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TMJ + MPD?
each other w ill benefit us both, but will especially benefit our patients. In short, le t’s quit bickering and listen to each other. ALAN GROSS, DDS, MS ELLIOT N. GALE, PHD STATE UNIVERSITY OF NEW YORK BUFFALO
cardiograph. We quote from his sum mary: “The evaluation of the symptom ‘sounds in the joint,’ im portant in general practice, is not easy w hen one considers its frequency in ‘healthy’ individuals.” Dr. Kirk speaks of an “attem pt to state w hat has been know n for years.” We w ould ask: to w hat inform ation is Dr. Kirk privy that the rest of us are not? It is only recently, through the efforts of Solberg and Rieder (referenced in the article), that epidem iologic data have become avail able on sam ples of US subjects; almost all of the other studies were done on Scan dinavian samples. He then . . . goes on to prod The Jour nal’s reviewers to be more discrim inating in their article selection. The authors can assure Dr. Kirk that The Journal’s review process on our article was a rigorous one. We received several pertinent sugges tions and criticism s that were helpful to us in revision of the article to its final form. A lth o u g h w e acknow ledge th e fine contributions of Farrar and McCarty in providing us w ith an anatom ic explana tion of joint noises, we strongly repeat that the clinical importance of clicking and crepitation is not yet clearly under stood in an otherw ise asymptomatic in d ivid u al. A ccording to our p hysician consultants, this is also true for other joints. We agree w ith Dr. Kirk that the patient w ith a TM disorder is often a difficult one to manage, but we m ust keep our m inds open and avoid espousing a single (or th o p e d ic ) p o in t of v iew . M ore e p i demiologic data, not less, are needed if w e’re going to resolve the many puzzling aspects of TM problems. In conclusion . . . we w ould like to ad dress ourselves to the unfortunate divi sion that exists betw een some dental re searchers and clinicians. We indict both groups: the researchers, who often too easily condem n clinicians for their al leged excessive interest in affairs of the m arketplace, not realizing the m any and v a r ie d p r e s s u r e s — e c o n o m ic a n d psychologic—on today’s dental practi tioners; and the clinicians, who often d ism iss n e c e ssa ry b asic in fo rm atio n gained by researchers as irrelevant to their clinical practice, failing to realize that it is this inform ation that will u lti m ately guide their therapy. Fortunately, there are many on both sides who do not share either of these polarized attitudes. An increased awareness of our need for 732 ■ JADA, Vol. 108, May 1984
1. Pollman, L. Sounds produced by the m andibu lar joint in young men. J Maxillofac Surg 8:155-157, 1980.
TM J + MPD? □ Dr. Farrar’s (Letters, October 1983) and Dr. Bobier’s (Letters, February 1984) posi tions concerning myofascial pain dys function (MPD) represent two common viewpoints. The term MPD syndrome has been ac curately defined and used to describe a particular condition for more than two decades. The term as currently used does not include disease processes w ithin the tem porom andibular joint (TMJ). I believe it w ould be m ost difficult to redefine a term that is so commonly used, w ithout causing a great deal of confusion. There fore, I believe the term MPD syndrome should rem ain as defined w ithout altera tion. To describe patients’ symptoms w ith out lim iting the description to a previ ously defined term, I suggest the term “Orom uscular pain.” The term is defined as “pain propagating from the muscles that are involved in the m ovem ent or stabilization of the m andible.” The pain from MPD syndrom e and from a TMJ condition can be included w ithin the term orom uscular pain. The m echanism of orom uscular pain that results from MPD has been extensively described in the literature and does not need to be dis cussed here. H ow ever, the m echanism th at p ro duces oromuscular pain in patients w ith internal derangem ent can be briefly dis cussed. In the healthy condition, the forces of m astication w ithin the TMJ are carried by the articular disk. W hen the disk is prolapsed forward, the condyle im pinges on the delicate and highly in nervated retrodiskal tissue. The low level of pain w ithin the joint elicits high levels of m uscular splinting to protect the deli cate tissue. The m uscular splinting pro duces symptoms often identical to MPD syndrom e, but not the result of MPD syn drome. It should be em phasized that m any TMJ problem s can produce m uscular splint ing. The majority of patients with internal derangem ents seldom isolate the source of pain to the TMJ. However, w hen the joint is reduced to a stable, stress-bearing position, the oromuscular pain rapidly subsides. Conversely, patients w ith MPD syndrom e may experience interm ittent
