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The impact of the American Dental Association's guidelines for the examination, diagnosis, and management of temporomandibular disorders on orthodontic practice
The impact of the American Dental Association’s guidelines for the examination, diagnosis, and management of temporomandibular disorders on orthodontic practice * Donald J. Rinchuse, D.M.D., MS., M.D.S.,** and Daniel J. Rinchuse, D.M.D., MS., M.D.S.** Greensburg,
Pa.
T
o eliminate some of the confusion regarding temporomandibular disorders, on June 1, 1982, Robert H. Griffiths, then president of the American Dental Association, initiated a 4-day conference whose ultimate purpose was to develop guidelines for the examination, diagnosis, and management of temporomandibular disorders. Present at this conference were the leading practitioners, educators, and researchers in the fields of occlusion and TM dis0rders.l These TM disorder guidelines, reprinted in this issue of the AMERICAN JOURNAL OF ORTHODONTICS, will henceforth be referred to as the ADA guidelines. The purpose of this editorial is twofold: First, the salient features of the ADA TM disorder guidelines will be renewed. Second, these guidelines will be analyzed with regard to their impact vis-&vis existing orthodontic practice. Few subjects in dentistry are as confusing or given to as many interpretations and misinterpretations as temporomandibular (TM) disorders. There appears to be a never-ending debate concerning the etiology and proper treatment of TM disorders. Because TM disorder investigations have failed to isolate one set of variables while controlling other variables, definitive answers to the questions that have been raised are lacking. Part of this problem of uncontrollable extrinsic variables is because of the numerous fac-
*Temporomandibular disorder guidelines were developed from the ADA President’s Conference on TM Disorders. **Associate professors of Orthodontics, University of Pittsburgh School of Dental Medicine, and Doctoral Students in Higher Education. Present address: Orthodontic Department, University of Pittsburgh, School of Dental Medicine, Salk Hall, 3501 Terrace Street, Pittsburgh, Pa. 15261.
518
tors that have impact upon the temporomandibular area. This is especially true when one considers the complex interrelationship between biologic, physiologic, and psychologic factors that are involved in craniomandibular articulation. In addition, such structures and influences as the brain, nerves, reflexes, joints, disks, ligaments, bone, muscle, etc. must all be accounted for. These complexities make research and the interpretation of findings more than a little difficult. Because of the confounded nature of TM disorder research, as well as ineptitude in research investigation analysis, a plethora of inaccurate conclusions have been drawn from possibly accurate clinical observations and research findings. For example, there are occlusionists’ who have equilibrated the dentition and/or repositioned the mandible3 and have observed relief of the patient’s TM disorder symptoms. They have concluded a priori from these observations that occlusal interferences and/or jaw position are the primary causative factors of TM disorders. However, such an interpretation is inappropriate. This axiomatic deduction, which concludes that treatment which ameliorates TM disorder symptoms succeeded because it treated the cause, may not be correct. It is not possible to conclude that a cause-and-effect relationship exists between TM disorders and certain variables when one considers that treatment may have been directed at alleviating the symptoms produced by the disorder rather than at the causes of the condition. Similarly, proponents of the myofascial paindysfunction (MPD) syndrome theory have observed that placebo drugs,4 placebo bite plates,j mock equilibration, biofeedback,7 and psychological counsellings have reduced or eliminated the subjective TM disorder
Volume 83 Number 6
symptoms. Some MPD proponents further state that, while many persons have long-standing malocclusions, most are free from TM disorders; what they do with their existing occlusion and neuromuscular apparatus in reacting to ‘ ‘distress ’ ’ is more significant than their occlusal status. Interpretation of these findings has resulted in the proponents of the MPD syndrome theory concluding that emotional stress is the causative factor in MPD.g However, critics of the MPD theory argue that a cause-and-effect relationship between emotional stress and MPD has not been proved; what has been proved is only that the conditions coexist.1° Another theory concerning the primary cause of TM disorders is that of internal derangement (anterior displacement of the disk) of the temporomandibular joint. Farrar and McCarty” have stated that proponents of the MPD syndrome and leading exponents of the TMJ syndrome do not take adequate account of the position and condition of the disk in explaining their theories. The advocates of this theory are quick to point out that only the subjective symptoms of MPD have been