I read with interest the article "A Model for Predicting Chronic TMD: Practical Application in Clinical Settings," by Dr. Jake Epker and colleagues (October JADA).
The article identified a means of predicting which patients with temporomandibular disorder symptoms would progress to a chronic state. While the accuracy rate of 91 percent predictability for those who would go on to chronic TMD from an acute condition sounded very good, the logic eluded me.
We have the means to diagnose and treat patients with muscle pain, limited opening and joint sounds, thereby preventing chronicity. Do we really need to predict it? History, examination, Doppler and imaging give us a very complete picture of what is happening within and without the joint capsule. Treatments as straightforward as equilibrium are remarkably successful.
It appears that two-thirds of the members of the research team are psychologists, which explains the psychological slant to the research and the article.
From a purely practical standpoint I have to ask, would I use an assessment because it provides me with "the opportunity to initiate alternative or adjunctive modes of treatment, such as biofeedback and cognitive-behavioral therapy, that may significantly decrease the negative consequences of chronic TMD"? Or would I simply eliminate the causes of the problems. Clearly the direct approach with preventative treatment would be preferred over mainly symptomatic treatment or predicting chronicity.
Additionally, many TMD patients have some psychological issues; I don’t believe their TMD stems from those issues. It seems more likely that their TMD problems contribute to their emotional state.
Since I don’t practice in a hospital or at a large university, perhaps I don’t see the extreme cases. The patients with TMD symptoms (as defined in the article) that I do see, almost always exhibit occluso-muscle problems.
If I can load their joints comfortably, establish anterior guidance in harmony with jaw movements, provide even contact in CR and harmonize all teeth vertically and horizontally in the neutral zone, then I can eliminate the symptoms of TMD. If I am unable to achieve all of these requirements, a referral is indicated, but seldom does it go beyond orthodontics.
I believe the profession and our patients would be better served if the National Institutes of Health funded research to discover more efficient and effective ways to treat TMD.
