Overtreatment “Successes”—What Are the Negative

Consequences for Patients, Dentists, and the Profession?

Charles S. Greene, DDS Aims: To describe how some management practices in the field of orofacial
Department of Orthodontics musculoskeletal disorders (also described as temporomandibular disorders
University of Illinois Chicago College of [TMDs]) are based on concepts about occlusal relationships, condyle positions,
Dentistry
Chicago, Illinois, USA
or functional guidance; for some patients, these procedures may be producing
successful outcomes in terms of symptom reduction, but in many cases, they can
Daniele Manfredini, DDS, MSc, PhD be examples of unnecessary overtreatment. Methods: The authors discuss the
School of Dentistry
Department of Biomedical Technologies
negative consequences of this type of overtreatment for both doctors and patients,
University of Siena as well as the impact on the dental profession itself. Special focus is given to
Siena, Italy trying to move the dental profession away from the old mechanical paradigms for
treating TMDs and forward to the more modern (and generally more conservative)
Correspondence to: medically based approaches, with emphasis on the biopsychosocial model.
Prof Dr Daniele Manfredini Results: The clinical implications of such a discussion are apparent. For example,
Viale Bracci, 53100 Siena
Italy
it can be argued that the routine use of Phase II dental or surgical treatments for
Email: [email protected]; managing most orofacial pain cases represents overtreatment, which cannot be
[email protected] defended on the grounds of symptom improvement (ie, “successful” outcomes)
alone. Similarly, there is enough clinical evidence to conclude that complex
Submitted July 6, 2022; accepted biomechanical approaches focusing on the search for an ideal specific condylar
January 20, 2023.
©2023 by Quintessence Publishing Co Inc.
or neuromuscular position for the management of orofacial musculoskeletal
disorders are not needed to produce a positive clinical result that is stable over
time. Conclusion: Typically, overtreatment successes cannot be easily perceived
by the patients or the treating dentists because the patients are satisfied and
the dentists feel good about those outcomes. However, neither party knows
whether an excessive amount of treatment has been provided. Therefore, both
the practical and ethical aspects of this discussion about proper treatment vs
overtreatment deserve attention. J Oral Facial Pain Headache 2023;37:81–90.
doi: 10.11607/ofph.3290

Keywords: orofacial musculoskeletal disorders, overtreatment, success,

temporomandibular disorders, temporomandibular joint

O
ne of the most gratifying aspects of being a medical doctor,
dentist, or other health care provider (HCP) is when a patient
responds positively to your treatments. However, such out-
comes are not necessarily related to the specific components of your
treatment—indeed, they can occur because you are treating, while you
are treating, or despite the treatments being provided. Distinguishing
from among these three possibilities is one of many challenges facing
all HCPs since all would like to claim the credit for positive outcomes.
Unfortunately, HCPs are not always open minded to considering al-
ternative explanations for treatment success that are unrelated to the
specific modalities being provided. For instance, the possibility of non-
specific improvement due to spontaneous recovery, placebo effects, or
regression to the mean (ie, the severity of the original problem dimin-
ishing over time) may confound our attempts to understand why each
patient got better.
Another potential confounding factor is the issue of how much treat-
ment is actually required to improve or resolve certain medical condi-
tions. Indeed, sometimes a treatment is judged successful because of
symptom improvement, but the patients are actually receiving an over-
treatment for their condition (ie, the symptoms would also have improved

