The dental Mount St. Helens is rumbling again. Controversy prevails and is making us even more divided. The April “Journal of the American Dental Association” (JADA) article on occlusion1 quotes a prominent editor of an orthodontic journal as stating “. . . neuromuscular school tells us that there is a range of acceptable positions (centric) . . . If we clinicians continue to place emphasis on establishing harmony between centric occlusion and some mythical centric relation, we are doing ourselves a disservice.” Rumble! Rumble! In the June JADA letters to the editor, a prominent professor of medicine states “this is the only area of the body where a joint and associated muscle problems are psychological, yet the only area of the body treated by dentists.”2 How much training did you get in this? Did you feel the ground shake a little? This July 2006 in Denver, the American Academy of Craniofacial Pain (AACP) presented one of the most professional meetings ever, with multiple highly acclaimed TMJ lecturers. All had important informative messages, but few agreed on the end product or the modalities needed to get there. Some advised to treat with a splint for a while, then see if symptoms would go away. Some advised to treat with a splint and medications, then see if symptoms go away. Some advised wearing a splint, then have orthodontics, or have the occlusion rebuilt, but some said not to. Some proposed a splint, then conservative surgery. Then some said radical complete replacement was required as other techniques had failed. At the end of the meeting, the panel of lecturers was asked questions. Each participant was respectful of the others' opinions, but it was evident that not all were in agreement. Basing diagnosis and treatment on half truths or mythical positions without parameters creates misunderstandings, sort of like taking items out of context to prove a point. Having mythical concepts creates salvos for the legal profession. I believe the seismographs are reporting. Even more disturbing is that certain orthodontic philosophies proclaim TMJ has nothing to do with orthodontics, yet can be treated with orthodontics, and that bicuspid extractions have NO relation to TMJ problems. A summary of the recent American Association of Orthodontists (AAO) convention in Las Vegas had no mention of any new breakthroughs pertaining to orthodontic TMJ management. However, the prominent orthodontic lecturer and educator McLaughlin3 states that TMJ is a main priority in orthodontic diagnosis and treatment. It is difficult to find much mention of TMJ in the “Journal of Clinical Orthodontics.” Could it be that orthodontics and TMJ really have no relationship? Maybe the orthodontic community wants to believe the literature from years ago that was funded by orthodontic research, to prove orthodontics had nothing to do with TMJ. Maybe they just don't want subjects like that to be approached right now due to all the new mechanics and new thoughts to avoid surgery. I’m starting to feel the ground shake, and I may even see a plume of smoke. Even more confusing is that the National Institutes of Health (NIH) is having a meeting in September 2006 to learn about comorbid health symptoms being reported by TMJ patients: fibromyalgia, chronic fatigue, myofascial pain, irritable bowel syndrome, restless leg syndrome, mitral valve prolapse, chemical sensitivity, dysmenorrheal tension, migraine headaches, and multiple systems illnesses. The NIH group wants an integrative approach to take into account the whole patient in a comprehensive manner. The NIH really wants a practical way to help patients who suffer from TMJ disorders, and it is appealing for help. The NIH is looking closely for established protocol for diagnosis and treatment, not more statistics. In the past NIH meetings, there were several negative factions presenting items such as the Teflon implant failure, surgical failures, and medication failures without much presentation allowed for successful modalities. There are successful treatment plans to learn from just as much as previous failures.4 I wonder what Hans Selye, Al Fonder, Vernon Grey, James Gary, John Witzig, and Robert Ricketts would say now. It's a shame that some of these founders died without seeing what they tried to teach for years starting to come to reality, or at least the growing desire to look at the body as a whole is being continued and not just looking at the teeth for the interrelationship. Today, we have visionaries like Drs. Brendon Stack, Harold Gelb, Charles Holt, Bill Hang, Duane Grummons, Grant Bowbeer, James Broadbent, Larry Wolford, Duane Keller, Terrance Spahl, Clifton Simmons and others who are placing their integrity and what they believe and feel is RIGHT above what is conventional, half true, and half false. They deem it as a responsibility to tell what they feel is the complete TRUTH. Sooner or later, the existence or lack of existence of this mythical imaginary position of the condyle is going to have to be addressed. If it is not, then it will be a catastrophic disservice to our profession and patients. Without definition and direction from our educational institutions and organizations, a heyday will result for those who place fear in every aspect of the practice of dentistry. Truth will have to prevail. The condyle must not be in an over-compressed position. John Mew gave the opinion that “a long term cure for malocclusion will not be found until the influence of the environment on oral posture is accepted and it will ultimately evolve from the application of scientific