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TMJ Arthrography
LETTERS TO THE EDITOR THE JOURNAL devotes this section to comment by readers on topics of current interest to dentistry. The editor reserves the right to edit all comm unications to fit available space and requires that all let ters be signed. Printed comm unications do not necessarily reflect the opinion or official policy of the Association. Your participation in this section is invited.
TMJ disease and treatment □ I b eliev e that it is the kind of hands-off approach to temporoman d ib u la r jo in t (TM J) d ia g n o sis by s u r g e r y , a r t h r o g r a p h y , an d r a diographs (as given by Drs. Hiatt and Darnall and by Dr. Sillers, April 1981) that has perpetuated the many theories about this poorly understood malady. Sooner or later the profession w ill realize that previous explanations of TMJ symptoms were largely a function of hit or miss results. In a profession where excellence in research is a stan dard rather than an ex cep tio n , it amazes me that we still teach and prac tice occlusal therapy on the basis of conjecture relative to a healthy condy lar position. It is time we come out of the dark ages and approach the prob lem by actually observing the position and motion of the joint and its disk. Dr. Farrar (January 1981) has done this. His explanation seems to be the first plausible, objective, and properly documented approach to disease and treatment of the TMJ. He has achieved this by facing the problem on the basis of what is, rather than what should be. WILLIAM A. CHOBY, DMD JOHNSTOWN, PA
TMJ arthrography □ I have been actively engaged in tem porom andibular joint (TMJ) ar thrography since August 1979, and am compelled to reply to the letter from Drs. Hiatt and Darnall (April 1981). They characterized TMJ arthrography as “expensive, potentially hazardous, and perhaps technically im possible rad iograp hic stud ies that provide probably insignificant information.” This would seem to be an injustice for those involved in the development of a trem end ous d iag n o stic aid in the treatment of TMJ disease. Expensive? Arthrograms for my pa tients are performed on an outpatient 822 ■ JADA, Vol. 102. June 1981
basis by a radiologist. The charges by the hospital and radiologist are rea sonable for the diagnostic data ob tained. The charges are low in com p a riso n w ith th o se for o th e r ra diological tests. Seldom does a week go by that I do not have at least one arthrogram performed, and I have never had a patient refer to the cost, much less complain that it was too “expen sive.” Potentially hazardous? Any proce dure that involves local anesthetic, ra diographic dye, and radiographs is “ potentially hazardous.” Like any technique of this type, it should be used only when considered essential for proper diagnosis; but to prevent its use because it is “potentially hazard ous” borders on the ridiculous. Technically impossible? I find it dif ficult to comprehend this statement after observing the radiologist time and again easily and effortlessly enter the inferior joint space with a 25-gauge needle and deposit 0.5 cc of dye. . . . Provide probably insignificant in formation? Do they classify perfora tion of a disk, adhesions of the disk to the fossa or condyle or both, or com plete dislocation of the disk as “insig nificant information?” Surely not. Do all patients who have arthrograms find themselves surgical cases? Of course not. In my practice, which is predomi nantly the treatment of TMJ and occlu sal dysfunction, possibly 5% of all pa tients require surgical intervention. I can assure you, and my thankful pa tients would agree, that TMJ arthro graphy certainly has a place in our “tool box” of diagnostic procedures to use in the treatment of chronic pain. CHARLES R. HOLT, DDS HURST, TEX
lenged by entrepeneurs who hope to reap dividends from an unsuspecting public. Their armamentaria include e x te n s iv e p re ss c o v e ra g e , e m o tionalism, and certain catchwords that tem porarily becom e a part of our everyday vocabulary. Som e of the more recent catchwords are “natural,” “Laetrile,” and “h olistic.” Not unexpectedly, the innumerable dollars and hours that have been spent on research and clin ical trials still have stood the test of time. I can ’t wait to see who the next group will be and what their new catchword will be. ROBERT C. GORSKI. DDS DETROIT
Pit and fissure sealants □ As a profession, we have consis tently presented “prevention” as an aspect of total patient care. I am con cerned about the attitude of third party carriers toward pit and fissure seal ants. Numerous studies have shown the effectiveness of sealants in reduc ing pit and fissure caries and the high rate of retention for sealants when properly performed (March 1981). Despite increasing scien tific evi dence in support of sealants as a tool to be used in a total program of preven tive dentistry, all of the major third party carriers in Pennsylvania refuse to include sealants in their coverage. This disregard for a major advance in preventive dentistry puts the financial burden on parents, and forces some parents to decline the service because of finances and reluctance to have a service performed which they inter pret as experimental (because of the insurance company’s lack of recogni tion of sealants). I think that it is time for the Ameri can Dental Association to request the third party carriers to shoulder their responsibility and cover all aspects of prevention in their dental benefits programs. STEVEN A. GRAUBARD, DDS FORT WASHINGTON, PA