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Greene et al

with less invasive strategies). Thus, when evaluating lines published by several scientific societies and
the effectiveness of a treatment, in addition to the tra- expert groups (eg, American Association for Dental
ditional disputes over conservative vs radical or med- Research; International Association for the Study of
ical vs surgical, we must consider the possibility of Pain; American Academy of Orofacial Pain; European
overtreatment in some cases. Academy of Orofacial Pain and Dysfunction) empha-
Regarding the field of temporomandibular dis- size the usefulness of a biopsychosocial approach
orders (TMDs), as well as several other topics sur- and the conservative treatments typically used in the
rounding the temporomandibular joint (TMJ), this has so-called Phase I, but warn against providing irre-
become an issue of growing concern in the 21st cen- versible dentoskeletal treatments except in rare cir-
tury.1–3 To further complicate matters, the very term cumstances (eg, TMJ surgical procedures with the
temporomandibular disorders has become increas- subsequent need to restore dental occlusion).10–13 A
ingly recognized as a problematic label for the various substantial amount of dental literature supports this
clinical disorders affecting the masticatory system. approach, with relatively high numbers of long-term
Therefore, in this paper, the authors will be using a successful outcomes being reported. Meanwhile,
different nomenclature for the categoric labeling of there is little or no published evidence that Phase II
these conditions: orofacial musculoskeletal disorders adds any benefit in terms of long-term success or pre-
(OMDs). These disorders will be subdivided into two vention of symptom onset or relapse.14–16 Therefore, it
main categories: myogenous problems and arthrog- seems reasonable to conclude that the routine use of
enous problems, with the latter including disc disor- Phase II treatments for managing most OMD cases
ders as well as degenerative diseases. Each of these represents overtreatment, which cannot be defend-
problem areas has the potential for being overtreated, ed simply on the grounds of successful outcomes.
with obvious negative consequences for all involved Similarly, there is enough clinical evidence to con-
parties, including the possibility of treatment failure. clude that a biomechanical approach focusing on
Because the term TMDs appears so often in the den- the search for any ideal specific condylar or neuro-
tal literature, many of the concepts and papers cited muscular position is not needed to produce a stable
in this paper will still utilize that term. and functional result at the end of a prosthodontic or
As Greene and Manfredini wrote in their paper orthodontic treatment.17,18
about the “third pathway,” many OMD patients are still
being treated according to the 20th century paradigm
of correcting occlusal disharmonies and reposition- Historical and Current Concepts of
ing TMJ relationships despite the voluminous research OMD Management
that has challenged the validity of this approach and
the multitude of studies that do not support an etio- Myogenous Disorders
logic association between OMDs and malocclusion, The symptoms arising from muscular problems are
unstable occlusion, and/or occlusal interferences.4 the most common phenomena seen in this field.
Moreover, as Manfredini and Poggio wrote in a paper They range from acute traumatic and hyperfunction-
about prosthodontic planning in patients with brux- al events associated with local myalgia to various
ism and/or TMDs, extensive restorative dental proce- chronic versions of myofascial pain. There may be
dures should not be regarded as a “treatment” for nonpainful symptoms (eg, stiffness, feeling of tension)
these conditions. On the contrary, the clinician should related to muscle fatigue, but pain and functional lim-
be aware that such patients may be more complex itation are the most common reasons for patients to
due to those problems.5 Similarly, the correction of seek treatment. In some cases, a chronic pain condi-
dental occlusion has even been extended by some tion may develop because the neuroplasticity of the
practitioners to the “correction” of body posture ab- nerves serving those muscles has been altered in the
normalities, without this treatment being backed up direction of persistent pain. Conservative treatments
by any solid scientific evidence.6–9 Yet, many patients directed at the muscles themselves as well as the re-
do report feeling better following all the above treat- sultant pain have been broadly discussed in the liter-
ments—but what does that really mean in terms of ature,19,20 so they will not be reviewed here.
actual treatment necessity? The most common form of overtreatment oc-
The terminology used by most dentists who utilize curs when the clinician believes that the origin of the
mechanistic treatments in treating OMD is to call the myogenous problems is due to wrong jaw positions
first part of their treatment protocols Phase I, with var- or occlusal disharmonies; therefore, a more “perma-
ious combinations of splint therapy, pain medications, nent” corrective procedure is purportedly required
and physical therapy. If successful, they then move to maintain a good long-term result. As mentioned
on to Phase II, in which the occlusal and jaw relation- earlier, this is the Phase I-Phase II fallacy, which irre-
ships are irreversibly modified. However, the guide- versibly changes the structural relationships within the

