Editorial:

“Why wouldn’t my dentist know that my jaw joint was going bad?” asks the all too often, perplexed dental patient. “Dental schools don't have enough time to teach about the TMJ in an already crowded curriculum further stressed with new and improved materials and techniques in most disciplines of dentistry. They just don't have any additional time,” I alibi. I'm getting tired of making excuses for the American Dental Association (ADA) and dental schools when the honest truth is that they are just indifferent.

How can you continue to ignore the dysfunctional temporomandibular joint while allowing dental students to place restorations on patients’ teeth that are attached to an unhealthy jaw? Shouldn’t the first step be to decide whether or not the main controlling joint is in a stable condition? Why continue to place good dental work on jaws that are destined to cause the patient more pain and problems?

Thirty years ago, when most of us were just learning about internal derangements, it was understandable that patients couldn’t find a good TMJ dentist in their immediate area. Now it’s embarrassing that more “good dentists” aren’t diagnosing early onset temporomandibular joint problems. The periodontists have done a fine job of getting all dentists and dental hygienists to probe around in their patients’ mouths for five mm pockets. It takes a lot less time to place your two fingers over the patients’right and left TMJs and feel for popping, clicking, and locking. This followed by a few well-placed questions should help the practitioner uncover a TM joint problem in the unsuspecting patient who is complaining of headaches. 

I am not the only one who has asked these questions. I learned from many mentors who were knowledgeable long before I would discover their truths for myself. A few of my mentors were: Weldon Bell, L.D. Pankey, Parker Mahan, Bill Farrar, Robert Ricketts, Clyde Wilkes, Harold Gelb, Peter Dawson, Peter Neff, Mariano Rocabado, Jack Haden, Janet Travell, and the list goes on.

Why then has it taken so long to implement these known concepts into the normal dental curriculum? Some would say, “a lack of published information.” In response to that, I would point out the 110 issues of CRANIO: The Journal of Craniomandibular Practice, as well as the Journal of Orofacial Pain, and other scientific journals whose manuscripts have and still are validating the basic concepts over and over again. Also, just this past year (2009), two new excellent resources have been published. One is a book by Clifton Simmons entitled, “Craniofacial Pain: A Handbook for Assessment, Diagnosis and Management” with 17 clinically practicing contributors.1 The other is a book by Noshir Mehta entitled, “Head, Face, and Neck Pain - Science, Evaluation, and Management: An Interdisciplinary approach.” It has 37 chapters, 722 pages and some 59 astute contributors.2 I point out these two books to show evidence of the maturity of this field.

What if you, ADA, choose not to accept these 30 plus years of labor and knowledge that have been prepared on your behalf to advance the profession of dentistry through better service to our patients? Who will assume the leadership—possibly medical orthopedics, ENT, osteopathic medicine, or even the chiropractic field? This information has been accomplished and undergirded with documentation for you. It’s been a long time since ADA President Robert H. Griffiths held “The President’s Conference on the Examination, Diagnosis, and Management of Temporomandibular Disorders” in Chicago in 1982. You need to show current involvement in this important area of development. 

You did a good job selecting Oral Maxillofacial Radiology as your 9th specialty area—what about now acknowledging TMD as well? It’s time ADA, come on along.

Gordon Christensen said in Dentistry Today (February 2000), “The three major diseases we treat are caries, periodontal disease, and occlusion. Occlusion remains the major untreated disease in dentistry today.”3 I personally would modify occlusion disease to include all TMJ, head, and neck pain. There are now sufficient Cone Beam C.T. units either in the offices of TMD practitioners or just down the street to provide an upgraded diagnosis of maxillofacial tumors, cervical calcifications, which could lead to carotid artery disease, unrecognized temporomandibular osteoarthritis, and/or developmental jaw malformations. Haven’t you been preaching for the last few years how dentistry should lead in medically relevant health issues of the head and neck? It’s time ADA, come on along.

Your appointment of Kathleen O’Loughlin as executive director is refreshing. However, for decades, your male-dominated boards have understood that TMD is a women’s problem. The most accepted office percentage is 85% female to 15% male ratio.4 Little, if anything, has been done to advance women’s health. Hopefully, there will be a more appropriate, apolitical consideration given this issue, in both your supported research and endorsed policy. It’s time ADA, come on along. 

