Temporomandibular disorders and science: A response to the critics
Charles S. Greene, DDS,a Norman D. Mohl, DDS, PhD,b Charles McNeill, DDS,c
Glenn T. Clark, DDS, MSc,d and Edmund L. Truelove, DDS, MSDe
This article was prepared and submitted to members of the TMD academic community for their endorse-
ment. A total of 120 people signed an endorsement; their names are available on request. (J Prosthet Dent
1998;80:214-5.)
T he diagnosis and treatment of temporomandibu-
lar disorders has been a controversial subject ever since
It is not the purpose of this brief article to review all
the detailed charges and countercharges associated with
it first appeared in the dental literature. The debate has this dispute. Instead, we would like to appeal to the
often been lively, but it has not usually been mean spir- common sense of the “silent majority” of clinicians who
ited. Most of the early disagreements were between have no special interest in this unpleasant business, but
various prominent clinicians (and their followers), each who are affected by their exposure to it whenever they
of whom advocated different concepts about what was pick up one of the journals cited and read the letters and
wrong with patients with temporomandibular disorders articles or attend a lecture or conference.1-6 The articles,
(TMDs) and what needed to be done about it. In addi- letters, or lectures that attack the National Institutes of
tion, several dental specialties such as prosthodontics, Health (NIH) for sponsoring certain types of orofacial
orthodontics, and oral surgery developed their own pain studies, or for publishing a TMD pamphlet that
parochial versions of the causes and cures for TMDs. they do not like, or for conducting national consensus
When the first academic studies of TMDs began to conferences on such an important topic (Garry JP, writ-
appear in the 1960s and 1970s, there were some ten communication, April 24, 1996), are likely to under-
inevitable conflicts, as research challenged some of the mine the respect which that agency deserves. Similarly,
traditional concepts and procedures. those written or spoken opinions that depict the TMD
Regrettably, this rather conventional level of schol- academic community as ivory-tower dental professors
arly disagreement about TMDs has declined in recent and behavioral scientists (as opposed to wet-fingered,
times and has been replaced instead by a lot of angry real dental clinicians) can only encourage the stubborn
rhetoric about the qualifications and motives of one members of the practitioner community to resist
group daring to criticize another. In most areas of med- change.* It is important to remember that most TMD
icine or dentistry, the fact that significant research find- academicians are continuously involved in direct patient
ings contradict a long-believed concept or assumption care for complex TMD and other orofacial pain patients
will eventually lead to the abandonment of that belief at university-based pain clinics.
by both researchers and clinicians. This conversion may Many of the criticisms of traditional surgical,
take some time but, if the evidence is substantial, it will occlusal, or jaw-repositioning modalities for treating
usually prevail and all but the most stubborn believers TMDs have come from short-term and long-term stud-
will move on to a new level. Unfortunately, the TMD ies, most of which have shown these methods to be
field seems to be one of those areas where such an excessive in terms of aggressiveness and irreversibility.
orderly transition is not occurring at this time, and the Of course, this implies that both the physical cost and
reasons for that include a distressing amount of antia- the monetary cost to these patients also is excessive,
cademic posturing by some in the clinical practitioner especially when so many controlled TMD treatment
community. Essentially, they argue that the collective studies have demonstrated both powerful placebo
anecdotal experiences of clinicians are more valid than effects and excellent responses to various conservative
the research findings that appear to contradict them. treatments. Therefore it would not be surprising if the
advocates for those aggressive procedures might feel
aDirector
threatened monetarily by the prospect of seeing their
of Orofacial Pain Studies, University of Illinois, College of
Dentistry, Chicago, Ill. methods become obsolete as a result of these negative
bChair, Department of Oral Diagnostic Sciences, School of Dental research findings. On the other hand, it would not be
Medicine, SUNY at Buffalo, Buffalo, N.Y. surprising if they resisted changing their methods
cDirector, Center for TMD and Orofacial Pain, School of Dentistry,
University of California, San Francisco, Calif. *Letters from the “Alliance of TMD Practitioners” to FDA, protesting
dChair, Orofacial Pain and Diagnostic Sciences, School of Den- the October, 1994 FDA Advisory Panel Meeting on TMD Devices.
tistry, University of California-Los Angeles, Los Angeles, Calif. Letters from the “Alliance of TMD Practitioners” to AADR/IADR
eChair, Department of Oral Medicine, School of Dentistry, Univer- protesting adoption of the TMD Scientific Information Statement.
sity of Washington, Seattle, Wash. AACR Reports 1996:18(4).