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 Greene et al

masticatory system, and this approach has not been to theoretically “recapture” the disc. In addition, we
shown to be medically necessary to manage symp- have discopexy and disc repositioning operations
toms in the long term.21 being performed in both open joint and arthroscopic
protocols; we have condylotomy operations to “sag”
Arthrogenous Disorders the condyle under the disc; and finally, we see some
The hard and soft tissues that comprise the TMJ are clinicians advocating total disc removal without any
subject to all the diseases and pathologies experi- replacement. Arguments are made that leaving a disc
enced by other joints in the body. These include the displaced in children and adolescents will reduce
simple clinical signs of mild pain upon chewing, which condylar height and cause mandibular asymmetry.
in some cases may progress to more complex con- While this phenomenon may occur in some cases,
ditions associated with persistent pain. Phenomena it is generally a small effect that is easily managed
of acute trauma or hyperfunction may initiate painful by orthodontic treatment. Others argue that condy-
intracapsular symptoms, while more chronic factors lar degeneration and arthritis will occur if the disc is
may lead to various forms of degeneration and arthri- not repositioned, but longitudinal studies show that a
tis (both systemic and local).22 Degenerative changes broad variety of outcomes are possible, ranging from
can be painless or painful, and severe resorption oc- mild bony remodeling in most cases to more severe
curs sometimes due to a peculiar disease known as changes in others. As is the case for many other over-
idiopathic condylar resorption.23 Once again, there is treatments, these procedures aiming to reposition the
a variety of conservative treatments ranging from sim- disc carry the risk of severe side effects and compli-
ple medications to injected compounds, and the rel- cations, while their clinical “success” in reducing pain
atively simple arthrocentesis procedure has provided and dysfunction is not superior to more conservative
relief for many people.24–26 However, overtreatment approaches.36,37
occurs when a surgical intervention is used prema- Within these premises, in the remainder of this pa-
turely or without adequate rationale. It may be easy per the authors will discuss the negative consequences
to persuade a symptomatic patient to allow intracap- of these various types of overtreatment, all of which
sular operations that range all the way to total joint are commonly seen in tertiary care centers where
replacement, and if they are “successful,” then every- orofacial pain experts study and treat such patients.
one is convinced it was necessary. Obviously, it is Of course, overtreatment of OMD cases can result in
true that certain advanced TMJ surgical procedures failures and indeed often does. When that happens,
can sometimes be indicated in cases of severe muti- it is a double tragedy because the irreversible chang-
lating arthrosis or TMJ ankylosis, but they should be es cannot be undone, and the likelihood of the patient
a last resort and have a strong biologic rationale for developing chronic pain is greatly increased. This is-
their usage.27,28 sue has been discussed previously in an article about
Regarding disc disorders, a combination of clini- iatrogenesis being a major factor in the development
cal and imaging data have shown that over one-third of chronic pain,1 but in the present paper, we wish to
of the population may have one or both TMJ discs emphasize the opposite problem: the situation in which
in a nonideal position, usually displaced in a forward treatment has produced symptomatic relief so both the
direction (ie, anterior disc displacement [ADD]), and patient and doctor may be persuaded that the trans-
that such disc positions are not necessarily associ- action was a good one. However, the negative con-
ated with symptoms.29–31 Depending on a number of sequences of this apparent success are relevant and
variables, these discs might make a noise upon mouth could have been avoided by using more appropriate
opening (reduction) or stay in the forward position.32 treatments. This discussion of overtreatment success
The great majority of these tissue derangements are will include the impact on the doctors and the patients,
not painful conditions, and they also are not necessar- as well as the impact on trying to move the dental pro-
ily progressive.33 Some patients will have episodes of fession away from the old mechanical paradigms and
pain, sticking, or locking associated with ADD, while forward to more modern medically based approaches.
others may develop a more serious and persistent Obviously, there are ethical aspects of this discussion
version. Once again, the natural course and conser- about proper treatment vs overtreatment, and they will
vative management of these phenomena has been de- also be considered here.
scribed elsewhere and will not be reviewed here.34,35 
Unfortunately, there has been a rebirth in some
clinical communities of procedures to “recapture” dis- Impact on the Patient
placed discs and reposition them over the condyles.
Without any convincing proof that such procedures Every patient who is experiencing symptoms expects
are necessary or successful in the long term, we two questions to be answered when consulting with
still have various types of oral appliances designed an HCP:

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Greene et al

1. What is happening (ie, what is the biologic for prosthetic or orthodontic situations, the use of cer-
problem and what are its causes)? tain technologic instruments and protocols may re-
2. What should be done to resolve this problem? sult in unnecessary biologic, psychologic, and social
expenses, the discussion of which goes beyond the
Thus, initial diagnosis can be the first step in a scope of this paper.43–49
correct and successful treatment process, but an ex- Other examples of overtreatment may not involve
aggerated diagnosis can lead to overtreatment. For specific changes in dental occlusion. For instance,
example, a symptom of facial pain may be correctly wearing an oral appliance 24/7 for months/years in-
diagnosed as a nonodontogenic neuropathic condi- stead of using it as a transient treatment modality may
tion based on patient history and physical examina- lead to occlusal, orthopedic, and/or neuromuscular
tion, and this condition can generally be managed with changes, as well as induce a psychologic dependence.
various medications. But if the HCP believes that such Similarly, using an oral appliance to “deprogram” the
problems are due to a classical trigeminal neuralgia, jaw muscles to establish the end-of-treatment (Phase
the diagnostic workup will be more extensive than II) mandible position does not have any solid biologic
needed, and the treatment process may escalate all or literature background, but this continues to be a
the way to neurosurgical procedures. belief that is hard to abandon for some communities
In this paper, the focus is mainly on the clinical of practitioners.50
management of OMDs because the same type of Unfortunately, in most cases, patients are not able
distorted diagnostic and treatment processes may be to evaluate the validity of certain complex procedures
seen in this domain regardless of whether the prob- used to carry out their dental treatments based on
lem is myogenous or arthrogenous. For instance, a some TMJ or occlusion dogma. At the conclusion of
patient who is experiencing masticatory muscle pain their elaborate treatment, patients may be satisfied
may be correctly diagnosed by taking a careful history because they felt pain relief in the case of musculo-
and performing an appropriate physical examination, skeletal symptoms or, in the case of extensive dental
and the conservative treatments for such problems procedures, because they have a nice-looking smile
will often produce a good outcome.38 However, some with good masticatory performance. 51–53 But what
patients with OMDs may also be experiencing comor- does this mean for the patients who encounter such
bidity with other pain conditions. In these cases, it is overtreating practitioners, even if they feel better after
likely that central sensitization and nociplastic pain are the treatment process is completed? Consequences
more important than peripheral inputs in the contribu- can include the following:
tion to the clinical picture.39,40 Therefore, a complex
diagnostic workup involving technologic devices and • The expenses involved will be much greater.54
sophisticated imaging for the OMD component may • The length of the treatment process will be much
produce an exaggerated diagnosis of that problem longer.55
while failing to consider the comorbidity issues. • Significant discomfort is likely to be produced
As argued in a previous paper about the “third both during and after the treatment process
pathway,” dentistry is unique in offering a third alterna- because of the invasiveness of the procedures
tive to the usual medical or surgical procedures used themselves. Furthermore, the extensiveness of
to treat other musculoskeletal disorders.4 The third the treatment may increase the risk of posttherapy
pathway involves a diagnostic workup for occlusal problems (eg, persistent dentoalveolar pain,
disharmonies and jaw malalignments, ultimately lead- occlusal dysesthesia, failed root canal treatments,
ing to a series of irreversible bite-changing and jaw- chipped ceramics, and other technical
repositioning procedures. Despite all the research complications.) In addition, patients may report
studies and clinical practice guidelines that deny the difficulty chewing because of the new occlusion
validity of this approach, it continues to be promot- and the altered mandible position.56
ed and used by various dental groups. Such an ap- • The irreversibility of the treatment cannot be
proach is sometimes advocated even in the absence undone, so the following risks may arise if things
of symptoms, with a multitude of instruments and do not go well: Initial success may turn to failure
“philosophies” that are proposed to “diagnose” prob- (recurrence of symptoms)57; major dentistry
lems with either the interarch occlusal relationships or may be poorly done or it may simply fail over
the position of the condyle within the glenoid fossa.41 time58; and occlusal complaints may arise due
This basically leads to the creation of new patients; to iatrogenic dysesthesia, a condition that often
ie, individuals without any real biologic problems who cannot be resolved.59
are instead convinced to start massive dental treat- • Finally, in the case of OMD pain, the wrong
ments for the correction of purported abnormalities.42 message is being communicated to the patient.
Furthermore, even when dental correction is needed Instead of modern pain management that

