TMJ Surgery: A “new” orthodontic standard of care

You know what they say….”The more things change, the more they stay the same”. Nothing could be more complimentary to this statement than a recent editorial that appeared in the American Journal of Orthodontics and Dentofacial Orthopedics in the July 2010 issue (1). Rarely do things of this nature become circulated among formal professional societies as rapidly as did this article. It is a summary of a position of the American Association for Dental Research (AADR). The formal statement contains 18 selected references. There is no contribution from any surgical society or information which addresses orthopedic disease or injury of the human jaw joint. It is unclear just what is to be done with this statement. Unfortunately, it supports a bias of 40 years or greater that people with “TMD” can simply manage their disorder themselves and that it is too multifactorial to comprehend.

Here are some excerpts from this editorial, published in what generally used to be accepted as the premiere journal for the specialty of dental orthodontics:

1. It is recommended that the differential diagnosis of TMDs or related orofacial pain conditions should be based primarily on the patient’s hitory, clinical examination, and when indicated TMJ radiology or other imaging procedures……This is truely a dental model of patient evaluation and management. With the pathology of TMJ disease not being taught to either dental or medical students in the US to any degree not to mention anything about dysfunctional biomechanics and how it destroys a human jaw joint over time….it is no wonder that this is such a controversial area. One can imagine physcians being trained to ignore extensive knowledge of all pathology of synovial joints, ramifications of injury, growth and development problems and dyfunctional conditions coming up with such a simpletonian initial statement such as this.

2. “In addition, various standarized and validated psychometric tests may be used to assess the psychosocial dimensions of each patient’s TMD problem.” …..In the 1960′s, the author of this editorial and a colleague authored a paper that influenced dental education to this day. It emphasized basically that much pain that individuals experience with this condition is psychological, self limiting, due to stress in their lives etc, etc. There was not even any acknowledgement that the human jaw joint can be injured in various ways, have specific synovial disease processes, and develop significant orthopedic abnormalities similar to any other joint in the body (not to mention photographs of pathology presented in this web site). Basically, such a statement continues to be taught in professional health care education…..In my personal experience, sure, patients with chronic pain become psychologically depressed or develop other issues when they are told they can manage their own problem….if they just cut out all the stress in their lives. Unbelievable…..no wonder there are so many frustrated people out there.
This statement, to me, is an indictment of the educational system for the past 40 years….presently it does little to mimick a medical model of evaluation at all….and perpetuates the accepted protocols that we can actually know all we need to know about a patient by just sitting down and listening to their story….if we get around to it, imaging studies might be of some use…etc etc.

The rest of the statement goes on to recommend that “conservative” treatment be exhausted….which is a good thing….but the problem with this this approach is that there is no education or emphasis on the 10% of patients with “TMD” (imagine that in orthopedics with the sophistication of knowledge of knee biomechanics and various conditions/classifications, that the best medical science could do is come up with “knee syndrome” or how about TFD…tibiofemoral disorder)…….

ASTMJS  (See ASTMJS.org) several years ago made requests to be allowed to show photographs of orthopedic disease of the human jaw joint and introduce the paradigm of dysfunctional/painful biomechanics. We were not invited to participate. The committee that put out this statement was actually a Neuroscience Group…..which means academicians who do wonderful but unfortunately are overbearing in that bias relative to cause…unappreciated injury….and long term effect on a human being. This approach is similar to the old parody of blind mice, feeling the legs of an elephant, and trying to debate just what it was that they were experiencing. A myoptic approach to be sure….and unfortunately one that is taught to students research relative to understanding the complicated neuro/biochemical mechanisms of chronic pain….

I guess what is the most disturbing about this statement is that it often is said that the operating room is the ultimate objective laboratory in health care. Here, obvious visual tissue  disease and injury unamenable to conservative health care methodologies are witnessed and entities that require surgery are acknowledged by reasonable providers….except those who create statements which for whatever reason choose to ignore true surgical disease not amenable to non surgical treatment. ASTMJS, several years ago approached members of this committee, on behalf of patients who had become significantly impaired from jaw joint fractures, ankylosis of the joint, ravages of arthritic disease and development of malocclusion etc. etc. It was our hope that the American Dental Association would petition the American Medical Association to  acknowledge and include these patients as human beings who deserved to be formally recognized in the AMA’s Guide to Impairment and Disability. Our request could not even get by individuals, some of whom represent this committee. The AMA was counting on support from the ADA that never came. In today’s world of correlation of imaging and surgical photographic confirmation, it is time for the dental model neuro/phycho/biochemical pain is…” something we can counsel you about providers“, to understand and acknowledge that their bias is just that….they are ignoring some very important data and science from other fields. My bias is that there are just as many patients who have been victimized by this mindset  (many make up large numbers now in patient advocacy groups)….one that is not willing to look at an orthopedic model of joint disease. 

Enough of my grandstanding…..and it is not that surgeons have not had their own biases distract their thinking as well. Over 25 years ago, we had our own version of the Gulf oil disaster happen in the world of TMJ surgery. We’ll talk about it next blog.

Charles S. Greene, editorial, “Managing patients with temporomandibular disorders: A new “standard of care”. Am J Orthod Dentofacial Orthop 2010; 138, 3-4.