Catchwords □ Through the years, the medical and dental establishments have been chal
Comment: The Council on Dental Ma terials, Instruments, and Equipment held a conference, “Pit and Fissure
TMJ disease and treatment □ I b eliev e that it is the kind of hands-off approach to temporoman d ib u la r jo in t (TM J) d ia g n o sis by s u r g e r y , a r t h r o g r a p h y , an d r a diographs (as given by Drs. Hiatt and Darnall and by Dr. Sillers, April 1981) that has perpetuated the many theories about this poorly understood malady. Sooner or later the profession w ill realize that previous explanations of TMJ symptoms were largely a function of hit or miss results. In a profession where excellence in research is a stan dard rather than an ex cep tio n , it amazes me that we still teach and prac tice occlusal therapy on the basis of conjecture relative to a healthy condy lar position. It is time we come out of the dark ages and approach the prob lem by actually observing the position and motion of the joint and its disk. Dr. Farrar (January 1981) has done this. His explanation seems to be the first plausible, objective, and properly documented approach to disease and treatment of the TMJ. He has achieved this by facing the problem on the basis of what is, rather than what should be. WILLIAM A. CHOBY, DMD JOHNSTOWN, PA
TMJ arthrography □ I have been actively engaged in tem porom andibular joint (TMJ) ar thrography since August 1979, and am compelled to reply to the letter from Drs. Hiatt and Darnall (April 1981). They characterized TMJ arthrography as “expensive, potentially hazardous, and perhaps technically im possible rad iograp hic stud ies that provide probably insignificant information.” This would seem to be an injustice for those involved in the development of a trem end ous d iag n o stic aid in the treatment of TMJ disease. Expensive? Arthrograms for my pa tients are performed on an outpatient 822 ■ JADA, Vol. 102. June 1981
basis by a radiologist. The charges by the hospital and radiologist are rea sonable for the diagnostic data ob tained. The charges are low in com p a riso n w ith th o se for o th e r ra diological tests. Seldom does a week go by that I do not have at least one arthrogram performed, and I have never had a patient refer to the cost, much less complain that it was too “expen sive.” Potentially hazardous? Any proce dure that involves local anesthetic, ra diographic dye, and radiographs is “ potentially hazardous.” Like any technique of this type, it should be used only when considered essential for proper diagnosis; but to prevent its use because it is “potentially hazard ous” borders on the ridiculous. Technically impossible? I find it dif ficult to comprehend this statement after observing the radiologist time and again easily and effortlessly enter the inferior joint space with a 25-gauge needle and deposit 0.5 cc of dye. . . . Provide probably insignificant in formation? Do they classify perfora tion of a disk, adhesions of the disk to the fossa or condyle or both, or com plete dislocation of the disk as “insig nificant information?” Surely not. Do all patients who have arthrograms find themselves surgical cases? Of course not. In my practice, which is predomi nantly the treatment of TMJ and occlu sal dysfunction, possibly 5% of all pa tients require surgical intervention. I can assure you, and my thankful pa tients would agree, that TMJ arthro graphy certainly has a place in our “tool box” of diagnostic procedures to use in the treatment of chronic pain. CHARLES R. HOLT, DDS HURST, TEX
lenged by entrepeneurs who hope to reap dividends from an unsuspecting public. Their armamentaria include e x te n s iv e p re ss c o v e ra g e , e m o tionalism, and certain catchwords that tem porarily becom e a part of our everyday vocabulary. Som e of the more recent catchwords are “natural,” “Laetrile,” and “h olistic.” Not unexpectedly, the innumerable dollars and hours that have been spent on research and clin ical trials still have stood the test of time. I can ’t wait to see who the next group will be and what their new catchword will be. ROBERT C. GORSKI. DDS DETROIT
Pit and fissure sealants □ As a profession, we have consis tently presented “prevention” as an aspect of total patient care. I am con cerned about the attitude of third party carriers toward pit and fissure seal ants. Numerous studies have shown the effectiveness of sealants in reduc ing pit and fissure caries and the high rate of retention for sealants when properly performed (March 1981). Despite increasing scien tific evi dence in support of sealants as a tool to be used in a total program of preven tive dentistry, all of the major third party carriers in Pennsylvania refuse to include sealants in their coverage. This disregard for a major advance in preventive dentistry puts the financial burden on parents, and forces some parents to decline the service because of finances and reluctance to have a service performed which they inter pret as experimental (because of the insurance company’s lack of recogni tion of sealants). I think that it is time for the Ameri can Dental Association to request the third party carriers to shoulder their responsibility and cover all aspects of prevention in their dental benefits programs. STEVEN A. GRAUBARD, DDS FORT WASHINGTON, PA
Catchwords □ Through the years, the medical and dental establishments have been chal
Comment: The Council on Dental Ma terials, Instruments, and Equipment held a conference, “Pit and Fissure