214 THE JOURNAL OF PROSTHETIC DENTISTRY VOLUME 80 NUMBER 2
GREENE ET AL THE JOURNAL OF PROSTHETIC DENTISTRY
because they have sincerely been impressed by seeing so incorporate information obtained from the
many cases of apparent clinical success over a period of patient’s history, clinical examination, and, when
years. Success in treating patients with TMDs is quite indicated, TMJ or other imaging. The choice of
common, and this type of positive experience tends to adjunctive procedures should be based upon pub-
reinforce the clinician’s convictions that his or her lished, peer-reviewed data showing diagnostic
treatment approach is valid. Unfortunately, it never efficacy. Diagnostic tests that may be proven in
addresses the confounding issues such as placebo future scientific reports to show the sensitivity
effects, spontaneous remissions, or cyclic fluctuations, and specificity required to separate normal sub-
let alone the issue of overtreatment. Few things are jects from TMD patients, or to distinguish
more satisfying to doctors than seeing their patients get among TMD subgroups, may be useful. Use of
better, even if their understanding of that outcome is unproven adjunctive tests and devices may pre-
incomplete or flawed. sent risk for clinicians and patients of reaching
The history of twentieth century medical science is either false-positive or false-negative diagnoses.
filled with many examples of this type of cognitive dis- (II) It is strongly recommended that, unless
sonance occurring among all kinds of medical practi- there are specific and justifiable indications to the
tioners when negative research results are reported contrary, treatment be based on the use of con-
about some familiar concept or procedure. Such feel- servative and reversible therapeutic modalities.
ings are understandable, but in the end, this is what real While no specific therapies have been proven to
scientific progress is all about: Both researchers and be uniformly effective, many of the conservative
clinicians have to be prepared to abandon some of their modalities have provided at least palliative relief
favorite theories and procedures from time to time from symptoms without producing harm.
throughout their careers. The most important thing is
that members of both groups must move on to the In conclusion, we can only hope that reasonable
future as gracefully as possible, rather than digging in practitioners will be able to sort through the current
their heels and throwing bricks at the opposition. After controversies in the TMD field as they have done in the
all, on a personal level, dentists and their families expect past. By understanding these disorders in a biopsy-
to receive the best evidence-based care from their own chosocial framework, by avoiding mechanistic thinking
doctors, and our patients have a right to expect the and treatments, and especially by treating our patients
same thing from us. with conservative and scientifically validated modalities,
In the field of temporomandibular disorders, all of us in the dental profession can potentially provide
researchers have been working on a variety of basic sci- a valuable service to the people who really count:
ence and clinical issues for more than 30 years, and a patients with TMD and their families.
considerable amount of agreement has been reached on
some of the major issues in this field. Recently, an REFERENCES
excellent summary of the current points of consensus in 1. Dawson PE. Diagnosis, management, and treatment of temporomandibu-
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2. Cooper BC. Who represents the TMD practitioner? J Craniomandib Pract
Research (AADR), and it was published as a Scientific 1996;14: 251-253.
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as follows, in its entirety: 4. Letters. J Am Dent Assoc 1997;128:140-8.
5. Guichet N. Lecture notes from American Equilibration Society meeting,
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The AADR recognizes that temporomandibu- 6. Dawson PE. Why NIH is wrong about “TMD.” J Craniomandib Pract
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7. American Association of Dental Research. Scientific Information State-
culoskeletal conditions that involve the temporo- ment. AADR Reports 1996;18(4).AQ1
mandibular joint (TMJ) or joints, the masticatory
muscles, or both. The consequences of these dis- Reprint requests to:
DR. CHARLES S. GREENE
orders can lead to difficulties in chewing and other DIRECTOR OF OROFACIAL PAIN STUDIES
oral function, acute and/or chronic pain, absence UNIVERSITY OF ILLINOIS AT CHICAGO
from or impairment of work or social interactions, COLLEGE OF DENTISTRY (M/C 835)
801 S. PAULINA ST.
and overall reduction in the quality of life. CHICAGO, IL 60612-7211
Based on the evidence from clinical trials Copyright © 1998 by The Editorial Council of The Journal of Prosthetic
Dentistry.
[emphasis added]: 0022-3913/98/$5.00 + 0. 10/1/90585
(I) It is recommended that the differential
diagnosis of TMDs or related orofacial pain
AUGUST 1998 215
