4 Readers' forum
The patient may not seek the care of the people the of them. To quote Dr Hudson directly, “Advising ortho-
orthodontist recommends. They may end up in an dontists to stop ‘all active treatment’ during TMD flare-
office with strong views of how orthodontics can ups is an opinion that I would suggest is not in the best
affect TMD. I have witnessed this happen to col- interest of any orthodontist.” Not only does he believe
leagues who would come to lament having taken that stopping treatment is often not a necessity, but
this route. They ended up standing on the sidelines he also worries that “it can implant in the patient’s/par-
while others controlled the narrative of events. I was ents’ perception that the orthodontic treatment is the
one such person 35 years ago. cause or aggravating factor in the TMD issue.” Later,
4. If we prepare a patient for orthographic surgery, we he suggests, “When there is clear evidence that a specific
cannot stop, and few surgeons will want to move orthodontic procedure is contributing to the problem,
forward. discontinue that aspect of the treatment and consider
5. There are some rare cases in which transitional alternative methods to achieve the correction.”
stages in orthodontics have significant occlusal al- Unfortunately, these clinical situations are not as
terations that a particular patient may have trouble simple to interpret as Dr Hudson implied. Because ortho-
adapting to before we achieve the functional goals dontists are dealing largely with adolescents, which is an
we aim for, that is, jumping a unilateral crossbite age when the initial onset of many TMD problems may
with a functional shift. In such a situation, we occur, the emergence of symptoms may be merely coin-
should never stop active treatment but manage cidental. However, although mentioning that the impact
the muscle and/or joint symptoms while completing of elastics, certain appliances, or severe bite-jumping
the correction. procedures might be the cause of TMD symptoms, he
encourages the reader to continue orthodontic treat-
I could go on with other more contentious points, but
ment while finding a workaround solution or modifying
I believe these are sufficient to suggest an improved
the original treatment plan, and at the same time
wording and order for the recommendations would be
manage the TMD condition. His comments suggest
as follows:
that a thorough history and examination can determine
1. Manage TMDs with conservative and reversible whether or not these orthodontic procedures were
therapies. responsible for creating the symptoms, but in reality
2. Do everything possible to continue active treatment there are no specific diagnostic procedures that can
to a stopping point that achieves most of your ortho- accomplish that goal.
dontic goals when TMD issues arise during active This same logic was applied over 30 years ago in the
treatment. When there is clear evidence that a specific famous Brimm vs Malloy malpractice case, as the ortho-
orthodontic procedure contributes to the problem, dontist in that case tried to “finish up” his treatment
discontinue that aspect of the treatment and consider while struggling with the TMD symptoms, and we all
alternative methods to achieve the correction. know how that turned out. Given that background and
the knowledge base that has accumulated since then,
I hope these suggestions can improve the thoughtful
we continue to recommend stopping active treatment
list provided by these distinguished authors.
for 3 very good reasons:
J. Michael Hudson
Decatur, Ill 1. There is no way at first to know if the etiology of the
Am J Orthod Dentofacial Orthop 2023;163:4 new symptomatology is coincidental or a response
0889-5406/$36.00 to the orthodontic procedures. Although we are
Ó 2022 by the American Association of Orthodontists. All rights reserved. fortunate that the vast majority of adolescents and
https://doi.org/10.1016/j.ajodo.2022.10.013 adults can tolerate the forces and unstable occlu-
sions produced by orthodontic treatment, we also
Authors’ response know that such procedures can exceed their adap-
tive capacity in some people.
2. By keeping the patient in a holding pattern for a
W e thank Dr Hudson for his thoughtful and mostly
complimentary comments on our article. Although
agreeing with 8 of the 9 recommendations we proposed
period of time with no active forces, the patient’s
muscles and joints can respond better to the typical
for contemporary orthodontists to consider regarding conservative treatments for TMD.
temporomandibular disorder (TMD) issues within their 3. If symptoms of TMD recur after successful manage-
clinical practice, Dr Hudson raised a concern about one ment as the active orthodontic treatment is resumed,
January 2023 Vol 163 Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Readers' forum 5
this is a major clue that the individual patient for Authors’ response
various reasons is unable to tolerate this particular
type of active orthodontic treatment, and significant
modifications and compromises will likely need to be
considered going forward.
