. Friedman cited, the conclusion of 77 percent of closed lock cases having muscle spasm (masticatory muscle hyperactivity, according to the study) is based on “symptomatic response to isometric force applied to the opening and closing jaw muscles.” A symptomatic response to isometric force testing of muscle merely suggests masticatory myalgia. Given that needle EMG of the muscle in pain was not performed, the conclusion is not valid.4 We do agree with Dr. Friedman that restriction of jaw range of movement can be the result of inflammation, and this is likely due to the patient’s avoidance of pain. However, marked restriction such as a less-than-20–millimeter opening is likely due to muscle co-contraction.2 Once again, careful history taking and examination will differentiate the intracapsular and extracapsular sources of pain. We acknowledge that muscle palpation can be misleading because, for example, “several structures overlie the masseter muscle.” However, this is the best tool we currently have to differentiate between the source of pain and site of pain. We dis-
agree with Dr. Friedman that muscle palpation does not distinguish between local muscle pain and referred pain. In fact, this is a basic principle to differentiate the two. Local provocation of the source of pain (local muscle pain) will elicit a pain response. However, local provocation of the site of pain may not elicit a pain response.5 As Dr. Friedman stated, the inferior lateral pterygoid muscle cannot be palpated, and hence it is examined by means of isometric force applied to the jaw. However, we disagree with his comments: “Except in some trauma cases, masticatory myospasm usually occurs gradually and is rarely painful at rest. This condition can be identified easily by means of muscle testing.” In many trauma cases, the muscle is in co-contraction, and this condition is often misdiagnosed as muscle spasm. Also, “muscle testing” does not differentiate between the different muscle pains. Therefore, pain upon muscle testing may merely suggest a local muscle soreness or myofascial pain (trigger point) and not myospasm. In summary, masticatory muscle spasm is not common. A positive response to resistive muscle tests alone is not diagnostic for masticatory muscle spasm. Also, a single test result rarely leads to a diagnosis in the field of orofacial pain. Hence, the combination of a thorough history and examination is required to establish the correct diagnosis. Ramesh Balasubramaniam, BDSc, MS Clinical Associate Professor School of Dentistry, University of Western Australia Perth
December 2008
Copyright © 2008 American Dental Association. All rights reserved. Reprinted by permission.
L E T T E R S
Andres Pinto, DMD, MPH Assistant Professor Department of Oral Medicine
Martin Greenberg, DDS Professor Department of Oral Medicine School of Dental Medicine University of Pennsylvania Philadelphia 1. de Leeuw R. Orofacial Pain: Guidelines for Assessment, Diagnosis and Management. 4th ed. Hanover Park, Ill.: Quintessence; 2008:156-157. 2. Lund JP, Donga R, Widmer CG, Stohler CS. The pain-adaptation model: a discussion of the relationship between chronic musculoskeletal pain and motor activity. Can J Physio Pharmacol 1991;69(5):683-694. 3. Balasubramaniam R, Ram S. Orofacial movement disorders. Oral Maxillofac Surg Clin North Am 2008;20(2):273-285. 4. Friedman MH. Closed lock: a survey of 400 cases. Oral Surg Oral Med Oral Pathol 1993;75(4):422-427. 5. Okeson JP, Bell WE. Bell’s Orofacial Pains: The Clinical Management of Orofacial Pain. 6th ed. Hanover Park Ill.: Quintessence; 2005:65-67.
HANDLING OF DHAT STUDY QUESTIONED
After reading Dr. Kenneth Bolin’s November JADA article, “Assessment of Treatment Provided by Dental Health Aide Therapists in Alaska: A Pilot Study” (JADA 2008;139[11]: 1530-1535) and Dr. Albert Guay’s accompanying commentary, “Commentary: Assessment of Treatment Provided by Dental Health Aide Therapists in Alaska” (JADA 2008;139[11]: 1536-1537), I am concerned for the editorial independence of this journal. The essence of a professional journal is the clear delineation between the scientific and the political. Here, the line was crossed. While Dr. Bolin’s article is doubtless controversial and challenges a position that the American Dental Association (ADA) spent hundreds of thousands of mem-
bers’ dollars promoting, the presence of a commentary written by an ADA employee criticizing Dr. Bolin’s article in the same issue is simply disgraceful. Plainly put, Dr. Guay’s “commentary” should have been sent to the editor and been subjected to the same editorial process as all other letters to the editor. To compound this breach of the separation between science and politics, Dr. Guay’s commentary was followed by the ADA policy on access to care (Berry J. “ADA on Access to Care.” JADA 2008; 139[11]:1538-1539). I take no issue with the ADA using its journal to express its corporate opinion; however, attaching it to a scientific article was an exercise in poor judgment. Over the past several decades, the scientific reputation of JADA has risen, and I have been pleased to support it as an author and reviewer. One ill-conceived decision has jeopardized the efforts of past editors, authors and reviewers. The future of JADA—whether it will be a premier dental journal or the “house organ” for the ADA— is at stake. The Journal owes its readers an explanation of this sorry situation and should commit to its readers that it will not happen again. Jay D. Shulman, DMD Dallas
Editor’s note: Letters to the editor provide a forum for an exchange of ideas and opinions. In this spirit, I thank Dr. Shulman for his comments. However, I believe certain of his observations must be addressed.