principles not from empirical mechanics.”5 Mew is not just talking about teeth, he's talking about TMJ and total body. Could this be why Grey and Gary were so concerned about airway, mouthbreathing, allergies, and comorbid symptoms? ADA officials are aware of the concern but don't know where to start as far as how to teach TMJ protocol, yet they have refused to allow such a specialty. It's sort of like it was in the 1970s: implants were not supposed to work, yet some GPs continued to place them until it became evident that implants were practical. Only when the scientific method and a large company became involved did implants become acceptable. Then the specialists (OSs, prosthos and perios) became the Specialists of Implantology. Don't think for a minute that the orthodontic specialists will want approval of any nonorthodontic TMJ specialty. Once a new protocol is established, they will jump and run to the front of the line to be the TMJ specialists, as some are already claiming to be. The only problem is that TMJ therapy requires new thought and time-consuming compassion, which involves new protocols for evaluation. Treatment will involve more than ideal tooth inclination or a special torque on a bracket or rectangular wires. Treatment will involve making sure the joint is healthy without compression or pain, then providing whatever mechanics, tooth movement, or prosthetics are necessary to stabilize and maintain functional joint health. Habitual occlusion and healthy functional muscular and structural occlusion will be defined. There are a few orthodontic texts and orthodontic specialists3 who are now teaching this protocol. Many pediatric clinicians, DDSs and DMDs, have been following a healthy jaw joint protocol for years. Maybe the orthodontic institutions will experience a Reagonomic trickle down effect. The ADA is having difficulty giving suggestions to the dental schools as to the multitude of basics that must be taught, but also all the new technology integration within the time frame to produce a finished product, much less the expenses involved to run the institutions. Some thought has even been given to initiating 5-year DDS programs. That would be all right, but we certainly need to stop being of disservice to our profession and give direction, not mystical vagueness. The old volcano is rumbling. Since no one wants to make a move unless it's evidence-based, we might as well wait until the earth stops spinning. We must understand that our own literature gurus cannot prove everything using the evidence base. Our own NIH researchers have found evidence of falsifying data in reports.6 the editor of one of our leading orthodontic journals addresses evidence-based controversies.7 He basically states that we will just have to take the word of the old guys. A JADA article states that the instrumentation used for occlusion and deprogramming splints is unequivocal, but is not evidence-based.3 I have a hard time determining the difference between half-right and half-wrong, or why common sense and practical applications cannot be applied to our bodies. Common sense would suspect that if you over-compress any joint in the body, something has got to give. Yet some dental professionals call this idiopathic mandibular condylar resorption, when four bicuspids are extracted and cinched back like a bridle on a horse in full Whoa.8 It seems that if given enough data for a statistician, one might be able to summarize and conclude that something is evidenced-based or not. It’s amazing to know that we have disproved that orthodontics and bicuspid extraction have anything to do with the TMJ, yet have definitely proven that all the instrumentation pertaining to occlusion is not evidence-based. I feel the ground really shaking now. Have you noticed all the media hype pertaining to what dental infections can do to the rest of the body (relationships between periodontal disease and premature birth, cardiovascular disease, and post-op ventilator pneumonia after intubation)? If you perform hospital dentistry, how much effort is placed on sterilizing the mouth or nasal airway during intubation? We know that the oral and nasal cavities are the harbors for many organisms. Hospitals and insurance companies are showing concern over the increased prevalence of ventilator pneumonia. Bacterial and viral organisms may spread. Have we taken something for granted? Has the oral cavity and the dental connection been overlooked as a relationship to the rest of the body? It’s a shame to know that veterinarians usually look at the mouth for diagnostic keys. They’ve been examining this way since day one. They are not looking for decay or crooked teeth. They are looking for color, pallor, texture of the tissue, consistency of saliva, etc., to help diagnose for vital disorders. I hate to tell you the second place they look. Comprehensive evaluations must be implemented by our profession by understanding the interrelationship between the oral tissues and systemic disorders, and vice versa. We must prepare for Multidisciplined Integrative Medicine: the dental profession will be involved. We, as dentists, might be our own worst enemies. We seem not to be on the same page at the same time. Maybe we must still graduate from grade to grade and learn in steps to understand. It's hard for some of us to believe that we need to be integrative in treatment. Do we really know why the airway is important, why the lowered blood oxygen saturation has an effect on health, or why that would make the teeth decayed or crooked? Why could TMJ cause, or be