relieved by psychological treatment modalities. The clinical, measurable symptoms of MPD, such as clicking and limitation of jaw opening, are often caused by internal derangement. lo They further elaborate: The disk is the center of the joint, interposed between the condyle and the fossa . . . . Recent studies using range-of-movement patterns, transcranial radiography, a manipulation technique to reduce the dislocated disk, condylar path measurements, arthrography, and surgery have demonstrated that almost 70 percent of all patients with TMJ symptoms have some form or degree of disk displacement.” They also believe that, with understanding of centric relation, the previous definition will need to be reappraised to include the relative position of the disk in relation to the condyle and fossa.” There are many logical arguments antithetical to the claims of the internal derangement theory. Critics of the theory argue that TMJ clicking is found in a modestly large proportion of the population who are also free from any apparent overt discomfort (pain or muscle tenderness). Although this may not be the ideal, it may be considered a somewhat “normal” or common finding. Thus, it can be argued that anterior displacement of the disk is not really a causative factor of TM disorders but a resultant effect. Finally, the proponents of the internal derangement theory are often criticized for “their overuse of diagnostic radiographs, splints, and surgery. ’ ’
Guest editorial
519
Other unsubstantiated theories concerning the primary cause of TM disorders are malalignment of the vertebrae, displacement of cranial bones and sutures, allergies, and malnutrition. Finally, even though the literature has indicated that the etiology of TM disorders is multifactorial,*2-1s many dental professionals have developed a priori etiologic theories based upon the analysis of limited variables. This has led some practitioners to adopt a somewhat trite, undifferentiated diagnosis, followed then by routine treatment plans. Since what has been described as “TMJ disorders” includes structures related to, but not necessarily limited to, the temporomandibular joint, the use of broad, nonspecific categories such as “TMJ dysfunction” was discouraged. A classification of TM disorders was adopted. This classification was divided into seven categories: masticatory disorders, problems involving derangement of the temporomandibular joint, problems that result from extrinsic trauma, degenerative joint diseases, inflammatory joint disorders, chronic mandibular hypomobility, and growth disorders of the joint. Certain guidelines were established regarding radiography and arthrography as related to diagnosis of TM disorders: 1. The use of radiographs for the purpose of assessing joint spaces was not considered a reliable diagnostic procedure. 2. Radiographs of the temporomandibular joint were considered necessary when an organic pathologic condition is believed to be present. A transcranial, transpharyngeal, or panoramic radiograph, to be used as a screening view, was justified. Tomography should be reserved for those patients in whom the screening radiograph showed a possible abnormality. 3. Transcranial radiography for the evaluation of condylar position was not considered as reliable as tomographic assessment of joint spaces, but in either case there was insufficient evidence that eccentricity of the condyle in the fossa was a diagnostic sign of a temporomandibular disorder. 4. TM radiography was not recommended as a routine diagnostic procedure to assess internal joint derangements. TMJ arthrography was considered a special diagnostic method with limited indications. ADA guidelines for the treatment of TM disorders was based upon a principle of conservative, reversible forms of therapy, as opposed to irreversible forms of
520
Guest editorial
therapy, whenever possible. In addition, it was stressed that there should be a scien@c basis for establishing a treatment modality. For example, occlusal appliances that are not designed to reposition the mandible or the dentition intentionally and permanently were considered a justified form of therapy, since they were considered conservative and also since there exists sufficient scientific evidence to support their efficacy. However, mandibular repositioning therapy intended to place the mandible permanently in a new position by means of prosthodontic treatment, orthodontic treatment, surgery, or functional occlusal appliances was considered an irreversible form of treatment and was not advocated for TM disorders if a more conservative approach could be used. Pharmacologic agents, such as nonaddictive analgesics and muscle relaxants, were considered useful on a short-term basis. Behavior therapy, such as biofeedback and relaxation training, is recommended for some dysfunction conditions involving the muscles of mastication and for those patients with chronic TM disorders who do not respond to conventional, conservative therapy. Surgery for the initial treatment of disk displacement was not recommended, since no evidence exists to support its