Treating Temporomandibular Disorders in the 21st Century:

Can We Finally Eliminate the “Third Pathway”?

Charles S. Greene, DDS Within the orofacial pain discipline, the most common group of afflictions is
Department of Orthodontics temporomandibular disorders (TMD). The pathologic and functional disorders
University of Illinois at Chicago College
of Dentistry included in this condition closely resemble those that are seen in the orthopedic
Chicago, llinois, USA medicine branch of the medical profession, so it would be expected that the same
principles of orthopedic diagnosis and treatment are applied. Traditional orthopedic
Daniele Manfredini, DDS, PhD
School of Dentistry therapy relies on a “Two Pathway” approach involving conservative and/or surgical
Department of Biomedical Technologies treatments. However, over the course of the 20th century, some members of the
University of Siena dental community have created another way of approaching these disorders—
Siena, Italy referred to in this paper as the “Third Pathway”—based on the assumption that
signs and symptoms of TMD are due to a “bad” relationship between the mandible
Correspondence to: and skull, leading to a variety of irreversible occlusal or surgical corrective
Prof Dr Daniele Manfredini
Via Ingolstadt 3 treatments. Since no other human joint is discussed in these terms within the
54033 Marina di Carrara (MS) orthopedic medicine communities, it has become progressively clear that the Third
Italy Pathway is a unique and artificial conceptual creation of the dental profession.
Email: [email protected] However, many clinical studies have utilized the medically oriented conservative/
surgical Two-Pathway model to diagnose and treat TMD within a biopsychosocial
Submitted May 9, 2019;
accepted April 8, 2020. model of pain. These studies have shown that TMD comprise another domain of
©2020 by Quintessence Publishing Co Inc. orthopedic illness that requires a medically oriented approach for good outcomes
while avoiding the irreversible aspects of the Third Pathway. This review presents
historical and current evidence that the Third Pathway is an example of unorthodox
medicine that leads to unnecessary overtreatment and further proposes that it is
time to abandon this approach as we move forward in the TMD field. J Oral Facial
Pain Headache 2020;34:206–216. doi: 10.11607/ofph.2608

Keywords: dental occlusion, jaw repositioning, orthopedics, temporomandibular

disorders, TMD

T
here is one trend in dentistry of which every dentist must be aware:
The profession is growing ever closer to the medical profession in
a variety of ways. The scientific basis for diagnostic and treatment
procedures relies on the same fundamental biologic principles, and the
clinical activities in both professions must be proposed and defended
on that basis. Thus, within all undergraduate dental colleges around
the world, dental students are receiving increasing exposure to medical
information that will influence how their patients should be evaluated.
Obviously, this leads to dental treatment protocols for each patient that
must take such information into account.
The two postgraduate dental disciplines with the deepest and most
sophisticated relationships with the medical profession are oral med-
icine and orofacial pain. Within the orofacial pain discipline, the most
common group of afflictions is temporomandibular disorders (TMD),
which are a diverse set of musculoskeletal conditions involving the
temporomandibular joints (TMJs) and their related structures.1 This
group closely resembles the pathologic and functional conditions com-
monly seen within the orthopedic medicine (OM) branch of the med-
ical profession. Consequently, the principles of orthopedic diagnosis
and treatment can be expected to play a significant role in the clinical
management of TMD patients. However, unlike most other common
orofacial pain conditions, TMD have been distinguished by a history
of controversies going back nearly 100 years that continue to have a