JADA, Vol. 139
For JADA to publish studies and commentaries on controversial topics stands as testament to our editorial autonomy—not as a sign that we have lost or relinquished our independence. The commentary by Dr. Albert Guay that accompanied Dr. Bolin’s article centered on the scientific merits of the study, not on its political implications. After reviewing Dr. Guay’s commentary, I felt it was appropriate for Dr. Bolin to respond to the critique and to publish both the commentary and Dr. Bolin’s response to it in the same issue. As Dr. Shulman notes, we also included a brief report on the ADA’s policies and activities related to dental care access. Our intent in combining and presenting these varied reports was to offer readers some context, some perspective on the topic of dental health aide therapists and the broader issue of access to dental care. We felt this would be particularly useful to those dentists who have not followed every aspect of this discussion as it has evolved over the years. I respect Dr. Shulman’s views on this matter, but I do not share his sentiments. He insists that I have sacrificed JADA’s autonomy. On the contrary, I believe that JADA, in presenting a balanced perspective on a controversial topic, has embraced its responsibility to foster open and honest debate, to contribute to an ongoing discussion and to allow disparate points of view to be heard.
http://jada.ada.org
Copyright © 2008 American Dental Association. All rights reserved. Reprinted by permission.
December 2008
1585
Mark H. Friedman, DDS Clinical Associate Professor of Medicine Clinical Associate Professor of Anatomy New York Medical College Valhalla, N.Y. 1. Friedman MH. Closed lock: a survey of 400 cases. Oral Surg Oral Med Oral Pathol 1993;75(4):422-427. 2. Friedman MH, Weisberg J. Pitfalls of muscle palpation in TMJ diagnosis. J Prosthet Dent 1982;48(3):331. 3. Friedman MH, Weisberg J. Screening procedures for temporomandibular joint dysfunction. Am Fam Physician 1982;25(6):157160. 4. Friedman MH, Agus B, Weisberg J. Neglected conditions producing preauricular and referred pain. J Neurol Neurosurg Psychiatry 1983;46(12):1067-1072. 5. Friedman MH, Weisberg J. Temporomandibular Joint Disorders: Diagnosis and Treatment. Hanover Park. Ill.: Quintessence; 1985.
Authors’ response: We thank Dr. Friedman for his interest in our article. However, we disagree with his comment that masticatory myospasm is common. This is a long-held belief not supported by the literature. Myospasm is an acute disorder characterized by sudden, involuntary, tonic contraction of the muscle.1 During a spasm, the muscle is acutely shortened, painful and with limitation in range of movement. It is diagnosed by use of needle electromyography (EMG), which will reveal sustained involuntary muscle contraction even at rest.1 A simple analogy is a cramp of the toe or calf. Moreover, based on the “pain adaptation model,” muscle pain is rarely a continuous negative phenomenon as seen in orofacial movement disorders; rather, it has an adaptive protective value to prevent further pain and dysfunction.2,3 Also, although the etiology of myospasm remains an enigma, it is likely centrally mediated rather than the result of a local temporomandibular joint disorder. 1584
JADA, Vol. 139
http://jada.ada.org
As for the myospasm’s being confused with other orofacial pains, a thorough history and examination should lead to the correct diagnosis. The secondary muscular condition that Dr. Friedman points to, which may occur in the presence of a constant deep pain input such as temporomandibular joint inflammation, dental trauma or persistent idiopathic facial pain (atypical facial pain), is likely masticatory muscle cocontraction and not myospasm. With regard to the study Dr. Friedman cited, the conclusion of 77 percent of closed lock cases having muscle spasm (masticatory muscle hyperactivity, according to the study) is based on “symptomatic response to isometric force applied to the opening and closing jaw muscles.” A symptomatic response to isometric force testing of muscle merely suggests masticatory myalgia. Given that needle EMG of the muscle in pain was not performed, the conclusion is not valid.4 We do agree with Dr. Friedman that restriction of jaw range of movement can be the result of inflammation, and this is likely due to the patient’s avoidance of pain. However, marked restriction such as a less-than-20–millimeter opening is likely due to muscle co-contraction.2 Once again, careful history taking and examination will differentiate the intracapsular and extracapsular sources of pain. We acknowledge that muscle palpation can be misleading because, for example, “several structures overlie the masseter muscle.” However, this is the best tool we currently have to differentiate between the source of pain and site of pain. We dis-
agree with Dr. Friedman that muscle palpation does not distinguish between local muscle pain and referred pain. In fact, this is a basic principle to differentiate the two. Local provocation of the source of pain (local muscle pain) will elicit a pain response. However, local provocation of the site of pain may not elicit a pain response.5 As Dr. Friedman stated, the inferior lateral pterygoid muscle cannot be palpated, and hence it is examined by means of isometric force applied to the jaw. However, we disagree with his comments: “Except in some trauma cases, masticatory myospasm usually occurs gradually and is rarely painful at rest. This condition can be identified easily by means of muscle testing.” In many trauma cases, the muscle is in co-contraction, and this condition is often misdiagnosed as muscle spasm. Also, “muscle testing” does not differentiate between the different muscle pains. Therefore, pain upon muscle testing may merely suggest a local muscle soreness or myofascial pain (trigger point) and not myospasm. In summary, masticatory muscle spasm is not common. A positive response to resistive muscle tests alone is not diagnostic for masticatory muscle spasm. Also, a single test result rarely leads to a diagnosis in the field of orofacial pain. Hence, the combination of a thorough history and examination is required to establish the correct diagnosis. Ramesh Balasubramaniam, BDSc, MS Clinical Associate Professor School of Dentistry, University of Western Australia Perth
December 2008
Copyright © 2008 American Dental Association. All rights reserved. Reprinted by permission.
