CRANIO: A 30-YEAR PERSPECTIVE IN A ‘CONTENTIOUS FIELD’
Welden Bell wrote the third guest editorial in our new journal, stating,
“The Journal of Craniomandibular Practice is destined to be the ‘mouthpiece’ for an important segment of dentistry.” I should have realized what the future would bring when I read the title of his thesis: “Peace by Common Consent,” in which he suggested, “this forum can serve to help establish ‘working peace’ among divergent schools of thought, which is an obvious need.” 1 For 30 years, the journal has tried to unite divergent schools of thought. The following are excerpted from editorials published in CRANIO over the years.
In 1988 I wrote an editorial titled, “Intraprofessional Dueling” and related it to a former European practice that was outlawed in the United States after the Civil War. I summarized the professional disagreements: “just as in dueling, neither men nor techniques are necessarily all good or bad. We must be careful not to throw out all the old in the name of progress, or prohibit a natural experimentation with the new.”2
A year later I reviewed “A Decade of Consensus Conferences,” which included dental implants, third molars, pain, and anesthesia and sedation in the dental office. My summary was, “in the past they have clearly not involved an area [TMD] that is quite so broad in scope or so multidisciplinary in practice… The identification of these problems is complex and the treatment of them varied. The logistics of establishing an appropriate panel and making lasting recommendations still remains a conjecture in advisability.”3
In another editorial welcoming the 1990s, I shared my feelings “that the upcoming decade will be a time of more scrutiny and less empiricism. Gone are the days when a cavalier diagnosis of TMJ syndrome is sufficient, either for the patient, our colleagues, or the insurance company. We must now be able to document our diagnosis and justify our treatment.”4 By far the most unfortunate event in the development in the field was the placement of Vitek implants covered with Propast without sufficient clinical trials. In the ‘90s, we included “FDA Notice to Physicians and Patients about the risks of TMJ implants.” The Vitek implants, covered with Propast coating, caused “implant failure, giant cell tumor reaction, bone degeneration,” and unprecedented damage to patients and surgical credibility.5 One study, by Henry and Wolford on Proplast-Teflon implant failure, reported that of 107 patients studied, 94 (87.9%) were females.6
In his editorial titled “What do a Leech and a Handpiece Have in Common?” Dr. Robert Adler stated that, “Dentistry faced a similar dilemma with orofacial pain. Major research efforts over the past decade have shown little or no correlation between orofacial pain and faulty occlusions, jaw positions and short legs.”7 Similarly, Parker Mahan’s editorial, “Teaching Pain and Stress Management” stated, “Head and neck pain and pathofunction covers such a broad array of scientific and anecdotal data that no one specialty can hope to manage those who suffer its ravages. Therefore, it behooves all of us who are interested in this problem to cooperate with each other and interact with each other; even going out of our way to do so. We should put aside our biases and distrusts of the other person if we are to make maximum progress in this worthwhile endeavor.”8
One outstanding, cooperative effort occurred when Doug Phillips, et al, met with representatives from nine major academies and societies from national TMD organizations, which came together to write a “Recommended Guide to the Evaluation of Permanent Impairment of the Temporomandibular Joint.” This was submitted to the American Medical Association (AMA) for inclusion in its Impairment Guides “blue book.”9 This major accomplishment demonstrated how a solid cooperative effort from various independent organizations could be productive for the entire field. It showed how an alliance of TMD organizations could lead in a positive way.