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 Greene et al

involves both the doctor and patient to reduce soning (ie, from general, controlled observations to
and avoid pain, the patient will believe that all the extrapolation of particular data) on which science
such problems must be “cured” by doctors!60 should be based.62
A side effect of the positive working environment
Therefore, it is reasonable to say that clinical suc- as described above is the resistance to opposing
cess (ie, symptom improvement) is not an adequate viewpoints and emerging new evidence. To put it
barometer for measuring the effectiveness of treat- simply—if it works, why should I change it? For most
ments provided to patients with OMDs. In particular, daily dental procedures, this reluctance is generally
it is now clear that the health and good function of not an ethical or overtreatment problem; instead, it
the stomatognathic system cannot be “diagnosed” is merely a difference of opinion about which meth-
based on theories involving some kind of “optimal” od to use (eg, which bur, which tooth preparation
condylar position, mandibular movement trajectory, strategy, which composite, which root canal treat-
or neuromuscular function. There is a fork in the road ment procedure, which cement). On the other hand,
for choosing between various approaches to treat- this reluctance becomes critical when applied to the
ment, and the patients cannot be expected to know more complex field of pain management, and to some
enough to make a decision about what is being of- degree it also applies to extensive prosthodontic or
fered to them. Therefore, the burden on every HCP orthodontic planning. Indeed, for decades, based
who treats orofacial pain patients is an ethical respon- on the precepts of so-called “gnathology”63—a term
sibility to provide the least amount of best available that is not even included in the MeSH library on
evidence-based care that matches their clinical diag- PubMed—concepts such as centric relation and its
nosis and the needs of their patients. purported biologic meaning have permeated dentist-
ry.64 Different variants of claims surrounding the need
to search for the ideal correspondence between
Impact on the Dentist form (ie, interarch relationship, inclination of the oc-
clusal plane, condylar position, type of guidance) and
Despite the amount of evidence suggesting caution function (ie, status of the stomatognathic system, ab-
in the interpretation of successful clinical outcomes sence of symptoms, ideal performance) have been
in the field of pain management, there may be sev- proposed. To the beginner’s eye, these theories are
eral reasons why a dentist is unable or unwilling to attractive because they seem logical, but scientific
consider alternative, less costly options. Dentists evidence in the form of deductive comparison vs oth-
have become accustomed to achieving a high degree er strategies has never been provided. Instrumental
of success in most of their daily office procedures. strategies involving procedures such as condylar
Thanks to the incredible technologic and theoretical tracking to plan prosthetic guidance, chairside elec-
progress of the past decades, there is now reason- tromyography to find neuromuscular and occlusal
able predictability for success in almost all dental balance, postural analysis to relate teeth contacts
procedures, from a simple Class I restoration to more to the presence of pain in other parts of the body,
complex implant-supported prostheses. Furthermore, or the use of so-called deprogramming appliances
there may be several equally valid methods for achiev- to find the ideal mandible-to-maxilla relationship are
ing those clinical successes. This means that once among the many examples of seemingly logical as-
a dentist has learned a technique or protocol or has sumptions that are actually made in the absence of
gained experience using a certain material, a positive biologic proof.65–67
treatment outcome is almost guaranteed. Regarding the treatment of OMDs, all the previ-
However, this type of positive experience in daily ously mentioned overtreatment strategies and tech-
practice also exposes dentists to confirmation bias, niques may produce apparent clinical successes in
which is defined as the tendency to search for, to in- some cases, but they fail to consider two important
terpret, and to favor and recall information in a way that factors:
confirms or supports one’s prior beliefs or values.61
Clinical examples are the claims that a certain com- 1. The self-limiting, fluctuating, and benign natural
posite, adhesive, or orthodontic bracket line is “better” course of most OMDS68–71: If a practitioner
than others. Consequently, practitioners working in excludes complex cases (eg, severe arthritis,
the dental environment are prone to adopt inductive multiple comorbid pains, severe Axis II
reasoning processes, which leads them to build gen- impairment, concurrent neuropathic conditions),
eralized theories from a series of uncontrolled per- they may utilize a variety of unnecessary
sonal experiences and observations. While such a instrumental approaches and clinical protocols
case-based approach may be useful in some specific with a reasonable probability of having success.
circumstances, it is the opposite of the deductive rea- If that dentist is a lecturer or a leader of a study