use. Also, meniscectomy was considered useful only in situations where the disk is so deranged, damaged, or diseased that no other alternative exists. Supporting evidence of the efficacy of osteopathic and chiropractic therapies was considered nonexistent. Also, no controlled scientific investigation has conclusively demonstrated that body muscle testing (applied kinesiology) is a reliable indicator of jaw dysfunction, that it can be used as a means of establishing proper jaw position or vertical dimension, or that it can provide useful information on the local or systemic health status of the patient. Finally, although some dentists firmly believe that a cause-and-effect relationship exists between occlusal problems and TM disorders, the ADA report stated that such a cause-and-effect relationship has not been conclusively shown. It has been demonstrated only that the two conditions frequently coexist and the nature of the relationship is, at this time, unclear. GENERAL
DISCUSSION
The ADA TM disorder guidelines were well written and well timed, and they may help alleviate gross mismanagement of TM disorder patients. Dentistry appears to be at a crossroads in terms of its involvement in temporomandibular disorders. One may ask whether dentistry is evolving into a profession not of prac-
Am. .I. Orthod. June 1983
titioners with a fundamental scientific background and logical rationale for treatment but, rather, one with a philosophic treatment rationale that may border in some extreme cases on “quackery. ” As dental practitioners, we have the professional obligation to act in accordance with scientific thinking, or one may ask what separates us from the masses of nonprofessional lay people. The confusion concerning TM disorders has led some dental practitioners in search of solutions to perform irreversible, unscientific treatments on their patients. It would seem that a more conservative, less aggressive treatment plan would be more appropriate for management of TM disorders since the scientific evidence in this area is, at best, speculative and confounded. It is claimed that during the past decade health quackery has been growing among the dental and medical professions. BarrettI and HerbertI have cited some examples among the dental profession involving nutrition and kinesiology. There are also untested claims about the physical benefits to athletes from mandibular orthopedic repositioning appliances (MORA splints) to increase strength and endurance. Orthodontic headgear and extractions have also been suggested as contributors to TM disorders. Some of these scientifically unfounded concepts have filtered their way into continuing education courses, scientific journals, and scientific organizations. Many of these misconceptions have been further perpetuated by course participants who, by association, have considered themselves experts and, through ignorance of science, have supported these unsubstantiated views to colleagues in both dentistry and medicine, to patients, and, worst of all, to the American public as a result of their appearances on local television talk s,hows. There is enough latitude in the guidelines to permit modest flexibility for those who are not overly aggressive in their treatment methods. If one takes exception to the ADA TM disorder guidelines, perhaps one might well question the scientific rationale for their own opinion(s) and take strides to scientifically substantiate the patient benefits. Finally, there are perhaps those who may challenge and discredit the ADA guidelines since they are in conflict with their own views. Possibly, since such names as Gelb, Farrar, McCarty, and Jenkelson were missing from the ADA advisory committee, some may call the guidelines biased. Dr. Ayer , I8 from the ADA Bureau of Economic and
Guest editorial
Volume 83 Number
521
6
Behavior Research and a leading participant in the conference, has assured us that all attempts were made to keep the conference as unbiased as possible and that the absence of some persons was merely coincidental since all the aforementioned men were invited. As he explained, in the organizing of such a large group, individual scheduling conflicts did not permit some to attend. Furthermore, attempts were made by the ADA group to find appropriate substitutes for those who could not attend. IMPACT
ON ORTHODONTIC
PRACTICE
The ADA guidelines would help clarify many situations that arise in orthodontic practice relative to TM disorders. Some dentists have a philosophic bias toward occlusal disharmonies and/or jaw position as the primary causative factors of TM disorders and treat accordingly.2* ls-*l The presence of a malocclusion obviously is not always associated with TM disorder. l** 13*Is, ** The routine recommendation of comprehensive orthodontic treatment for all TMdisorders would be an unfounded and an exaggerated recommendation. SUMMARY