Jeffrey Okeson said it this way in his Editorial entitled “Challenging the Fringe”:
“The existence of fringe information is not wrong, but in fact, very appropriate.” We must continue to challenge our treatment concepts with sound scientific principles so as to uncover more and more truths, enabling better and more effective treatments for our patients.10
Henry Gremillion thought it “might be most appropriate to view TMD cases where occlusion serves as a significant factor, as ‘maladaptive occlusions’…. This term connotes both cause and result,” he wrote. “It takes into consideration the peripheral and central mechanisms currently viewed as being involved with masticatory parafunction and the response to such. It also encompasses the psychosocial aspects as related to initiation and perpetuation of masticatory dysfunctional processes. This term embodies the different aspects incorporated in the biopsychosocial model, whereas the term malocclusion may imply primarily a commonly found structural relationship.”11
In his guest editorial, “Good Science, Bad Science, and Scientific Double-Talk,” Allen Moses reported “The ’expert panel’ at the recent NIH/NIDR Technology Assessment Conference on Management of Temporomandibular Disorders concluded that there is neither data to support many commonly held beliefs in TMD, nor data to support the superiority of any method of management as being better than a placebo.” He stated that, “We are being forced to deal with academic double-talk instead of clinical reality.” Furthermore, Moses wrote, “Funding should be cut off for projects by basic researchers wasting time and money trying to establish what TMD is not.”12
From April 29 through May 1, 1996, the National Institute of Dental Research and the National Institutes of Health Office of Medical Applications Research (OMAR) convened a technology assessment conference on Management of Temporomandibular Disorders (TMD). James N. Campbell, M.D., a neurosurgeon sitting on the panel, wrote, in the Guest Editorial, “A Consensus Panel Looks at TMD,” that he “was struck by the many parallels between the problem of back pain and TMD.” He was also “struck by the scholarship in the field.” “The panel strongly encouraged close cooperation between private practitioners, academics, and the government in conducting focused, well-controlled clinical trials of treatment,” Campbell wrote.13
Pete Dawson responded to Campbell’s editorial with his own: “Why NIH is Wrong About ‘TMD,’”14 in which he wrote, “…the term TMD is used to define many different types of disorders in many different types of tissues. The report fails to differentiate specific types of disorders in its assessment of different treatments and etiologies.” He offered some suggestions to the NIH, if they were serious in finding correct answers (and he believed they were), a few of which included that they, “Evaluate the role of occlusion in relation to orofacial pain, masticatory muscle pain, or TMJ disorders using improved standards of research”; “Re-evaluate the NIH statement that “The pain (of TMD) eventually goes away with little or no treatment”; and “Follow Yancey’s rules for clinical research.”15
One controversy concerned the ADA Specialty Application and its withdrawal. A joint statement outlined four mutual goals to further develop the field. Presidents of orofacial pain and temporomandibular disorder organizations, Robert Adler (AAOP), Barry Cooper (ICCMO), Charles Holt (AAHNFP), and Teri-Ross Icyda (AES) signed this statement. The four common goals were: 1.) To improve diagnosis and treatment of patients entrusted to our care 2.) To share our clinical and research expertise 3.) To support outcome studies 4.) To support education, training, and recognition of professionals who work in this field.16 And in his editorial entitled, “Orofacial Pain Specialty Opposition: A Call to De-Fragment,” Keith Kinderknecht, while speaking for the Alliance, stated that the AAOP- proposed specialty application does not fulfill the ADA’s six requirements for specialty recognition.17
The American Alliance of TMD Organizations, representing nine professional organizations with memberships totaling over 10,000, reacted to an opinion article placed erroneously in the Clinical Sciences section of the JPD in which the authors Greene, Mohl, McNeil, Clark and Truelove responded to critics as “mean spirited.” The Neuroscience Group of the IADR, at their 1997 meeting, asked for signatures from their supporters and American University Teachers of Orofacial Pain Programs (AUTOPP). 18 From these mailings, 120 people signed the endorsement and approximately one third were from outside the U.S.
This Alliance, which represents the majority of practicing U.S. TMD clinicians, voiced their disapproval of using a scientific section of JPD to promote an opinion paper. The Alliance is here for the long haul, with its purpose to support the patients’ well being, and to protect the practitioners’ rights and freedom to practice in the field of TMD within the scope of their care, skill, knowledge, judgment and scientific information.19
While writing “Tribes,” an editorial on failed unity, I quoted advice a dentist grandfather of an oral surgeon colleague of mine received prior to entering dentistry: “’Dentists are an unusual group. They arrange their firing squad in a circle, aiming in.’ Of course this has nothing to do with wet- and dry-fingered dentists criticizing each other’s techniques or lack thereof. I am equally sure it has little to do with misunderstandings and lack of communication among dentists who practice in clinical settings and those who teach in dental schools or those who review for insurance companies.” “What if all these groups “buried the hatchet” so to speak, and decided that it is of common interest to work together on issues where we have major agreement, and resolve differences equitably?”20 Rich Cohen, in his guest editorial proffered, “I feel that patients deserve our combined efforts in addressing the issue of access to care. This will involve concentrating on our similarities and common goals rather than on our differences.”21
In my open letter to the ADA, I asked, “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?”