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 Greene et al

pernicious effect on the practice of caring for such Third Pathway is a unique and artificial conceptual
patients.2,3 creation arising from the dental profession based on
This paper discusses the traditional OM ap- a biologic and mechanical viewpoint that deserves
proaches to management of medical orthopedic to be challenged. The authors intend to show, by
problems, described as the “Two-Pathway” model, reviewing the available evidence, that this is indeed
and then contrasts this approach with what is hap- the case, and further intend to argue that it is time to
pening in some dental communities. In the Two- abandon this approach as we move forward in the
Pathway model, strategies to manage patients in the TMD field.
clinical setting belong to either a conservative or a
surgical group of treatment. Why Did the Dental Profession Create a
The conservative medical approach incorpo- Third Pathway?
rates many noninvasive modalities as well as many Establishing a Diagnosis. Since no other branch of
self-management strategies. Several different adjec- the medical profession has proposed a malpositioning-­
tives are used to describe the benign, reversible, and repositioning approach to diagnosing or treating
nonradical nature of these approaches, with some other human joint disorders, it would be expected
words that are merely descriptive and others that are that the TMJ has some unique features that make it
more judgmental. The other approach is the surgical possible, and even attractive, to analyze TMD pa-
domain, where again a variety of procedures may be tients in such a framework. The most obvious ana-
utilized (ranging all the way from various intracap- tomical feature is the fact that no other joint has a
sular interventions to total joint replacements), and, definitive stopping mechanism external to the joint
again, for which a variety of descriptive and judgmen- structures that requires the joint to move into a spe-
tal adjectives are used. However, this is not a binary cific position upon “seating” of the opposing parts.
choice model, but rather a continuum or spectrum of This “stop” occurs when the maxillary and mandibu-
possible clinical approaches to both diagnosis and lar teeth (which are located several inches away from
treatment, with the utilization of many reasonable the TMJs) meet in maximum intercuspation (MIP). In
combinations of and compromises between these healthy dentate patents, teeth meet in a precise and
two approaches as medical practitioners deal with repeatable manner, and this event will determine with
each individual case. great precision and repeatability where the mandib-
However, when it comes to TMD, the dental ular condyle will end up relative to the skull when the
profession has created another approach in which mouth is fully closed.
neither of these pathways plays much of a role. Therefore, when patients began to report to their
That pathway, which will be referred as the “Third 20th century dentists that they were having symptoms
Pathway,” is based on three assumptions4–6: involving the TMJ region, it was not entirely unreason-
able to hypothesize that their joints and muscles were
1. The mandible-to-skull relationship at the condylar not comfortable due to some malalignment of the
level may not be “good” (also described as dental occlusion. Oddly enough, this kind of thinking
misaligned, malpositioned, acquired, nonideal, arose more from the early work of an otolaryngologist
suboptimal, etc). named Costen than from any dental experts. Costen
2. This relationship can be analyzed by a variety of observed that many patients who reported facial pain
so-called “diagnostic” methods, ranging from in his practice were either partially or fully edentu-
pushing on the chin to measurements using lous and thought that mandibular overclosure was
sophisticated electronic devices. the reason for developing symptoms.7 Subsequent
3. If the existing jaw relationship is deemed to be occlusal and skeletal disharmony theories proposed
“bad,” then it can be improved by a variety of by many dental clinicians were mostly variations on
irreversible dental techniques, ranging from this theme, with the macro-overclosure replaced by a
occlusal adjustments to orthognathic surgery. variety of mini-disharmonies (occlusal interferences,
deep bites, crossbites, etc). Many narrative and sys-
It should be pointed out that no other human joint tematic reviews over the past decade have comment-
is discussed in these terms within the OM medical ed on this topic.8–10
community. No physician questions whether your Because both occlusal relationships and TMJ re-
knee or shoulder is in the right place or correctly lationships could be tentatively measured using many
aligned, or whether the femur of your hip is proper- clinical techniques, this kind of mechanistic thinking
ly seated in its acetabulum. Moreover, there are no inevitably led to a variety of analytic procedures, rang-
specific OM treatment protocols designed to per- ing from simple chin manipulations to complex kine-
manently reposition any other joints into some kind siographic recordings. For instance, radiographs of
of “better” relationship. Therefore, it is clear that this the TMJ could be measured for concentricity of the

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Greene et al

condyle-fossa relationship, or articulators could be with self-referenced treatment theories based on