related to, reflux disorders, dizziness, neck pain, or ringing ears? Then, there's the biggie, could cranial sutures shift? This may be why some dentists don't want to treat TMJ patients, while some strive for the opportunity. This may be why some patients are referred to as having psychological disorders, whereas a TMJ practitioner may sympathize and treat them, knowing that if they live with chronic pain and dysfunction long enough, they just might develop a psychological disorder. Could this be what Selye called his Breaking Point?9 Listen and watch for the rumbling, as the ADA is going to have to take a stand, or else hire some more lawyers to once again defend a nebulous position for those who utilize TMJ therapy in their practices. Trying to defend half truths is very costly and not effective. The NIH , ADA, and AMA are struggling to provide direction in an effective, practical manner to benefit TMJ patients and not just a group of PhD statisticians. Frighteningly, in one of Rickett's last interviews,10 he stated that he lectured for nine hours at a prominent orthodontic graduate school that had not heard of or utilized a quad helix expansion appliance. Some graduate orthodontic programs still are using only lateral cephs for Gold Standard diagnostics without 3-dimensional evaluation. I wonder why graduate orthodontic schools are scrambling for instructors? I have attended a prominent orthodontic school for continuing education and asked how they address a dislocated or clicking joint, and it seemed to me that they looked at me as if I were from another planet. They then respond and say, “I usually send them to one of those TMJ guys, you know Dr. so and so, over in Fort Worth.” Those TMJ guys cannot treat by half evaluations and vague mythical positions of harmony of occlusion; they attempt to pinpoint the dysfunction and treat to the most functional position within anatomical reason. Harold Gelb11 compiled literature by a group of different doctors attempting to explain the concept of the integrative thought process to present craniomandibular treatment concepts, beginning with the interrelationship of basic anatomy (nutrition, airway, posture, foot posture, gait, cervical posture, etc.) all the way through dental modalities and treatment, to the finish of treatment by surgical intervention, if needed, to retention and maintenance. He could have gone into even more minute detail, but he kept the presentation simple for the first time reader. The concept is one of few, but is the continuation of what Fonder12 was saying years ago in the “Dental Physician.” Will it take something catastrophic to make our dental/medical community wake up? It will happen and we will know it, especially if it is one of our loved ones or friends who has suffered. We will know once we discover that our patient has been misdiagnosed and actually suffered from TMJ disorder and exhibited many of those symptoms described as comorbid. Dentistry is changing at warp speed whether we like it or not. We cannot continue to go against technological trends. TMJ diagnosis and treatment has changed for the better and is not the same as it was years ago. Patients have suffered from old philosophies, and the practice of dentistry as a whole will suffer if we will not open our minds and face reality. Then and only then will we study and research to know the truth by which we can effectively practice. True, nature and time have come along and beautified the landscape of Mt. St. Helens, and there is not too much we are going to do to stop volcanic eruptions, but there is something we can do and our readers can do about the TMJ controversy. Stand up for what you believe in. If you are either a seasoned practitioner who has observed the changes or fresh out of medical/dental/health care school, contact the ADA or your representative, join organizations that support CRANIO, and learn what is new in the latest TMJ research. At least listen to the concepts and judge for yourself. No longer can we base our diagnosis and treatment on mythical theorems and vague interpretations. Seek the truth as truth is reality and should not be hidden any longer. I wonder if we can control the rumble.
Sam L. Beavers, D.D.S., D.I.M.
Chair of Education
The International Association of
Orthodontics
Little Rock, Arkansas
References
1. Rinchuse DJ, Kandamsy S: Centric relation. A historical and contemporary orthodontic perspective. J Am Dent Assoc 2006; 137:494-501.
2. Friedman M: Psychosocial confusion. Letter to the editor.. J Am Dent Assoc 2006; 137:721.
3. Arnett W, McLaughlin RP: Facial and dental planning for orthodontists and oral surgeons. St. Louis: Mosby 2004.
4. Huang GJ, LeResche L,Critchlow CW, Martin MD, Drangsholt MT: Risk factors for diagnostic subgroups of painful temporomandibular disorders. J Dent Res 2002; 81:284-288.
5. Mew J: What are we to believe? TM Diary J Am Acad Craniofac Pain :14-17.
6. Kintisch E: Scientific misconduct: researcher faces prison for fraud in NIH grant applications and papers. Science 2005; 307:1851.
7. Keim R: The weight of evidence. J Clin Ortho 2004; 38:121-122.
8. McLaughlin RP, Bennett J, Treviesi H: Systemized orthodontic treatment mechanics. 2001:182.
9. Selye H: The story of the adaptation syndrome. Acta, Inc. 1952.
10. White L: Interview of Dr. Robert Ricketts. Part 3. www.orthodonticcyberjournal.com 2004.
11. Gelb H: New concepts in craniomandibular and chronic pain management. Mosby-Yearbook 1994.
12. Fonder A: The dental physician. Medical Dental Arts 1977.
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