There appears to be no simple diagnosis and treatment plan for the management of TM disorder patients. A differential diagnosis of TM disorders should be based upon a logical classification that incorporates a number of variables, such as masticatory disorders, problems involving derangement of the TMJ, problems that result from extrinsic trauma, degenerative joint diseases, inflammatory joint disorders, chronic mandibular hypomobility, and growth disorders of the joint. In the absence of definitive scientific research pertaining to TM disorders, the ADA has established guidelines for the examination, diagnosis, and management of TM disorders. Most often, treatment of TM disorders has been anecdotal and directed at allaying the symptoms and not particularly directed at the cause. The general recommendation of the ADA guidelines regarding TM disorder treatment is that it be conservative, reversible, and based upon scientific data whenever possible. These general recommendations, although nebulous, point to the fact that we simply have not progressed far enough to develop a consensus plan concerning the most appropriate treatment for each and every patient with TM disorders. The problems in the patient population are too complex and varied for an outline or “cookbook” type of treatment plan. Since orthodontists have become more involved in
the treatment of TM disorders, some may re-evaluate their thinking in light of the ADA TM disorder guidelines. The orthodontist may also have to resolve conflicts that arise over differing opinions regarding the major issues involved in TM disorder examination, diagnosis, and treatment. Too often simplistic models of natural phenomena may be misleading and inaccurate, as is true of some existing models which explain TM disorders. It is time that we, as members of the great profession of dentistry, critically evaluate current literature in order that we may responsibly justify our diagnoses and treatment modalities. In light of the fact that the more knowledge we accumulate, the more we should realize how much we do not know, it might be wise for us to reflect upon the following quotation from Shakespeare: The fool doth think he is wise, but the wise man knows himself to be a fool. -As
You Like It, Act V, Scene 1
REFERENCES 1. Griffiths, Robert H.: Report of the President’s Conference on the Examination, Diagnosis, and Management of Temporomandibular Disorders, J. Am. Dent. Assoc. 106: 75-77, 1983. 2. Dawson, P. E.: Evaluation, diagnosis, and treatment of occlusal problems, St. Louis, 1974, The C. V. Mosby Company. 3. Gelb, H.: Clinical management of head, neck and temporomandibular joint pain and dysfunction: A multidisciplinary approach to diagnosis and treatment, Philadelphia, 1977, W. B. Saunders Company. 4. Laskin, D. M., and Greene, C. S.: Correlation of placebo responses and psychological characteristics in myofascial paindysfunction patients, 1. A. D. R. Abstr. 282, p. 119, 1970. 5. Green, C. S., and La&in, D. M.: Long-term evaluation of conservative treatment for myofascial pain-dysfunction syndrome, J. Am. Dent. Assoc. 89: 13651368, 1974. 6. Goodman, P., Greene, C. S., and La&in, D. M.: Response of patients with myofascial pain-dysfunction syndrome to mock equilibration, J. Am. Dent. Assoc. 92: 755, 1976. 7. Dohmann, R. J., and Laskin, D. M.: An evaluation of electromyographic biofeedback in the treatment of myofascial paindysfunction syndrome, J. Am. Dent. Assoc. 96: 856-860, 1978. 8. Lupton, D. E.: Psychological aspects of temporomandibular joint dysfunction, J. Am. Dent. Assoc. 79: 131, 1969. 9. Laskin, D. M.: Etiology of the pain-dysfunction syndrome, J. Am. Dent. Assoc. 79: 148-152, 1969. 10. Farrar, W. B.: Craniomandibular practice: The state of the art; definition and diagnosis, Cranio-mandibular Practice 1: 4- 12, Dec.-Feb., 1982-1983. 11. Farrar, W. B., and McCarty, W. L., Jr.: The TMJ dilemma, J. Ala. Dent. Assoc. 63: 19-26, 1979. 12. Egermark-Eriksson, I., Ingerwall, B., and Carlsson, G. E.: The dependence of mandibular dysfunction in children on functional and morphologic malocclusion, AM. J. ORTHOD. 83: 187-194, 1983. 13. Greene, C. S., et al.: The TMJ pain-dysfunction syndrome: Heterogeneity of the patient population, J. Am. Dent. Assoc. 79: 1170, 1969.
522
Guest editorial
14. Glickman, I.: Clinical periodontology, ed. 4, Philadelphia, 1972, W. B. Saunders Company, p. 827. 15. Sadowsky, L., and BeGole, E. A.: Long-term status of temporomandibular joint function and functional occlusion after orthodontic treatment, AM. J. ORTHOD. 78: 201-212, 1980. 16. Barrett, S.: The health robbers, Philadelphia, 1976, George Stickley & Company. 17. Herbert, V.: Nutrition cultism, Philadelphia, 1980, George Stickley & Company. 18. Ayer, W. A.: Personal communication, March 17, 1983.
Am. J. Orthod. June 1983
19. Roth, R.: Temporomandibular pain-dysfunction and occlusal relationships, Angle Grthod. 43: 136- 153, 1973. 20. Lucia, V. 0.: The gnathological concept of articulation, Dent. Clin. North Am. pp. 183-197, March, 1962. 21. Parker, W. S.: Centric relation and centric occlusion-An orthodontic responsibility, AM. J. ORTHOD. 74: 48 l-500, 1978. 22. Glickman, I., Martignoni, M., Haddad, A., and Roeber, F. W.: Further observations on human occlusion monitored by intraoral telemetry, I.A.D.R. Abstr. 612, p. 201, 1970.
