Fragmentation of the groups treating TMJ disorders has been a continuous problem in dentistry, with consensus ever eluding us as we consider the occlusal aspects of our treatment. There have been personality cults often bordering on the religious. The orthodontic community now claims that orthodontics has nothing to do with TMJ disorders, the AOP has adopted a medical/ psychological model where the patients are crazy, occlusion therapy is a myth or fraud upon the public, and the best treatment is an ever growing list of prescriptions. There are 20 plus definitions of centric relation which proponents say is valuable for repeatability, but they cannot even repeat the definition. Neuromuscular proponents are more interested in rest position and healthy muscles, while another group says occlusion is joint-based. The science of dots and the abolishing them is what many think temporomandibular dysfunction (TMD) is all about. Passions become inflamed and various groups seek specialty status in the ADA. The National Institute of Dental and Craniofacial Research (NIDCR) believes any permanent changes should be avoided and that orthotics change the bite. The Future is Now. The National Heart, Lung, and Blood Institute (NHLBI) has declared that TMJ disorders have sleep and cardiovascular consequences that need to have the pathophysiology understood. It is time to evaluate airway, swallowing, and breathing as part of the picture. We must embrace this as an opportunity to unite us in a medical model, not based primarily on drug treatment and behavioral therapy, but on the autonomic and postural effects of the stomatognathic system and how they relate to airway and sleep, as well as pain. We must re-examine what we do, not in terms of how the teeth meet, but how the entire system functions. This is not to say that how the teeth meet is not important. The articles published by Shimshack, et al.1,2 published in CRANIO on 200-300% increases of medical spending across the entire spectrum of medical specialties in patients with temporomandibular disorders substantiate the importance of treating these disorders or, at the very least, understanding the pathophysiology. The future of TMD research is not just the intricacies of the TM joints and musculature, but in epidemiological studies of the effects of these disorders on medical costs, life expectancy, and quality of life. I challenge the NIDCR to put aside its bias against clinicians and to reduce the political clout of certain groups that leads to inequitable distribution of research funds to the same groups repeatedly and to work with the NHLBI on more expansive research. There are large cohort studies that are already funded that could easily add limited TMD evaluation of signs and symptoms yielding impressive epidemiological data while conserving tax dollars. We must re-examine concepts of vertical dimension, centric relation, and bicuspid extractions for their effect on airway and tongue posture. We need to go back and evaluate the work of people like Jim Garry, Brian Palmer, and Edgil Harvold on the development of airway problems and the dental consequences, as well as the developing work of Farrand Robson and his oral systemic balance. We need to integrate treatment of sleep- disordered breathing into our practices and question whether to treat these problems only at night or to look for underlying structural discrepancies and treat these problems 24 hours a day. The American Academy of Dental Sleep Medicine has been the leading force in securing an enviable working relationship with the medical sleep community. Their meetings are a gathering place where TMD practitioners meet on common ground, leaving behind the petty squabbling that has plagued the TMD community. Recognizing sleep apnea as a temporomandibular disorder at night opens up a common basis to evaluate that same condition during the day. The TMD Alliance should invite the Academy of Dental Sleep Medicine to join its ranks. The September 2006 legislative update of the NHLBI site states that the Senate bill encourages further TMJ disorder studies as part of an almost three billion dollar budget. All dentists interested in treating patients with sleep disorders or TMD should download the NHLBI paper which can be found at http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf or by typing NHLBI into Google and then entering “TMJ” into the search section. This is vital information that all of us must read, understand, and share with our medical and dental colleagues. We should also contact the ADA and demand that they act responsibly and re-examine the TMD issues and set up a conference that looks at the physiologic aspects of TMJ disorders. The ADA must reclaim the field for dentists and recognize the importance of TMD disorders. The ADA should publish the entire NHLBI paper in its journal and promote the oral-systemic connection of TMD, as it has promoted the connection between periodontal disease and health. I do not advocate specialty status for any TMD or sleep organization, even though more than one of the organizations to which I belong are pushing for specialty with the ADA.
Ira Shapira, D.D.S.
Gurnee, Illinois
References
1. Shimshak DG, Kent RL, DeFuria MC: Medical claims profiles of subjects with temporomandibular joint disorders. J Craniomandib Pract 1997; 15(2): .150-158.
2. Shimshak DB, DeFuria MC: Health care utilization by patients with temporomandibular joint disorders. J Craniomandib Pract 1998; 16(3): 185-193.
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