TMJ pain. Therefore, the presence or ab sence of TMJ pain is not diagnostic. Because muscles propagate the pain, orom uscular pain can result from MPD syndrom e or problems in the area. Con sequently, a w ide variety of therapies have been successfully used to relieve orom uscular pain. The variations of suc cessful therapies have ranged from m edi ta tio n to su rg ery . T he a b a tem en t of symptoms is the result of the tendency of the particular procedure to relieve the m uscle spasms that are propagating the pain. Ultimately, the long-term resolu tion of either condition m ust depend on arresting the disease process. .. . We need a term that includes MPD syn drome and TMJ problems. Both condi tio n s affect the m anner in w hich the m andible articulates w ith the skull. It w ould seem natural to refer to this dys functional relationship as sim ply m an dibular dysfunction. Regardless of what we call the disease process, we m ust rec ognize the validity of both concepts. By doing so, we w ill be able to provide our patients w ith the best possible care. JAMES N. ROSS, DDS BRENHAM, TEX
TM treatment □ T he co n tro v e rsy s u rro u n d in g the treatm ent of tem porom andibular disor ders w ill not abate until the dental com m unity insists on the same rigor d e m anded by other scientific disciplines. We can all agree that patients w ith tem porom andibular problems have some m ix of c o n trib u tin g s tr u c tu r a l a n d psychologic com ponents. The m u lti faceted nature of the problem may require h elp from other h e alth professio n als (such as physical therapists). Surely we are obligated to treat objec tively those aspects of the problem that we can quantify. With the ready availabil ity of the m andibular kinesiograph and the electromyograph, there is sim ply no excuse for c o n tin u ed conjecture and speculation. These instrum ents . . . yield reproducible, clinically useful structural inform ation. T his inform ation can be tra n sla te d into specific, q u a n tifia b le treatm ent for the patient. As dentists, we owe our patients at least this much. . . . STEPHEN C. GLOVER, DDS HAYS, KAN
N2O and chemically dependent patients □ The article by Drs. Duncan and Moore (February) reviewing adverse reactions to nitrous oxide fails to m ention a signifi cant danger to the recovering chemically d e p en d e n t p atient. (I in c lu d e the al coholic patient in the term “chemically dependent.”)
cardiograph. We quote from his sum mary: “The evaluation of the symptom ‘sounds in the joint,’ im portant in general practice, is not easy w hen one considers its frequency in ‘healthy’ individuals.” Dr. Kirk speaks of an “attem pt to state w hat has been know n for years.” We w ould ask: to w hat inform ation is Dr. Kirk privy that the rest of us are not? It is only recently, through the efforts of Solberg and Rieder (referenced in the article), that epidem iologic data have become avail able on sam ples of US subjects; almost all of the other studies were done on Scan dinavian samples. He then . . . goes on to prod The Jour nal’s reviewers to be more discrim inating in their article selection. The authors can assure Dr. Kirk that The Journal’s review process on our article was a rigorous one. We received several pertinent sugges tions and criticism s that were helpful to us in revision of the article to its final form. A lth o u g h w e acknow ledge th e fine contributions of Farrar and McCarty in providing us w ith an anatom ic explana tion of joint noises, we strongly repeat that the clinical importance of clicking and crepitation is not yet clearly under stood in an otherw ise asymptomatic in d ivid u al. A ccording to our p hysician consultants, this is also true for other joints. We agree w ith Dr. Kirk that the patient w ith a TM disorder is often a difficult one to manage, but we m ust keep our m inds open and avoid espousing a single (or th o p e d ic ) p o in t of v iew . M ore e p i demiologic data, not less, are needed if w e’re going to resolve the many puzzling aspects of TM problems. In conclusion . . . we w ould like to ad dress ourselves to the unfortunate divi sion that exists betw een some dental re searchers and clinicians. We indict both groups: the researchers, who often too easily condem n clinicians for their al leged excessive interest in affairs of the m arketplace, not realizing the m any and v a r ie d p r e s s u r e s — e c o n o m ic a n d psychologic—on today’s dental practi tioners; and the clinicians, who often d ism iss n e c e ssa ry b asic in fo rm atio n gained by researchers as irrelevant to their clinical practice, failing to realize that it is this inform ation that will u lti m ately guide their therapy. Fortunately, there are many on both sides who do not share either of these polarized attitudes. An increased awareness of our need for 732 ■ JADA, Vol. 108, May 1984