used to provide a bench-top view of the occlusal the interpretation of “diagnostic findings” produced
relationships based on various methods of recording. using various unproven diagnostic procedures and
These approaches were proposed for diagnostic pur- protocols.
poses despite the fact that no baseline values or nor-
mality ranges existed for determining what a “good” What Does the Literature Say About the
or “bad” condyle position ought to be, while ignoring Third Pathway?
the fact that TMJ functional anatomy cannot be repro- Throughout most of the 20th century, the dental
duced by articulators. All of these measurement and literature has described the above procedures in
evaluation systems had a built-in bias about what was terms of clinical concepts and protocols rather than
biologically acceptable so that clinicians could render by presenting controlled clinical trials and stud-
judgements about their findings in several ways. ies. Scorecards of successful case outcomes were
Treatments Based on Diagnosis. Once the idea a frequent feature of such papers. For most of that
was accepted that some “negative” features of a pa- century, the focus was on myogenous and arthrog-
tient’s MIP could be a major etiologic factor in the enous pain conditions, with little or no attention paid
development of a TMD condition, it was then logical to the articular disc. Near the end of that century,
to utilize various dental techniques and procedures attention shifted more to the topic of TMJ disc dis-
to “correct” that relationship.11 Of course, this also placements, and articles began to focus on how to
meant that the original TMJ position would now be treat these conditions. For the sake of brevity, this
permanently altered. In some cases, this irreversible article will not cite or summarize the hundreds of old
approach was the only treatment provided, with no case reports and anecdotal papers dealing with early
preceding attempts to relieve pain, reduce inflam- uses of splints and jaw repositioning methods as de-
mation, or relax sore muscles. Some other clinicians scribed in the above section for treating muscle and
preferred to begin their TMD treatment with various joint pain. Instead, the focus of this literature review
conservative measures (such as medications, phys- was on one specific corner of the TMD universe, the
ical therapy, home care, etc) to relieve symptoms Third Pathway approach to recapturing anteriorly dis-
and to identify a purported “ideal” mandible posi- placed discs, in order to demonstrate how this model
tion before initiating any irreversible treatment. This has influenced clinical practice in the TMD field.
approach became known as the Phase 1–Phase 2 With this objective in mind, a systematic
method and included a wide variety of treatment pro- search was performed in the Medline database on
cedures. Approaches (with or without a Phase 1) led June 4, 2019, to identify clinical trials that compared
to irreversible modifications to the dentition; for exam- the treatment effectiveness of permanent mandible
ple, as soon as the initial diagnosis was “established,” repositioning (MR) strategies to any other treatment
a complete occlusal adjustment (equilibration) could modalities for patients with TMJ disc displacement.
be performed, a complete orthodontic correction Out of more than 18,000 results retrieved with the
could be initiated, or a complete full-mouth recon- keyword “temporomandibular disorders,” 172 arti-
struction could be carried out. cles remained after combining that keyword with “jaw
However, the most commonly used treatment repositioning.” Of these, 157 papers were left after
modality in this mechanistic framework was the oral limiting the search to clinical trials, but even the 15
appliance (splint) approach because it was argued remaining articles were not specifically designed to
that the response to such treatment would determine address the topic of mandible repositioning for TMD
what subsequent steps must be taken. These appli- purposes.
ances were variously described as jaw muscle relax- In general, studies on repositioning strategies are
ers, deprogrammers, joint unloaders, bite openers limited to early papers on the use of anterior repo-
for establishing a new vertical dimension of occlu- sitioning (AR) appliances that aim to recapture the
sion (VDO), and other labels based on the person- disc and improve symptoms in patients having disc
al concepts of each clinician. Since the MIP in all of displacement with reduction.12–15 Some investiga-
these procedures was being temporarily altered by tions have reported that joint sounds can be reduced
wearing a splint, any positive responses in terms of more with AR appliances than flat appliances, which
symptomatic improvement were seen as indicators is an implicitly obvious finding based on the rationale
of (1) the validity of the initial diagnostic and etio- of using AR to place the condyle under the displaced
logic theory, and (2) the need for making permanent disc. However, no literature is available that confirms
changes in jaw position based on the new occlusal/ the long-term superiority of any definitive disc-repo-
jaw relationship. sitioning strategies in comparison to conservative
In short, the entire conceptual framework of the approaches for pain management in such cases.
Third Pathway was based on circular reasoning Over 30 years ago, some authors suggested that