W e want to thank Dr Spencer for taking the time to
write a letter about “R-E-S-P-E-C-T” to the editor
regarding our paper (Kandasamy S, Rinchuse DJ, Greene
So we thank Dr Hudson for his suggestions regarding CS, Johnston LE Jr. Temporomandibular disorders and
this issue, but we continue to believe that our original orthodontics: what have we learned from 1992-2022?
recommendation is appropriate for dealing with such Am J Orthod Dentofacial Orthop 2022;161:769-74).
problems. He was disappointed at our original and to-the-point
Sanjivan Kandasamy response to the letter from Dr Antosz, which was not in-
Donald J. Rinchuse tended to be disrespectful. Instead, it was intended to be
Charles S. Greene very brief because Dr Antosz was challenging every
St Louis, Mo, Midland, Western Australia, Australia, aspect of our paper, and we felt it would be impossible
Greensburg, Penn, and Chicago, Ill to argue all those points within the provided format.
However, that response elicited requests from other
Am J Orthod Dentofacial Orthop 2023;163:4–5 readers as well as Dr Spencer to provide more specific an-
0889-5406/$36.00
Ó 2022 by the American Association of Orthodontists. All rights reserved.
swers to the main issues raised; therefore, we have writ-
https://doi.org/10.1016/j.ajodo.2022.10.014 ten the following comments, which we hope will be
appreciated by all parties concerned.
After reading our paper, Dr Antosz stated that he had
Is this respect? experienced several emotions, including disbelief, anger,
annoyance, and frustration. Space does not permit a
aving just finished reading an excellent article from
H Ethics in Orthodontics by Dr Peter M. Greco titled,
“R-E-S-P-E-C-T” (Greco PM. R-E-S-P-E-C-T. Am J Or-
lengthy answer to all the points he raised, but we hope
our response will help address some of his distressed
feelings.
thod Dentofacial Orthop 2022;162:151), I was some- Ultimately, Dr Antosz feels that the specialty of
what shocked to turn back to the reply section in orthodontics, the evidence-based literature, and espe-
which Drs Donald J. Rinchuse, Charles S. Greene, Lysle cially our paper collectively fail to recognize, appreciate,
E. Johnston, Jr, and Sanjivan Kandasamy provided a and discuss so-called functional occlusion and its rela-
rather snarky (in my opinion) short reply, “We thank Dr tionship to temporomandibular disorders (TMDs).
Antosz for submitting what amounts to ‘exhibit A’ in According to Dr Antosz, the specialty generally fails to
our case. The defense rests.” The question must be identify that particular version of a “bite” problem,
asked, “Is this respect?” which requires the practitioner to stabilize the bite
Is their reply simply, “We have no defense”? It is a with a piece of plastic and then address the occlusion
confusing defense at best, but I, as a reader, am disap- with orthodontics and/or restorative treatment.
pointed the editors did not require these authors to We want to establish a few key points.
defend their article’s content in the excellent manner First, the literature and our paper do not demean the
that other authors usually defend their articles in the value of orthodontics, nor does it criticize trying to
American Journal of Orthodontics and Dentofacial Or- achieve an ideal occlusion. Our paper was not about
thopedics. Certainly, we should all prefer that future how to achieve a functional occlusion or any other
disagreement, without regard to the subject matter, be particular orthodontic/occlusal concept.
submitted with respect to the more gentlemanly forms Secondly, this paper concentrated on what has
of discussion and content usually exhibited in the Amer- changed in the TMD field since 1992. After reading
ican Journal of Orthodontics and Dentofacial Orthope- our paper, Dr Antosz believed that “clearly nothing”
dics rather than a shameful 2 liner that was allowed to be had changed in 30 years. However, if he had read past
printed as a rebuttal. the first sentence, he would have quickly realized that
Gerald W. Spencer there have been significant changes to the dental profes-
Sedalia, Mo sion’s understanding of TMDs since 1992. Along with
Am J Orthod Dentofacial Orthop 2023;163:5 most of the expert orofacial pain community, orthodon-
0889-5406/$36.00 tists have moved from a dental and mechanical-based
Ó 2022 by the American Association of Orthodontists. All rights reserved. TMD diagnosis and management model to a bio-
https://doi.org/10.1016/j.ajodo.2022.10.011
psychosocial and medical model of care.
American Journal of Orthodontics and Dentofacial Orthopedics January 2023 Vol 163 Issue 1