“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.’” Speaking to the idea that TMD is a ‘women’s problem,’ I wrote, “the most acceptable office percentage is 85% female to 15% male ratio. 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.” “The results of inadequate TMD treatment lead to higher medical expenses; the numbers don’t lie. It’s time ADA, come on along.”22
Noshir Mehta, in his editorial, “A Call To Civility,” said, “I think it is a time for us to take a step back and be professionals; not all researchers are out to get the clinician, and not all clinicians are out to just make money.”23
My first Concepts Editorial in CRANIO 1982 ended with a quote from an unknown author: “It’s not the quarry; it’s the chase. It’s not the trophy; it’s the race.”24 And I invited others to join in the pursuit of knowledge. Many did join in by sending in manuscripts that were accepted for publication. To date, CRANIO has accepted over a thousand manuscripts and guest editorials that have been published. Our editors have worked hard to improve submitted manuscripts that needed improvement prior to publication. And we’ve accepted many others that have needed no revisions. Currently we accept around 48% of all manuscripts that are submitted.
No one has joined in the “pursuit of knowledge” with more enthusiasm and outstanding work ethic than Clifton Simmons, who appears on the front cover of this issue. ‘Clif’ has not only recently edited a leading book in the field of craniofacial pain, but he has also prepared a detailed rebuttal of Dr. Charles Greene’s editorial which was published in the Journal of the American Dental Association (JADA) in September, 2010.
You would think that this field, after maturing for 30 years (and it was not new in 1982), would have agreed on the most basic tenants. Surprise! There is a subset of practitioners who treat most patients psychosocially. While the majority of clinical practitioners treat most patients physiologically or orthopedically. Clifton explains it so well that I will only refer you to the Special Report in this issue (PAGE #). We have had a Special Report section in the journal, which was introduced in the Instructions to Authors 12 years ago. It is so special that this is the first time we have used this section in CRANIO. If you follow Clifton’s logic, you can see that practitioners who deny their patients the benefits of orthopedically correcting their temporomandibular joint problems early on may actually be practicing inappropriately.
How do psychosocial-practicing doctors actually treat their TMD patients? Many, it appears, turn to drugs to alleviate their patients’ pain. There are enough illegal “pill mills” around without some of our well-educated doctors (many of whom may even apply for United States grant money) supplying patients with continuous narcotic prescriptions for their TMD pain. Government agencies and regulators can data mine current state and national pharmacy databases.25 The results could be surprising.
Thirty years ago there were not enough clinically-trained TMD practitioners spread throughout the United States, much less the world, to expect patients to have a real choice in their health care. Now, however, most patients in the U.S. live within an hour’s drive or less of someone who can either treat their problem, or intelligently discuss options and suggest one or more area professionals who can treat their problem effectively. That is a major difference in the past thirty years, and I hope CRANIO has played a role in this development.
It would appear that Dr. Greene provided multiple journals with the same or similar information, likely in a simultaneous submission format. It is not known which publication actually received Dr. Greene’s manuscript first. The JADA thinks it owns the rights, and because it is the largest publication to have received the manuscript, that is probably true. But how can an almost identical submission sent to the American Journal of Orthodontics and Dentofacial Orthopedics (AJODO), which stated that Greene’s work was submitted and accepted in April 2010 (the committee met on March 3, 2010), be explained? It was published in the AJODO July 2010 issue.26 This was two months before the copyright and publication date of September 2010 of the Journal of the American Dental Association.27 Additionally, two more of Dr. Greene’s look-alike articles were published in Quintessence Vol. 41 No. 8, Sept. 201028 and Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology Vol. 110 No. 2, Aug. 201029. Was this a credible practice or just a rush to submit and publish a manuscript before discovery or awareness?