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Greene et al

club, those successes may end up creating is therefore often quite minimal. Instead, their edu-
“disciples” who are unaware that the cases cation in this area was (and in many cases still is)
presented are often prescreened to pick up the based on old precepts emphasizing the parameters
ideal candidates to sell a theory. of ideal function and attempting to reproduce it ar-
2. The neuroplastic and adaptation capability of tificially with dental procedures. Under the strange
the stomatognathic system77–74: If a practitioner assumption that technically skilled dentists and lab-
utilizes some complicated technique to oratory technicians know a lot about function thanks
“diagnose” OMD problems and to plan to their expertise using articulators, the process of
subsequent extensive restorative/reorganization learning and teaching function followed an invert-
treatments, it is likely that some of the case ed path with respect to the usual one; ie, instead
outcomes will be successful. The dentist just of transferring medical and biologic concepts to the
needs to avoid deviating too much from the technical equipment, the opposite strategy was fol-
habitual maximum intercuspation to have a very lowed, and application of anatomy concepts were
reasonable probability of having “functional” “adapted” to the available technical devices. The
success, again creating disciples who are heritage of the classic gnathology era is that many
unaware of the overtreatment. prosthodontic and orthodontic teachings at the un-
dergraduate level contain several hours of formative
For those who follow these professional pathways, credits that deal with the topics of articulators, re-
there are financial disincentives in abandoning their cording of the mandible position, and other tech-
dogmas. Along with income-related issues, other im- nical parameters that would purportedly evaluate
portant factors may reinforce their belief systems and and promote “function.”75 As a result, the emerging
explain the reluctance to “do less.” Among those fac- dental practitioner is, on average, not even aware
tors, the fact that some practitioners are linked to (and of the fact that the TMJ condyles are biologically
in some cases are also the founders or stockholders variable in terms of symmetry, size, shape, trajecto-
of) companies that produce TMJ-related diagnos- ry, and position. Having graduated with this back-
tic and treatment products is certainly problematic. ground, they are at risk of being exposed to a variety
Likewise, the fact that some practitioners have cre- of nonacademic continuing education courses and
ated a personal brand or agency to sell courses is other postgraduate educational activities that deal
clearly a conflict of interest when they present their with the TMJ and promise to get deeper into those
“method” to the dental audience. topics.76
Finally, disciples of certain philosophies tend to Due to these shortcomings of the undergradu-
affiliate with other “true believers” in various study ate dental education system, which are not unique
clubs, professional societies, and so-called insti- to any specific countries,77–79 a proliferation of con-
tutes, thereby increasing their resistance to change tinuing education courses, self-proclaimed institutes,
and their hostile attitude toward “scientists.” All of this and study clubs has been noted. In many countries,
is amplified in the social network era, which has an the main source of postgraduate information on TMJ
impact on the profession that will be discussed in the function and dysfunction is now represented by pri-
following section. vate courses, often held under some company banner
and/or by professionals without a certified education
in the field. Associations of “gnathologists” are still
Impact on the Dental Profession alive in several countries, often proposing events with
clear commercial links to overdiagnosis and overtreat-
The classic educational model in most dental col- ment devices. Orthodontists, who are the purported
leges around the world aims to provide undergrad- experts in function in the minds of most patients and
uate students with a certain level of fundamental general practitioners, are still often considered the
information that is then refined in university-based best choice for the referral of “TMD” patients, thus
postgraduate and specialty courses. However, this contributing to the persistent difficulties in dismantling
model has often failed to reach the goals of driving the old “TMJ-occlusion” connection.80 The term TMD
education based on evidence-based knowledge and is used here on purpose to denote that a simple ac-
preparing dentists who are able to understand the ronym of the umbrella term, without any phenotyping
medical components of the profession. For example, of symptoms and etiology, is still often misused as a
generations of dentists have not been sufficiently diagnostic label for such problems. Even in this new
exposed to the basic scientific concepts required to decade, it is not rare to see “debates” sponsored by
understand TMJ anatomy and orthopedics because companies or non–orofacial pain associations to cre-
of the complexity of such teachings, and their expo- ate audiences and give the impression of novelty in
sure to concepts regarding management of OMDs support of old gnathologic claims by refreshing the