Pa.
T
o eliminate some of the confusion regarding temporomandibular disorders, on June 1, 1982, Robert H. Griffiths, then president of the American Dental Association, initiated a 4-day conference whose ultimate purpose was to develop guidelines for the examination, diagnosis, and management of temporomandibular disorders. Present at this conference were the leading practitioners, educators, and researchers in the fields of occlusion and TM dis0rders.l These TM disorder guidelines, reprinted in this issue of the AMERICAN JOURNAL OF ORTHODONTICS, will henceforth be referred to as the ADA guidelines. The purpose of this editorial is twofold: First, the salient features of the ADA TM disorder guidelines will be renewed. Second, these guidelines will be analyzed with regard to their impact vis-&vis existing orthodontic practice. Few subjects in dentistry are as confusing or given to as many interpretations and misinterpretations as temporomandibular (TM) disorders. There appears to be a never-ending debate concerning the etiology and proper treatment of TM disorders. Because TM disorder investigations have failed to isolate one set of variables while controlling other variables, definitive answers to the questions that have been raised are lacking. Part of this problem of uncontrollable extrinsic variables is because of the numerous fac-
*Temporomandibular disorder guidelines were developed from the ADA President’s Conference on TM Disorders. **Associate professors of Orthodontics, University of Pittsburgh School of Dental Medicine, and Doctoral Students in Higher Education. Present address: Orthodontic Department, University of Pittsburgh, School of Dental Medicine, Salk Hall, 3501 Terrace Street, Pittsburgh, Pa. 15261.
518
tors that have impact upon the temporomandibular area. This is especially true when one considers the complex interrelationship between biologic, physiologic, and psychologic factors that are involved in craniomandibular articulation. In addition, such structures and influences as the brain, nerves, reflexes, joints, disks, ligaments, bone, muscle, etc. must all be accounted for. These complexities make research and the interpretation of findings more than a little difficult. Because of the confounded nature of TM disorder research, as well as ineptitude in research investigation analysis, a plethora of inaccurate conclusions have been drawn from possibly accurate clinical observations and research findings. For example, there are occlusionists’ who have equilibrated the dentition and/or repositioned the mandible3 and have observed relief of the patient’s TM disorder symptoms. They have concluded a priori from these observations that occlusal interferences and/or jaw position are the primary causative factors of TM disorders. However, such an interpretation is inappropriate. This axiomatic deduction, which concludes that treatment which ameliorates TM disorder symptoms succeeded because it treated the cause, may not be correct. It is not possible to conclude that a cause-and-effect relationship exists between TM disorders and certain variables when one considers that treatment may have been directed at alleviating the symptoms produced by the disorder rather than at the causes of the condition. Similarly, proponents of the myofascial paindysfunction (MPD) syndrome theory have observed that placebo drugs,4 placebo bite plates,j mock equilibration, biofeedback,7 and psychological counsellings have reduced or eliminated the subjective TM disorder
Volume 83 Number 6
symptoms. Some MPD proponents further state that, while many persons have long-standing malocclusions, most are free from TM disorders; what they do with their existing occlusion and neuromuscular apparatus in reacting to ‘ ‘distress ’ ’ is more significant than their occlusal status. Interpretation of these findings has resulted in the proponents of the MPD syndrome theory concluding that emotional stress is the causative factor in MPD.g However, critics of the MPD theory argue that a cause-and-effect relationship between emotional stress and MPD has not been proved; what has been proved is only that the conditions coexist.1° Another theory concerning the primary cause of TM disorders is that of internal derangement (anterior displacement of the disk) of the temporomandibular joint. Farrar and McCarty” have stated that proponents of the MPD syndrome and leading exponents of the TMJ syndrome do not take adequate account of the position and condition of the disk in explaining their theories. The advocates of this theory are quick to point out that only the subjective symptoms of MPD have been relieved by psychological treatment modalities. The clinical, measurable symptoms of MPD, such as clicking and limitation of jaw opening, are often caused by internal derangement. lo They further elaborate: The disk is the center of the joint, interposed between the condyle and the fossa . . . . Recent studies using range-of-movement patterns, transcranial radiography, a