In our journal experience, CRANIO has joined with other world editors to deny publishing rights to those authors who have made similar submissions, even though they were submitted to publications on different continents. So thirty years later, misinformation is still being catapulted into multiple publications under the guise of “the closest thing to date to a true standard of care in this contentious field.”30
I perceive that, at least in the near future, there will still be a need for a publication, i.e. CRANIO, to stand up against weak claims that are accepted by unsuspecting editors who do not have the depth of knowledge to be discriminative in this complex area of dentistry. Welden Bell’s 1983 Guest Editorial said it best. “It should be the objective of every researcher and clinician to dedicate his or her efforts to finding and identifying truth, regardless of where ‘the chips may fall.’ For, in the end, truth will sit in judgment.”1 It is even possible, at this 30-year milestone, that the need for an honest publication may be necessary for another 30 years. Who knows what this “contentious field” may require.
REFERENCES
1. Bell, WE: Peace by Common Consent. J Craniomandib Pract 1983; 1 (3):13
2. Lunn, RH: Intraprofessional Dueling. J Craniomandib Pract 1988; 6 (2):100-101
3. Lunn, RH: A Decade of Consensus Conferences. J Craniomandib Pract 1989; 7 (3):171-172
4. Lunn, RH: Farewell 80’s, Welcome 90’s. J Craniomandib Pract 1989; 7 (4):257-258
5. Lunn, RH: The Decathlon Dentist Adds A New Event. J Craniomandib Pract 1992; 10 (3):165-166
6. Henry CH, Wolford LM: Treatment outcomes for temporomandibular joint reconstruction after Proplast-Teflon implant failure. J Oral Maxillofac Surg 1993; 51(4):352-360
7. Adler, RC: What Do A Leech and a Handpiece Have in Common? J Craniomandib Pract 1993; 11 (1):1
8. Mahan PE: Teaching Pain and Stress Management. J Craniomandib Pract 1993; 11 (2):82
9. Phillips, et al.: Recommended Guide to the Evaluation of Permanent Impairment of the Temporomandibular Joint. J Craniomandib Pract 1989; 7 (1):13-21
10. Okeson, JP: Challenging the Fringe: J Craniomandib Pract 1995; 13 (3):139-141
11. Gremillion, HA: TMD and Maladaptive Occlusion: Does a Link Exist? J Craniomandib Pract 1995; 13 (4):205-206
12. Moses, AJ: Good Science, Bad Science, and Scientific Double-talk J Craniomandib Pract 1996; 14 (3):170-172
13. Campbell, JN: A Consensus Panel Looks at TMD. J Craniomandib Pract 1996; 14 (3):173-174
14. Dawson, P: Why NIH is Wrong About TMD. J. Cranio Practice 1997; 15 (1):1-3.
15. Yancey SM: Ten rules for reading clinical research reports. Am J Orthod and Dentofac Orthop 1996; 5:558-564
16. Adler R, Cooper BC, Holt C, Icyda TR: ADA Specialty Application Update. J Craniomandib Pract 1997; 15 (4):271
17. Kinderknecht, K: Orofacial Pain Specialty Opposition: A Call to De-Fragment. J Craniomandib Pract 2000; (18): 73-77.
18. Temporomandibular disorders and science: a response to the critics [letter]. To: All members of IADR/AADR Neuroscience Group and/or AUTOPP, June 1, 1997
19. Tilley LL et al.: A Look at the Facts. J Craniomandib Pract 1998; 16 (4):207-210
20. Lunn, RH: Tribes. J Craniomandib Pract 2006; 24 (1):3
21. Cohen, J: Working Together Toward Common Goals. J Craniomandib Pract 2005; 23 (1):1
22. Lunn, RH: It’s Time ADA, Come on Along (An open letter to the American Dental Association). J Craniomandib Pract 2010; 28 (2); 76-79
23. Mehta, N: A Call to Civility. J Craniomandib Pract 2011; 29 (2):92
24. Lunn, RH: The Emergence of a Concept. J Craniomandib Pract 1982; 1 (1):10A
25. Donaldson, M: The Spider-Man Principle. JADA 2011: 142 (11): 1229-1231.
26. Am J Orthod Dentofac Orthop 2010; 138:3-4
27. J Am Dent Assoc 2010; 141; 1086-1088
28. Quintessence International 2010; 41 (8):623-624
29. OOOOE 2010; 110 (2):137-139
30. Green, CS: Managing the Care of Patients With Temporomandibular Disorders: A New Guideline for Care. J Am Dent Assoc 2010; 141;1086-1088
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