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 Greene et al

AR strategies failed to take into account the tri-di- Third Pathway by appraising it in terms of medical ne-
mensional features of the joint while also ignoring the cessity and biologic plausibility.
fact that factors other than disc position contribute
to pain symptoms.16,17 In addition, the progressive in- Medical Necessity and Biologic Plausibility
crease in knowledge regarding the natural course of If the Third Pathway, which relies on analyzing TMJ
TMJ clicks has shown that most do not progress to a relationships and repositioning the mandible, is tru-
more serious TMJ disorder. Together with the emerg- ly valid and worthwhile as a treatment approach for
ing observations that disc displacement is frequently TMD signs and symptoms, it should meet the criteria
accompanied by adaptive morphologic changes (es- for being medically necessary and biologically plau-
pecially in the retrodiscal tissues), this has disman- sible for some or all of the patients suffering from
tled the rationale for targeting treatment toward disc these conditions—in other words, it should be possi-
recapture, thus diminishing the potential indications ble to demonstrate through clinical research that this
for the use of AR appliances. approach is not only biologically plausible, but also
In summary, the findings from the literature re- that it produces positive results for some or all TMD
viewed in this search can be summarized as follows: patients that cannot be achieved by other means.
This section will consider whether that evidence has
• Early reports of positive outcomes regarding the been produced.
effectiveness of MR reflect a misunderstanding A recent paper by Greene and Obrez has raised
regarding the treatment targets of pain reduction the question of medical necessity directly in its ti-
and avoiding development of joint degenerative tle: “Treating Temporomandibular Disorders with
changes. Ultimately, the important studies on Permanent Mandibular Repositioning: Is It Medically
these phenomena show that recapturing the TMJ Necessary?”18 The article discussed six criteria for
disc is not necessary to reduce pain, reduce medical necessity and concluded that the concept
future degenerative joint disease problems, or of mandibular repositioning did not sufficiently satisfy
establish a definitive stability of the disc position. any of them:
• In the short term, there are some clinical
suggestions that AR appliances may be superior 1. The medical condition (ie, mandibular
to flat appliances in providing pain relief in malpositioning) is generally not recognized as a
patients having disc displacement with reduction. valid health problem or disease.
It is biologically plausible that this outcome has 2. The diagnostic tests used to assess whether
more to do with capsular distension and load the patient has this condition are not valid with
change than any actual improvement in condylar acceptable specificity and sensitivity.
position or disc-condyle relationships, thus 3. The patient’s condition will not get worse unless
making permanent condylar repositioning again a specific Third Pathway procedure is done.
not recommendable. 4. The clinical procedures required for MR do not
• Well-controlled comparative studies have never have specificity for addressing the patient’s
been performed over the years to see if one particular problem (eg, symptoms of TMD).
group (ie, a group treated with conservative 5. The procedures are not clinically efficacious for
therapies) shows better or worse outcomes than managing TMD problems according to evidence-
another group undergoing MR treatments. based criteria (ie, they could be effective due to
• There have been prospective studies to deter- other reasons, such as placebo effects or natural
mine whether presymptomatic dental procedures fluctuations).
(equilibration, orthodontics, orthognathic surgery, 6. It has not been demonstrated that most TMD
bite opening, etc) would prevent later onset of cannot be generally resolved by performing less
TMD conditions, and the outcome evidence is invasive procedures that do potentially have high
almost entirely negative for such studies. benefit-to-risk ratios.

Thus, the available evidence suggests that the One might think that well-controlled comparative
Third Pathway approach for TMJ repositioning has studies would have been performed over the years
not been proven necessary for treating either simple to assess whether a group of TMD patients treated
muscle or joint TMD problems, nor for the long-term with conservative therapies shows better or worse
treatment of displaced disc conditions (ie, disc re- outcomes than another group provided with MR
capture), even after decades of practice. In the ab- treatment. However, no such side-by-side study has
sence of such evidence, it seems reasonable instead ever been published, and it is doubtful that an insti-
to discuss the possible clinical usefulness of the tutional review board from any academic institution