manipulation technique to reduce the dislocated disk, condylar path measurements, arthrography, and surgery have demonstrated that almost 70 percent of all patients with TMJ symptoms have some form or degree of disk displacement.” They also believe that, with understanding of centric relation, the previous definition will need to be reappraised to include the relative position of the disk in relation to the condyle and fossa.” There are many logical arguments antithetical to the claims of the internal derangement theory. Critics of the theory argue that TMJ clicking is found in a modestly large proportion of the population who are also free from any apparent overt discomfort (pain or muscle tenderness). Although this may not be the ideal, it may be considered a somewhat “normal” or common finding. Thus, it can be argued that anterior displacement of the disk is not really a causative factor of TM disorders but a resultant effect. Finally, the proponents of the internal derangement theory are often criticized for “their overuse of diagnostic radiographs, splints, and surgery. ’ ’
Guest editorial
519
Other unsubstantiated theories concerning the primary cause of TM disorders are malalignment of the vertebrae, displacement of cranial bones and sutures, allergies, and malnutrition. Finally, even though the literature has indicated that the etiology of TM disorders is multifactorial,*2-1s many dental professionals have developed a priori etiologic theories based upon the analysis of limited variables. This has led some practitioners to adopt a somewhat trite, undifferentiated diagnosis, followed then by routine treatment plans. Since what has been described as “TMJ disorders” includes structures related to, but not necessarily limited to, the temporomandibular joint, the use of broad, nonspecific categories such as “TMJ dysfunction” was discouraged. A classification of TM disorders was adopted. This classification was divided into seven categories: masticatory disorders, problems involving derangement of the temporomandibular joint, problems that result from extrinsic trauma, degenerative joint diseases, inflammatory joint disorders, chronic mandibular hypomobility, and growth disorders of the joint. Certain guidelines were established regarding radiography and arthrography as related to diagnosis of TM disorders: 1. The use of radiographs for the purpose of assessing joint spaces was not considered a reliable diagnostic procedure. 2. Radiographs of the temporomandibular joint were considered necessary when an organic pathologic condition is believed to be present. A transcranial, transpharyngeal, or panoramic radiograph, to be used as a screening view, was justified. Tomography should be reserved for those patients in whom the screening radiograph showed a possible abnormality. 3. Transcranial radiography for the evaluation of condylar position was not considered as reliable as tomographic assessment of joint spaces, but in either case there was insufficient evidence that eccentricity of the condyle in the fossa was a diagnostic sign of a temporomandibular disorder. 4. TM radiography was not recommended as a routine diagnostic procedure to assess internal joint derangements. TMJ arthrography was considered a special diagnostic method with limited indications. ADA guidelines for the treatment of TM disorders was based upon a principle of conservative, reversible forms of therapy, as opposed to irreversible forms of
520
Guest editorial
therapy, whenever possible. In addition, it was stressed that there should be a scien@c basis for establishing a treatment modality. For example, occlusal appliances that are not designed to reposition the mandible or the dentition intentionally and permanently were considered a justified form of therapy, since they were considered conservative and also since there exists sufficient scientific evidence to support their efficacy. However, mandibular repositioning therapy intended to place the mandible permanently in a new position by means of prosthodontic treatment, orthodontic treatment, surgery, or functional occlusal appliances was considered an irreversible form of treatment and was not advocated for TM disorders if a more conservative approach could be used. Pharmacologic agents, such as nonaddictive analgesics and muscle relaxants, were considered useful on a short-term basis. Behavior therapy, such as biofeedback and relaxation training, is recommended for some dysfunction conditions involving the muscles of mastication and for those patients with chronic TM disorders who do not respond to conventional, conservative therapy. Surgery for the initial treatment of disk displacement was not recommended, since no evidence exists to support its use. Also, meniscectomy was considered useful only in situations where the disk is so deranged, damaged, or diseased that no other alternative exists. Supporting evidence of the efficacy of osteopathic and chiropractic therapies was considered nonexistent. Also, no controlled scientific investigation has conclusively demonstrated that body muscle testing (applied kinesiology) is a reliable indicator of jaw dysfunction, that it can be used as a means of establishing proper jaw position or vertical dimension, or that it can provide useful information on the local or systemic health status of the patient. Finally, although some dentists firmly believe that a cause-and-effect relationship exists between occlusal problems and TM disorders, the ADA report stated that such a cause-and-effect relationship has not been conclusively shown. It has been demonstrated only that the two conditions frequently coexist and the nature of the relationship is, at this time, unclear. GENERAL
