I always appreciate a letter to the editor concerning one of my articles because, often, important issues not highlighted in the article are raised. Dr. Olson’s letter, although well-intentioned, fell far from the mark in his statement that he found "some discrepancies that I feel should be pointed out to the profession regarding patients with temporomandibular disorder, or TMD."
First of all, in terms of graduate students who were trained by Dr. Ellis to make TMD diagnoses, it should be clearly noted that the research diagnostic criteria for TMD, or RDC/TMD—the development of which was funded by the National Institute of Dental and Cranial Facial Research and which subsequently was published by Dworkin and LeResche1—allows for the standardization and replication of studies of TMD because it offers reliable and valid diagnostic criteria that are reproducible among clinical researchers.
These standardized diagnostic criteria—which employ both self-report, as well as a structured evaluation of physical symptoms such as limitations relating to mandibular function, pain and tenderness of the muscles of mastication, the TMJ, and so on—can be administered by individuals who are appropriately trained. This was the goal of Dr. Ellis in training these research assistants.
Moreover, as we have noted in our earlier publications, routine "recalibration" sessions are conducted to be certain that there continues to be a high degree of reliability in these ratings. This RDC has made a significant contribution to TMD research because one of the traditional major roadblocks in the scientific investigation and potential development of effective treatment for TMD had been the often poor agreement among clinical researchers as to which symptoms to include in defining patient samples.
Other than the agreement that the two major clinical features of most TMD patients are pain and dysfunction, patients present unique combinations of symptoms (both physical and psychosocial) that make it difficult to classify them as a homogeneous group.
I suggest that Dr. Olson read the article by Dworkin and LeResche,1 which emphasizes the clinical significance of the RDC in terms of classifying TMD subtypes along two major axes.
This classification system embraces a biopsychosocial perspective of TMD, as well as other types of pain syndromes, and supports the use of multidisciplinary treatment modalities. Indeed, the biopsychosocial model of pain emphasizes the complex and dynamic interaction among physiological, psychological and social factors that often result in, or maintain, chronic pain conditions such as TMD.
There are numerous scientific articles that have demonstrated the heuristic value of this biopsychosocial model. I strongly recommend that Dr. Olson read this literature, as well as become familiar with the RDC/ TMD for a more standard and objective assessment of TMD. A thorough biopsychosocial clinical examination was administered by the clinical research staff when evaluating the TMD patients in this study.
In terms of the second issue raised by Dr. Olson, I am not suggesting that dentists themselves administer psychological measures. With the embracement of a biopsychosocial model, all areas of medicine and dentistry are starting to use consultants to help them evaluate certain aspects of the biopsychosocial functioning of patients. Many dentists have access to psychologists to help them in the administration of appropriate psychosocial measures.
Relatedly, Dr. Olson is correct in pointing out that the MMPI-2 is not the most appropriate test for chronic pain patient evaluations. However, this was not suggested in our article. It was just mentioned as one of the many psychosocial tests that may prove useful for certain patients.
We also indicated that the Multidimensional Pain Inventory, Axis II of the RDC, the Beck Depression Inventory BDI and the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, or DSM-IV, diagnoses were collected on all patients. This was because we wanted to provide the most comprehensive assessment of our cohort of patients to determine which measures might be most suitable for evaluation.
Indeed, in current psychological assessment, the notion that one particular test will provide a total understanding of a patient is a very outdated notion. It usually takes a combination of tests, as well as the integration with physical findings (that is, a biopsychosocial evaluation), to develop a comprehensive understanding of the patient. This is what we attempted to highlight in this article.
We in no way suggest that dentists should be psychologists or that psychologists should be dentists, only that the simultaneous evaluation in both domains needs to be conducted to more comprehensively capture important issues that may prevent the development of TMD chronicity. How this is accomplished depends on the ingenuity of the particular health care professional.
Finally, the third, fourth and fifth issues raised by Dr. Olson were not relevant to the present article. We did not attempt to evaluate traumatic vs. nontraumatic TMD development. This would require another study.
We did not evaluate whether acute TMD patients had other somatic or pain problems.
Again, this would require another study, although evaluating such problems is not included in the RDC Axis I category and are picked up only indirectly using the Axis II dimensions.
Finally, the mention of research on the psychological mechanism of "defense" as related to pain, proposed in the psychotherapy literature, is an outmoded notion embracing an earlier, overly simplistic biomedical approach to dental and medical disorders. The attempt to try to distinguish between psychogenic and functional pain has not proven to be effective in the scientific literature over the last three decades and no longer is employed in current clinical research.
I hope these comments help readers of JADA better understand the current biopsychosocial approach to the assessment and treatment of dental/ medical disorders such as TMD. I would recommend several other readings to more thoroughly acquaint them with this particular perspective.2–4
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