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Greene et al

would approve such a study today in light of current a condylar position that looks “wrong.” Likewise, a
knowledge. deprogramming splint may produce muscular re-
However, it bears reminding that the paper by sponses that allow the condyles to wander some-
Greene and Obrez does not rule out the possibility where further backward or forward from their original
that some patients may need major occlusal modifi- position. It must be kept in mind, however, that all of
cations for a variety of dental reasons. Every patient these findings are self-referential, which means that
who undergoes orthodontic or reconstructive den- they are based on the original assumptions that led
tal treatment will have both a new TMJ position and the clinician to make that type of assessment in the
new occlusal relationships established as a routine first place. Thus, it is not surprising that there is a
component of these complex processes. In addition, complete absence of literature in support of those
a person who has had a severe form of degenera- theories.25–29 Therefore, this type of circular logic
tive TMJ arthritis (eg, juvenile rheumatoid arthritis, cannot be cited as proof that the patient has a mal-
idiopathic condylar resorption) will certainly need to positioned TMJ and will require irreversible occlusal
have a new occlusion established once the prima- changes to correct it.
ry disease is under control. However, none of these Another common argument to support the need
scenarios are related to the common arthrogenous for MR comes from positive responses to oral appli-
or myogenous forms of TMD, so they should be dis- ance (OA) therapy. As early as the 1970s, Ramfjord
cussed under the rubric of conventional dentistry. and Ash were claiming that successful OA therapy
proved that the occlusion was the original cause
Are There Subgroups of TMD Patients Who for developing a TMD condition and that this proof
May Need Third Pathway Treatment? was sufficient to justify irreversible equilibration and
Because TMD are a heterogenous group of clinical restorative procedures.30 Similar arguments have
problems, there is no single treatment protocol for been made for bite-opening appliances used in pa-
managing all types of patients, especially considering tients who were presumed to have loss of VDO (or
the well-known complex interface between Axis I (ie, “bite collapse”) and therefore would need to have
muscle or joint disorders) and Axis II (ie, psychosocial bite-opening occlusal work if their symptoms im-
issues) findings.19,20 This reality has been well recog- proved with OA treatment. It was not until the last
nized in the 21st century literature on these topics. third of the 20th century that researchers began to
Publications like the Diagnostic Criteria for TMD (DC/ demonstrate that positive responses to OA therapy
TMD), the American Association of Orofacial Pain did not require a second phase of irreversible den-
(AAOP) Guidelines, the American Association of Oral tal treatment.31–34 As a result, the idea of considering
and Maxillofacial Surgeons (AAOMS) Parameters of OAs to be valuable primarily as symptom-relieving
Care, and the European Academy of Orofacial Pain orthotic devices has become widely accepted and
and Dysfunction (EAOPD) recommendations provide remains the standard rationale among TMD experts
much information to clinicians about how to deal with today.35,36
this variety of clinical challenges.21–24 None of these Finally, there is the argument presented by some
guideline documents advocate the Third Pathway ap- that failure to respond to currently recommended
proach as discussed in this paper. conservative TMD treatments provided within a bio-
Nonetheless, it seems appropriate to ask the psychosocial framework could be the justification for
question: Is there a subgroup of TMD patients who “escalating” to the more aggressive forms of TMD
might have a malpositioned condyle-fossa relation- treatment. The general concept of escalating from
ship who would then benefit from the Third Pathway conservative treatment protocols to more aggressive
approach to treatment? One way of providing an an- ones is well-accepted in many areas of the normal
swer would be to compile a list of subjective symp- Two-Pathway system of medical practice, but it can-
toms that would indicate the need for MR treatment, not be applied to every type of medical condition—for
but until now, no reputable group of researchers or example, there are almost no examples of headache
clinicians has produced such a list. A different pic- conditions that would be improved or eliminated by
ture emerges, however, when discussing so-called some kind of surgery, no matter how poorly the pa-
objective signs and findings. For example, manipula- tient is responding to standard medical approaches.
tion of the mandible might produce a finding of cen- On the other hand, the orthopedic field contains
tric relation (CR) that does not coincide with the MIP many examples of legitimate escalation from con-
of the patient’s teeth. This is usually is described as servative treatment to a variety of more aggressive
a CR-MIP discrepancy, and the difference is called treatments. However, this applies almost entirely to
a “slide.” Similarly, electronic “diagnostic” machines arthrogenous conditions or to spinal disc and nerve
may find a discrepancy between “neuromuscular” conditions (in back and neck pain problems), not
CR and MIP, while radiographic images may show to most common myogenous disorders. As for the