1. Pollman, L. Sounds produced by the m andibu lar joint in young men. J Maxillofac Surg 8:155-157, 1980.
TM J + MPD? □ Dr. Farrar’s (Letters, October 1983) and Dr. Bobier’s (Letters, February 1984) posi tions concerning myofascial pain dys function (MPD) represent two common viewpoints. The term MPD syndrome has been ac curately defined and used to describe a particular condition for more than two decades. The term as currently used does not include disease processes w ithin the tem porom andibular joint (TMJ). I believe it w ould be m ost difficult to redefine a term that is so commonly used, w ithout causing a great deal of confusion. There fore, I believe the term MPD syndrome should rem ain as defined w ithout altera tion. To describe patients’ symptoms w ith out lim iting the description to a previ ously defined term, I suggest the term “Orom uscular pain.” The term is defined as “pain propagating from the muscles that are involved in the m ovem ent or stabilization of the m andible.” The pain from MPD syndrom e and from a TMJ condition can be included w ithin the term orom uscular pain. The m echanism of orom uscular pain that results from MPD has been extensively described in the literature and does not need to be dis cussed here. H ow ever, the m echanism th at p ro duces oromuscular pain in patients w ith internal derangem ent can be briefly dis cussed. In the healthy condition, the forces of m astication w ithin the TMJ are carried by the articular disk. W hen the disk is prolapsed forward, the condyle im pinges on the delicate and highly in nervated retrodiskal tissue. The low level of pain w ithin the joint elicits high levels of m uscular splinting to protect the deli cate tissue. The m uscular splinting pro duces symptoms often identical to MPD syndrom e, but not the result of MPD syn drome. It should be em phasized that m any TMJ problem s can produce m uscular splint ing. The majority of patients with internal derangem ents seldom isolate the source of pain to the TMJ. However, w hen the joint is reduced to a stable, stress-bearing position, the oromuscular pain rapidly subsides. Conversely, patients w ith MPD syndrom e may experience interm ittent
TMJ pain. Therefore, the presence or ab sence of TMJ pain is not diagnostic. Because muscles propagate the pain, orom uscular pain can result from MPD syndrom e or problems in the area. Con sequently, a w ide variety of therapies have been successfully used to relieve orom uscular pain. The variations of suc cessful therapies have ranged from m edi ta tio n to su rg ery . T he a b a tem en t of symptoms is the result of the tendency of the particular procedure to relieve the m uscle spasms that are propagating the pain. Ultimately, the long-term resolu tion of either condition m ust depend on arresting the disease process. .. . We need a term that includes MPD syn drome and TMJ problems. Both condi tio n s affect the m anner in w hich the m andible articulates w ith the skull. It w ould seem natural to refer to this dys functional relationship as sim ply m an dibular dysfunction. Regardless of what we call the disease process, we m ust rec ognize the validity of both concepts. By doing so, we w ill be able to provide our patients w ith the best possible care. JAMES N. ROSS, DDS BRENHAM, TEX
TM treatment □ T he co n tro v e rsy s u rro u n d in g the treatm ent of tem porom andibular disor ders w ill not abate until the dental com m unity insists on the same rigor d e m anded by other scientific disciplines. We can all agree that patients w ith tem porom andibular problems have some m ix of c o n trib u tin g s tr u c tu r a l a n d psychologic com ponents. The m u lti faceted nature of the problem may require h elp from other h e alth professio n als (such as physical therapists). Surely we are obligated to treat objec tively those aspects of the problem that we can quantify. With the ready availabil ity of the m andibular kinesiograph and the electromyograph, there is sim ply no excuse for c o n tin u ed conjecture and speculation. These instrum ents . . . yield reproducible, clinically useful structural inform ation. T his inform ation can be tra n sla te d into specific, q u a n tifia b le treatm ent for the patient. As dentists, we owe our patients at least this much. . . . STEPHEN C. GLOVER, DDS HAYS, KAN
N2O and chemically dependent patients □ The article by Drs. Duncan and Moore (February) reviewing adverse reactions to nitrous oxide fails to m ention a signifi cant danger to the recovering chemically d e p en d e n t p atient. (I in c lu d e the al coholic patient in the term “chemically dependent.”)