DISCUSSION
The ADA TM disorder guidelines were well written and well timed, and they may help alleviate gross mismanagement of TM disorder patients. Dentistry appears to be at a crossroads in terms of its involvement in temporomandibular disorders. One may ask whether dentistry is evolving into a profession not of prac-
Am. .I. Orthod. June 1983
titioners with a fundamental scientific background and logical rationale for treatment but, rather, one with a philosophic treatment rationale that may border in some extreme cases on “quackery. ” As dental practitioners, we have the professional obligation to act in accordance with scientific thinking, or one may ask what separates us from the masses of nonprofessional lay people. The confusion concerning TM disorders has led some dental practitioners in search of solutions to perform irreversible, unscientific treatments on their patients. It would seem that a more conservative, less aggressive treatment plan would be more appropriate for management of TM disorders since the scientific evidence in this area is, at best, speculative and confounded. It is claimed that during the past decade health quackery has been growing among the dental and medical professions. BarrettI and HerbertI have cited some examples among the dental profession involving nutrition and kinesiology. There are also untested claims about the physical benefits to athletes from mandibular orthopedic repositioning appliances (MORA splints) to increase strength and endurance. Orthodontic headgear and extractions have also been suggested as contributors to TM disorders. Some of these scientifically unfounded concepts have filtered their way into continuing education courses, scientific journals, and scientific organizations. Many of these misconceptions have been further perpetuated by course participants who, by association, have considered themselves experts and, through ignorance of science, have supported these unsubstantiated views to colleagues in both dentistry and medicine, to patients, and, worst of all, to the American public as a result of their appearances on local television talk s,hows. There is enough latitude in the guidelines to permit modest flexibility for those who are not overly aggressive in their treatment methods. If one takes exception to the ADA TM disorder guidelines, perhaps one might well question the scientific rationale for their own opinion(s) and take strides to scientifically substantiate the patient benefits. Finally, there are perhaps those who may challenge and discredit the ADA guidelines since they are in conflict with their own views. Possibly, since such names as Gelb, Farrar, McCarty, and Jenkelson were missing from the ADA advisory committee, some may call the guidelines biased. Dr. Ayer , I8 from the ADA Bureau of Economic and
Guest editorial
Volume 83 Number
521
6
Behavior Research and a leading participant in the conference, has assured us that all attempts were made to keep the conference as unbiased as possible and that the absence of some persons was merely coincidental since all the aforementioned men were invited. As he explained, in the organizing of such a large group, individual scheduling conflicts did not permit some to attend. Furthermore, attempts were made by the ADA group to find appropriate substitutes for those who could not attend. IMPACT
ON ORTHODONTIC
PRACTICE
The ADA guidelines would help clarify many situations that arise in orthodontic practice relative to TM disorders. Some dentists have a philosophic bias toward occlusal disharmonies and/or jaw position as the primary causative factors of TM disorders and treat accordingly.2* ls-*l The presence of a malocclusion obviously is not always associated with TM disorder. l** 13*Is, ** The routine recommendation of comprehensive orthodontic treatment for all TMdisorders would be an unfounded and an exaggerated recommendation. SUMMARY