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 Greene et al

TMJ, surgery can be a first-choice approach that often become obsessive about pursuing various
is indicated for select joint disorders rather than a kinds of occlusal treatment.40–42
second-step, unspecific attempt to provide pain re- • Surgical or occlusal treatments to reposition
lief.37–39 However, failure to respond to a variety of the mandible may be attempted in patients who
well-conducted clinical procedures (eg, medications, primarily have either myogenous TMD or some
physical therapy, self-care, or OA) for treating both other form of orofacial pain referred to the TMJ
arthrogenous and myogenous conditions is not rare area. This will usually produce not only a failure
in TMD pain patients. When symptoms of myogenous to improve, but also a likelihood of worsening the
origin (both local types and general conditions, such entire facial pain situation.43
as fibromyalgia) are the main problem, there is no • There is a tendency for peripheral pain problems
surgical option available to use as an “escalation” for to become central sensitization problems over
treating those patients. time. Delays in providing appropriate treatment or
Unfortunately, the Third Pathway offers dentists wasting time and resources on a Third Pathway
an alternative for analyzing and treating TMD patients approach will often lead to this kind of negative
who are not responding to currently recommend- outcome. This can lead to chronification of
ed conservative treatment protocols, regardless of pain, which is one of the greatest challenges
whether their problems are arthrogenous or myog- faced by all clinicians treating pain. Predictors
enous. Given the arguments presented above about for that outcome are limited, but it is known
the general validity of this Third Pathway, this must that, among other things, misdiagnosis,
be considered as an example of unorthodox medicine undertreatment, delays in treatment, failure to
rather than an example of true escalation. Because address psychologic impairment, and multiple
the use of Third Pathway treatments is still widely ad- invasive treatments enhance the risk of chronic
vocated, the possible side effects and negative con- pain development.44,45 Since Third Pathway
sequences of that approach must be discussed next. treatments are usually carried out over a
fairly long time, this adds to their potential for
What Are the Risks of Third Pathway increasing this risk.
Treatment Procedures? • Many patients have reported a worsening
It is difficult to imagine that any set of irreversible of their pain due to the bite-changing and
treatment protocols would not carry some risk with jaw-repositioning aspects of Third Pathway
them. In medical circles, these are referred to as risk/ treatment.46,47 This kind of secondary
benefit ratios, and it often can be argued that the po- complication will likely make it even more difficult
tential benefits will most likely outweigh the risks. In to resolve the clinical situation.
many cases, a specific medical problem may require
the use of irreversible therapies, and the risks will Orofacial pain experts who work in university
simply have to be explained to the patient as part of and hospital clinics around the world have reported
the informed consent process. seeing all of these above phenomena in their patient
So, the question is: Where does the Third populations. Because they often function as tertiary
Pathway approach, as described in this paper, fall care centers, they probably see more of these nega-
on that risk/benefit spectrum? Given the weak evi- tive scenarios than any normal dental practice would
dence for this approach and the existence of more encounter.
conservative and traditional treatments for managing
TMD, the following list of outcomes should be seri- Why Does the Third Pathway Continue to be
ously considered. Because each of them has been Widely Used in the TMD Field?
discussed extensively in the dental literature, they will In spite of the lack of scientific support, concepts
only be briefly described here: and treatments based on the Third Pathway have
not yet been fully abandoned in orofacial pain med-
• Development of occlusal awareness/ icine. On the contrary, they are still widely accepted
dysesthesia/hypervigilance is not uncommon and utilized clinically by many members of the dental
in patients who have undergone extensive community. There are at least six reasons for this par-
occlusion-changing procedures, regardless adoxical situation: (1) the type of disease; (2) history
of whether they were for routine dental of early concepts; (3) cultural beliefs; (4) social rea-
processes—such as orthodontics or full-mouth sons; (5) the market of self-proclaimed experts; and
reconstruction—or for treating TMD. Despite (6) financial issues.
the fact that there is no guaranteed way to Type of Disease. As discussed in the above sec-
reestablish the original occlusion, such patients tions on diagnosis and treatment, signs and symp-

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Greene et al

toms of TMD are typically fluctuating and mostly pothesize that subjects with high levels of psycholog-
self-limiting, as in the case of many other muscu- ic distress and certain personality profiles as seen in
loskeletal conditions.48–51 Within the Two Pathway many chronic TMD patients may be candidates for a
model, treatment is mainly provided in the form of good placebo response.
symptomatic management, and there is much overlap The average practitioner is used to fixing problems
among many of the treatment approaches directed and to performing inductive reasoning (ie, “I do this, it
toward TMJ or muscle pain relief.52 For arthrogenous works, so I build a hypothesis of action”), without any
pain, dysfunction, and disease, however, TMJ arthro- deductive strategy (ie, “I build a hypothesis of action,
centesis and surgery are two examples of specific and I will test it with comparative trials”). Deductive
treatment modalities.53 Many TMD patients improve approaches are the modus operandi of clinical re-
regardless of the specific treatment approach, while searchers, who are too often negatively described as
a minority of patients progress toward chronicity or “messengers living in ivory towers.” Remarkably, this
persistence of symptoms in a way that suggests they bias occurs despite their extensive clinical expertise
are vulnerable to a poor response to any intervention. and their evidence-based pleas for general dentists
Recent studies suggest that there are some pre- to think as a physiatrist or a neurologist when dealing
dictive factors to explain such outcomes, but they are with TMD and orofacial pain patients.
difficult to identify early in the clinical situation.54–56 History of Early TMJ Concepts. Unfortunately,
This means that, at least to a certain extent, treatment the impact of the original Costen theory of mandib-
outcome is achieved “by chance”; ie, independent of ular overclosure and jaw malpositioning is still alive
the putative causal reasons.57 This has important im- and well 85 years after its proposal. It is not infre-
plications for Third-Pathway approaches that require quent for an orofacial pain expert to receive patients
irreversible changes of dental occlusion and condyle who are referred by some general physicians or other
positioning within the TMJ fossa because they are nondental professionals because of the presence of
based on the false premise that such treatment is Costen’s syndrome. This is not just an old name for a
indicated if the patient responded well to the initial disease, but a concept that survives in many medical
reversible treatment. When clinical improvement is and allied health schools, where very limited infor-
produced by this Phase 1–Phase 2 approach, both mation on TMD is often provided. As for the dental
the dentist and patient may be persuaded that the profession itself, the figure of the “gnathologist” as
entire treatment package was both necessary and the dental professional who takes care of jaw dys-
responsible for the positive outcome. function by correcting mechanical problems in the
Such paradoxes are well known to expert TMD teeth-to-mandible position is a myth that should be
and orofacial pain practitioners. The majority of cur- past its time.61
rently recommended treatments share several com- Today, stomatognathic physiology is a much
mon objectives: in the physical domain, there is a broader field than the classical gnathologic view of
focus on restoration of jaw function, achievement of mechanical concepts of CR and cast mounting on
dental and orthopedic stability, and relief from pain. articulators for diagnosing purported dysfunction.
In the psychosocial domain, improvement in quality of Based on that, it is recommendable that international
life, reduction in psychologic distress, and improve- academies and recognized experts/board members
ment in pain-related impairment are fundamental must attempt to increase cross-specialist knowl-
targets independent of the Axis I diagnosis. Due to edge on this issue. This is already occurring in var-
the generally benign natural course and good remis- ious national and international pain groups (eg, the
sion with mild self-care regimens, symptomatic im- International Association for the Study of Pain [IASP],
provement can be partially attributed to the familiar International Association for Dental Research/
“regression to the mean”; ie, the tendency for severe International Network for Orofacial Pain and Related
initial symptoms to get better over time.58 Disorders Methodology [IADR/INfORM]), but not
Such observations are supported in part by see- within most dental specialties or in other disciplines.
ing “waiting-list” patients improving during certain Cultural Beliefs. A side effect of this historical
clinical trials despite not yet receiving any treatment. heritage is the widespread cultural belief that pain in
Moreover, recent neurophysiologic advances have the face depends on something being wrong in the
given the placebo effect the deserved dignity of be- teeth-to-mandible position and other similar mechan-
ing recognized as an active treatment, the positive ical theories. As a result, the vast majority of patients
effects of which are related to the patient’s expec- seeking TMD advice still believe they have some kind
tations and go far beyond the simple psychologic ef- of mandibular malpositioning or teeth misalignment.
fect on the patient’s attitude toward the disease.59,60 Patient forums on the internet, and even associations
At present, there are no instruments to predict the of people having TMD symptoms, have been creat-
profiles of placebo responders, but one might hy- ed to share experiences and find reciprocal support