Surely by now, ADA, you are familiar with the Shimshack studies that were published in CRANIO in 1997 and 1998.5,6 You should be, because I discussed the findings over the years with several members of your executive board. The study shows that out of 692,707 Blue Cross Blue Shield members, 1097 matched exactly on all four criteria (age, sex, relationship, and employer group). They were divided into two categories: a. patients with a TMJ diagnosis (TMJ population) and b. patients without a TMJ diagnosis (non-TMJ population). Over a two-year period, the amount paid out for the non-TMJ population was $5,406,835 while the TMJ population was $10,814,535 or almost exactly twice as much and required only a diagnosis. It did not follow up on case completions or finalized treatment results. It does, however, clearly show the impact on the patient’s health, involving treatment in other medical fields, such as the digestive system and musculoskeletal system, etc. Pregnancy was the only medical claim that was the reverse (or diminished). Apparently, if most TMD patients have headaches, then fewer pregnancies will result. These numbers show the significance of a TMD diagnosis. The patients, diagnosed and treated earlier, would become healthy sooner,7 thus using fewer insurance dollars and saving insurance companies money. Delayed care, conversely, leads to chronic cases that are less amenable to early inexpensive intervention.  The results of inadequate TMD treatment lead to higher medical expenses; the numbers don’t lie. It’s time ADA, come on along.

Now that President Obama and Congress have passed and signed health care changes, there is still the need for reason and logic to prevail. Why not show the American public how an early diagnosis and treatment of TMJ problems could save 25-50% in medical care costs involving a TMD diagnosis? This estimate doesn't even include time lost from work. One source states that facial pain conditions alone cost approximately $1.9 billion per year, and the quality of life costs for the facial pain patient are often incalculable.2 A Swedish six-year study emphasized the benefit of TMJ treatment in reduced costs to society of days of sick leave are more than five times the treatment costs for the patients.8

The field of TMJ associations has unified under The American Alliance of TMD Organizations9 (an alliance of TMD organizations, Chris Brown, Chairman, Versailles, IN). The Alliance is comprised of ten groups representing over 16,000 practitioners. The member organizations represent most of the major TMJ practitioners. Their bylaws allow support for various projects and positions that a majority of the groups accept. This is a positive example of the TMD field solidifying its leadership. 

Like a good general who sends his scouts out first to assess the situation, we have been doing this for you for years. Now it has been done ADA; the field is scouted, and victory is assured. It’s time ADA, come on along. 

                        Riley H. Lunn, D.D.S., Editor

                        Chattanooga, Tennessee

 

References

1. Simmons HC, ed.: Craniofacial pain: a handbook for assessment, diagnosis and management.          Chattanooga, TN: Chroma, 2009.

2. Mehta NR, Maloney GE, Bana DS, Scrivani SN, eds.: Head, face, and neck pain: science, evaluation, and management. Hoboken, NJ: Wiley-Blackwell, 2009.

3. Christensen G: The future of dentistry. Dentistry Today 2000; 66(2):39-41.

4. Lunn RH. Should TMD be a woman's issue? J Craniomandib Pract 1995; 13(3):142.

5. Shimshak DG, Kent RL, DeFuria M: Medical claims profiles of subjects with temporomandibular joint disorders. J Craniomandib Pract 1997; 15(2):150-158.

6. Shimshak DG, DeFuria M; Health care utilization by patients with temporomandibular joint disorders. J Craniomandib Pract 1998; 16(3):185.

7. Simmons HC, Gibbs SJ: Anterior repositioning appliance therapy for TMJ disorders: specific symptoms relieved and relationship to disk status on MRI. 2005; J Craniomandib Pract 23(2):89.

8. Bjorne, A, Agerberg, G: Reduction in sick leave and costs to society of patients with Meniere's Disease after treatment of temporomandibular and cervical spine disorders: a controlled six-year cost benefit study. J Craniomandib Pract 2003 21(2): 143.

9. The American Alliance of TMD Organizations:

American Academy of Craniofacial Pain

        American Academy of Pain Management

        American College of Prosthodontics

        American Equilibration Society

        International Association of Comprehensive Aesthetics

        International Association for Orthodontics

        International College of Cranio-Mandibular Orthopedics

        Pennsylvania Craniomandibular Society

        Sacro Occipital Technique Organization,

        Tennessee C.R.A.N.I.O.