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 Greene et al

technologic message (eg, digital articulators to “di- Thus, it seems important that evidence-based teach-
agnose” function). Within this context, national acad- ings on these topics should be included not only at
emies that should promote the study of pain and (dys) the undergraduate level, but also in prosthodontic and
function in some countries are still limited by their orthodontic programs to help young dental graduates
linkages to various dental associations, while interna- be better prepared for their own practice, as well as
tional academies sponsor large meetings that appeal for obtaining a better appraisal of the situation within
to expert communities but are not likely to reach the their dental community as far as the management of
ordinary clinical dentist. orofacial pain is concerned.
The difficulty of transferring an evidence-based Given the above premises, it must be concluded
message about the modern standards of care for that ethics are the guiding principle of any decisions
managing OMD patients to general dentists has that dentists make when they encounter patients with
a negative impact on the profession in general. OMDs.42,83 Ethical dilemmas about the importance
Moreover, a negative perception about dentists is of finding a balance between the patient’s needs (ie,
generated within communities of unsatisfied patients receiving the minimum amount of treatment that is
and medical doctors as reports of iatrogenic dam- really necessary from a medical viewpoint) and doc-
age continue to grow. Advocacy groups of patients tors’ expectations (eg, financial remuneration, ego
blaming “Phase II” doctors for either mistreating satisfaction, and relationships with companies and
or overtreating them without success are flourish- colleagues) will be a core part of any professional’s
ing in social networks, a raw reality unique to the career journey.
dental profession. In spite of the well-documented
neutrality of orthodontics with respect to causing or
curing OMDs, professional liability claims against Conclusions
orthodontists who “caused” a TMJ click are not
rare. Also, high-quality prosthodontists, restorative In this paper, the negative consequences of over-
dentists, and even orofacial pain practitioners can treatment, either in the form of planning extensive
be judged inadequate or not sufficiently updated by dental reorganization based on purported TMJ ab-
their patients because they do not use fancy instru- normalities or correcting dental occlusion to manage
ments in their diagnostic and treatment protocols. the symptoms of pain and dysfunction, have been
All these negative factors contribute to creating a discussed. Such consequences include the impact
gap between our profession and the other medical on doctors and patients, as well as the impact of try-
branches; indeed, it is difficult to find comparable ing to move the dental profession away from the old
examples of the overtreatment of patients in other mechanical paradigms and forward to more modern
musculoskeletal or neurologic fields. medically based approaches.
The recent recognition of the Orofacial Pain spe-
cialty in the United States, which will hopefully be fol-
lowed by similar achievements in other countries and Clinical Implications
includes the study of musculoskeletal pain conditions
(ie, OMDs), is surely an important starting point to • This paper helps clinicians better understand
defining an official professional framework of refer- the concept of providing the minimum amount
ence.81 Despite the efforts of the scientific commu- of treatment needed to fulfill the expectations
nity, the gap between scientific knowledge of these of the typical OMD patient and solve their chief
conditions and the typical clinical practice within the complaints.
community is often quite significant. Luckily, there • Successes that are based on overtreatment
are some very good initiatives for implementing stan- strategies still permeate the clinical management
dardization of the approach to OMD diagnosis and of OMDs and have a negative impact on the
treatment at the community level, but these are still patient, the dentist, and the profession.
limited in number and restricted to a few countries,
such as Sweden.82 As expressed previously, this situ-
ation is due in part to many misconceptions about the Acknowledgments
biologic and psychosocial features of the conditions
affecting the TMJ, which frequently have a positive C.S.G.: conceptualized the paper, wrote an early draft, and re-
natural evolution. Unfortunately, many dentists also vised the final manuscript; D.M.: wrote the text, performed the lit-
erature search, and approved the final version for submission. The
seem to lack an understanding of and appreciation
authors report no conflicts of interest.
for the adaptation of the stomatognathic system to
the typical minor shifts in mandibular position that are
necessary for prosthodontic or orthodontic reasons.

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Greene et al

20. Kapos FP, Exposto FG, Oyarzo JF, Durham J. Temporomandibular

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