L E T T E R S
Andres Pinto, DMD, MPH Assistant Professor Department of Oral Medicine
Martin Greenberg, DDS Professor Department of Oral Medicine School of Dental Medicine University of Pennsylvania Philadelphia 1. de Leeuw R. Orofacial Pain: Guidelines for Assessment, Diagnosis and Management. 4th ed. Hanover Park, Ill.: Quintessence; 2008:156-157. 2. Lund JP, Donga R, Widmer CG, Stohler CS. The pain-adaptation model: a discussion of the relationship between chronic musculoskeletal pain and motor activity. Can J Physio Pharmacol 1991;69(5):683-694. 3. Balasubramaniam R, Ram S. Orofacial movement disorders. Oral Maxillofac Surg Clin North Am 2008;20(2):273-285. 4. Friedman MH. Closed lock: a survey of 400 cases. Oral Surg Oral Med Oral Pathol 1993;75(4):422-427. 5. Okeson JP, Bell WE. Bell’s Orofacial Pains: The Clinical Management of Orofacial Pain. 6th ed. Hanover Park Ill.: Quintessence; 2005:65-67.
HANDLING OF DHAT STUDY QUESTIONED
After reading Dr. Kenneth Bolin’s November JADA article, “Assessment of Treatment Provided by Dental Health Aide Therapists in Alaska: A Pilot Study” (JADA 2008;139[11]: 1530-1535) and Dr. Albert Guay’s accompanying commentary, “Commentary: Assessment of Treatment Provided by Dental Health Aide Therapists in Alaska” (JADA 2008;139[11]: 1536-1537), I am concerned for the editorial independence of this journal. The essence of a professional journal is the clear delineation between the scientific and the political. Here, the line was crossed. While Dr. Bolin’s article is doubtless controversial and challenges a position that the American Dental Association (ADA) spent hundreds of thousands of mem-
bers’ dollars promoting, the presence of a commentary written by an ADA employee criticizing Dr. Bolin’s article in the same issue is simply disgraceful. Plainly put, Dr. Guay’s “commentary” should have been sent to the editor and been subjected to the same editorial process as all other letters to the editor. To compound this breach of the separation between science and politics, Dr. Guay’s commentary was followed by the ADA policy on access to care (Berry J. “ADA on Access to Care.” JADA 2008; 139[11]:1538-1539). I take no issue with the ADA using its journal to express its corporate opinion; however, attaching it to a scientific article was an exercise in poor judgment. Over the past several decades, the scientific reputation of JADA has risen, and I have been pleased to support it as an author and reviewer. One ill-conceived decision has jeopardized the efforts of past editors, authors and reviewers. The future of JADA—whether it will be a premier dental journal or the “house organ” for the ADA— is at stake. The Journal owes its readers an explanation of this sorry situation and should commit to its readers that it will not happen again. Jay D. Shulman, DMD Dallas
Editor’s note: Letters to the editor provide a forum for an exchange of ideas and opinions. In this spirit, I thank Dr. Shulman for his comments. However, I believe certain of his observations must be addressed.
JADA, Vol. 139
For JADA to publish studies and commentaries on controversial topics stands as testament to our editorial autonomy—not as a sign that we have lost or relinquished our independence. The commentary by Dr. Albert Guay that accompanied Dr. Bolin’s article centered on the scientific merits of the study, not on its political implications. After reviewing Dr. Guay’s commentary, I felt it was appropriate for Dr. Bolin to respond to the critique and to publish both the commentary and Dr. Bolin’s response to it in the same issue. As Dr. Shulman notes, we also included a brief report on the ADA’s policies and activities related to dental care access. Our intent in combining and presenting these varied reports was to offer readers some context, some perspective on the topic of dental health aide therapists and the broader issue of access to dental care. We felt this would be particularly useful to those dentists who have not followed every aspect of this discussion as it has evolved over the years. I respect Dr. Shulman’s views on this matter, but I do not share his sentiments. He insists that I have sacrificed JADA’s autonomy. On the contrary, I believe that JADA, in presenting a balanced perspective on a controversial topic, has embraced its responsibility to foster open and honest debate, to contribute to an ongoing discussion and to allow disparate points of view to be heard.
http://jada.ada.org
Copyright © 2008 American Dental Association. All rights reserved. Reprinted by permission.
December 2008
1585