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 Greene et al

while searching for the best advice on how to find the and educational activities of clinical interest for gen-
right dentist to fix their own mandible position. eral dentists.
Social Issues. A possible reason for some pa- Financial Issues. For years, the TMJ has been
tients to keep believing in the Third Pathway is that jokingly referred to as “the money joint.” Self-
sometimes people are afraid of admitting emotional proclaimed experts have organized courses on occlu-
and psychologic issues. It is not rare that a patient sal dogmas and have sold Third Pathway treatments
with TMD pain due to stress sensitivity–related mus- that can produce thousands of dollars/euros for the
cle tension prefers to give credit to some mechanical dentists who follow their teachings. In addition, there
theory instead of discussing inner issues. The fact are many academies, institutes, and study clubs that
that many patients with chronic pain often present exist to promote Third Pathway approaches to TMD
with a complex medical history, in addition to the management.
presence of comorbid conditions (eg, headache, This attitude is not likely to change in the near fu-
irritable bowel syndrome, gastritis, dysmenorrhea, ture, especially given the five other reasons of Third
affective disorders), further complicates their inter- Pathway survival listed above. However, it would be
action with the dentist.62,63 Therefore, instead of dis- interesting to see a future detailed discussion based
cussing such issues with their dentist—which could on the emerging concepts of dental marketing and
create a fundamental therapeutic partnership by productivity. Indeed, there could be arguments pre-
sharing responsibilities with the caregiver64—those sented in support of the idea that providing current
patients may tend to see the dentist only as the pro- TMD standard-of-care treatments (ie, conservative
fessional figure who must find a mechanical solution approaches) may be even more productive in terms of
to fix the problem. net income than correcting dental occlusion. Despite
Market of Self-Proclaimed Experts. The current the large amount of money that a full-mouth resto-
era of dental practice is characterized by a positive ration approach based on the Third Pathway can
interchange of knowledge among professionals with generate, an analysis of costs (eg, lab technicians,
different expertise. In many countries, the main acad- materials, staff, total time needed [cost per hour])
emies organize yearly multidisciplinary events to fa- would be interesting to assess the real financial ad-
cilitate communications among experts and provide vantage of following the Third Pathway. For instance,
better management of patients in the clinical setting. marketing analysis could assess the effectiveness of
For instance, orthodontists can frequently attend or- TMD clinics providing an ideal care regimen based
thodontic symposia or congresses with qualified ex- on a simple flat appliance delivery plus three to five
perts lecturing on how to manage the periodontium 30-minute cognitive behavioral therapy sessions
with orthodontic forces, how to understand the sur- by comparing this protocol to Third Pathway clinics
gical difficulties of creating enough space to place spending years of unnecessary time for each patient.
implants, or how to evaluate prosthodontic needs to At present, country-to-country differences in terms of
realize esthetic success after an orthodontic treat- insurance markets make it difficult to provide a global
ment. Such strategies are effective ways of creating picture, but any possible efforts on this delicate issue
a virtuous circle to improve the quality of the pro- could reveal information that may contribute to dis-
fession, and, generally speaking, the presentations couraging irreversible approaches.
meet high standards of quality. It is hard to imagine
a periodontist speaking in front of an important ortho
audience and giving “personal” information not in line Conclusions
with the recognized periodontal academies.
Unfortunately, the situation is quite different when In this paper, the term “Third Pathway” was intro-
it comes to “expert” speakers on TMD presenting duced as a shorthand label for the early traditional
at various congresses or meetings. An audience of method of managing TMD, which of course is still
dentists may be exposed to some excellent and cur- strongly persisting in the profession. That method in-
rent concepts by certain speakers, while others may cludes diagnostic assessments of occlusal, skeletal,
be exposed to outdated and very personalized theo- and TMJ relationships as likely factors in the etiolo-
ries. Similarly, at the same congress where dentists gies of various TMD conditions, leading to a variety
can listen to top-tier periodontists or prosthodontists, of bite-changing and jaw-repositioning therapies. It is
they also may be offered a debate on occlusion and based on concepts and procedures that are unique
TMD, with a series of anecdotal claims by profes- to the dental profession and the TMJ because no
sionals without any certified education in TMD and/or other branch of orthopedic medicine utilizes such as-
orofacial pain. This makes it even more fundamental sessments or treatments for other body joints.
for the orofacial pain academies to organize events