There appears to be no simple diagnosis and treatment plan for the management of TM disorder patients. A differential diagnosis of TM disorders should be based upon a logical classification that incorporates a number of variables, such as masticatory disorders, problems involving derangement of the TMJ, problems that result from extrinsic trauma, degenerative joint diseases, inflammatory joint disorders, chronic mandibular hypomobility, and growth disorders of the joint. In the absence of definitive scientific research pertaining to TM disorders, the ADA has established guidelines for the examination, diagnosis, and management of TM disorders. Most often, treatment of TM disorders has been anecdotal and directed at allaying the symptoms and not particularly directed at the cause. The general recommendation of the ADA guidelines regarding TM disorder treatment is that it be conservative, reversible, and based upon scientific data whenever possible. These general recommendations, although nebulous, point to the fact that we simply have not progressed far enough to develop a consensus plan concerning the most appropriate treatment for each and every patient with TM disorders. The problems in the patient population are too complex and varied for an outline or “cookbook” type of treatment plan. Since orthodontists have become more involved in
the treatment of TM disorders, some may re-evaluate their thinking in light of the ADA TM disorder guidelines. The orthodontist may also have to resolve conflicts that arise over differing opinions regarding the major issues involved in TM disorder examination, diagnosis, and treatment. Too often simplistic models of natural phenomena may be misleading and inaccurate, as is true of some existing models which explain TM disorders. It is time that we, as members of the great profession of dentistry, critically evaluate current literature in order that we may responsibly justify our diagnoses and treatment modalities. In light of the fact that the more knowledge we accumulate, the more we should realize how much we do not know, it might be wise for us to reflect upon the following quotation from Shakespeare: The fool doth think he is wise, but the wise man knows himself to be a fool. -As
You Like It, Act V, Scene 1
REFERENCES 1. Griffiths, Robert H.: Report of the President’s Conference on the Examination, Diagnosis, and Management of Temporomandibular Disorders, J. Am. Dent. Assoc. 106: 75-77, 1983. 2. Dawson, P. E.: Evaluation, diagnosis, and treatment of occlusal problems, St. Louis, 1974, The C. V. Mosby Company. 3. Gelb, H.: Clinical management of head, neck and temporomandibular joint pain and dysfunction: A multidisciplinary approach to diagnosis and treatment, Philadelphia, 1977, W. B. Saunders Company. 4. Laskin, D. M., and Greene, C. S.: Correlation of placebo responses and psychological characteristics in myofascial paindysfunction patients, 1. A. D. R. Abstr. 282, p. 119, 1970. 5. Green, C. S., and La&in, D. M.: Long-term evaluation of conservative treatment for myofascial pain-dysfunction syndrome, J. Am. Dent. Assoc. 89: 13651368, 1974. 6. Goodman, P., Greene, C. S., and La&in, D. M.: Response of patients with myofascial pain-dysfunction syndrome to mock equilibration, J. Am. Dent. Assoc. 92: 755, 1976. 7. Dohmann, R. J., and Laskin, D. M.: An evaluation of electromyographic biofeedback in the treatment of myofascial paindysfunction syndrome, J. Am. Dent. Assoc. 96: 856-860, 1978. 8. Lupton, D. E.: Psychological aspects of temporomandibular joint dysfunction, J. Am. Dent. Assoc. 79: 131, 1969. 9. Laskin, D. M.: Etiology of the pain-dysfunction syndrome, J. Am. Dent. Assoc. 79: 148-152, 1969. 10. Farrar, W. B.: Craniomandibular practice: The state of the art; definition and diagnosis, Cranio-mandibular Practice 1: 4- 12, Dec.-Feb., 1982-1983. 11. Farrar, W. B., and McCarty, W. L., Jr.: The TMJ dilemma, J. Ala. Dent. Assoc. 63: 19-26, 1979. 12. Egermark-Eriksson, I., Ingerwall, B., and Carlsson, G. E.: The dependence of mandibular dysfunction in children on functional and morphologic malocclusion, AM. J. ORTHOD. 83: 187-194, 1983. 13. Greene, C. S., et al.: The TMJ pain-dysfunction syndrome: Heterogeneity of the patient population, J. Am. Dent. Assoc. 79: 1170, 1969.
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14. Glickman, I.: Clinical periodontology, ed. 4, Philadelphia, 1972, W. B. Saunders Company, p. 827. 15. Sadowsky, L., and BeGole, E. A.: Long-term status of temporomandibular joint function and functional occlusion after orthodontic treatment, AM. J. ORTHOD. 78: 201-212, 1980. 16. Barrett, S.: The health robbers, Philadelphia, 1976, George Stickley & Company. 17. Herbert, V.: Nutrition cultism, Philadelphia, 1980, George Stickley & Company. 18. Ayer, W. A.: Personal communication, March 17, 1983.
Am. J. Orthod. June 1983
19. Roth, R.: Temporomandibular pain-dysfunction and occlusal relationships, Angle Grthod. 43: 136- 153, 1973. 20. Lucia, V. 0.: The gnathological concept of articulation, Dent. Clin. North Am. pp. 183-197, March, 1962. 21. Parker, W. S.: Centric relation and centric occlusion-An orthodontic responsibility, AM. J. ORTHOD. 74: 48 l-500, 1978. 22. Glickman, I., Martignoni, M., Haddad, A., and Roeber, F. W.: Further observations on human occlusion monitored by intraoral telemetry, I.A.D.R. Abstr. 612, p. 201, 1970.