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Greene et al

Table 1 Summary of Main Arguments and Reasons for Abandoning the Third Pathway in the
Management of TMD
Argument Reason
The TMJ is just another human joint; follow orthopedic medicine Conservative strategies and, when required, surgical interventions
strategies (ie, Two Pathway model) to manage typical TMD provide better clinical outcomes for TMD patients within the
problems. Two-Pathway model.
Signs and symptoms of TMD are not due to a “bad” relationship Normative values of a “good” TMJ relationship do not exist in
between the mandible and the skull nor to nature due to biologic variability, and “malocclusions” are present
so-called “occlusal disharmonies.” in many individuals independently of the presence of TMD.
Purported “biometric” strategies to determine the ideal condyle A tentative centric relation–maximum intercuspation discrepancy
position within the glenoid fossa, whether based on muscle- can be identified in all individuals and differs depending on the
or joint-oriented manual or instrumental manipulation approaches, analytic technique used, so it cannot be used as a confirmation of
are based on theories and speculations from various individual any specific TMD diagnosis.
“experts.”
The entire theoretical framework of the Third Pathway is based Clinical success of Third Pathway strategies can occur, but
on circular reasoning; the “diagnostic” findings inevitably lead to those outcomes are not related to the presumed underlying
irreversible treatments. mechanical reasons. Failure to consider the type of disease,
placebo effects, spontaneous remissions, and psychologic
issues are just some of the confounding factors that affect the
interpretation of successful clinical outcomes.
Patients may be exposed to unnecessary overtreatment when Risks of Third Pathway treatment include the possible
Third Pathway methods are used for diagnosis and treatment. development of occlusal dysesthesia and hypervigilance,
in addition to chronification of pain due to central sensitization.

Over the past 50 years, however, that concept has sufficient evidence to justify its routine use in dental
been challenged from two different directions. First, practice. For those who wish to argue the opposite
there have been many studies questioning the validity viewpoint, the burden of proof to overcome this pow-
or utility of these so-called “diagnostic” findings (eg, erful evidence lies with them.
“good” or “bad” occlusal or joint relationships). These
studies have led to concerns about the medical ne-
cessity of performing the irreversible dental treatment Acknowledgments
procedures that are commonly done. Second, a sep-
arate line of research has emerged in which inves- The authors did not receive any funding to prepare this manu-
tigators have totally ignored the Third Pathway and script. The authors declare they have no conflicts of interest.
instead utilized the medically oriented conservative/
surgical treatment model (Two-Pathway approach) to
diagnose and treat TMD. This approach also included References
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