"Les différences entre les hommes and les femmes sont importantes!"
We appreciate the opportunity to respond to Dr. Marbach’s comments regarding our article. We believe that the points he raised are relatively appropriate ones, although all are issues that can be explained or clarified.
First of all, Dr. Marbach expressed concern regarding the designation of acute and chronic categories. Some explanation of our criteria for classification is in order, as the statement in our article was admittedly somewhat vague because of space limitations.
We considered patients to have acute TMD if they had never been diagnosed or had been diagnosed less than six months before our evaluation. As part of that definition, we considered the "seeking of treatment" to also serve as an indicator of the presence of symptoms, even if a formal diagnosis never had been given. Therefore, a person who had never sought treatment for his or her symptoms, or had only done so within the six months before evaluation, would meet our criterion for acute.
Furthermore, we were not as reckless as Dr. Marbach would have the reader believe in making our classifications. Any questionable classifications were discussed at weekly research team meetings, and the dentists involved in the study made case-by-case decisions regarding group placement.
In using these criteria, it was our intention to remain as close to the accepted definition of acute as possible, while still maintaining as much objectivity as possible. We decided that we would not rely solely on a patient’s report of symptom onset, but instead require some "seeking of treatment" as a criterion—an act that would be more likely to have a specific date associated with it.
Unfortunately, the large research project that this article came out of was begun in 1994. Therefore, we set our study criteria before the availability of Raphael and Marbach’s1 important article that suggests patient report of pain onset is reliable. I also would like to point out that our definition of acute and chronic is one that has been used in several other recent studies coming out of our research project.2,3
Regarding Dr. Marbach’s second concern, namely questions regarding the grouping of patients by RDC4 classification, a few clarifications should be made. To begin with, although not listed in the article, the percentages per group were as follows:
- – men with acute TMD: Group I, 25 percent; Group II, 25 percent; Group III, 29.2 percent;
- – men with chronic TMD: Group I, 41.3 percent; Group II, 34.8 percent; Group III, 26.1 percent;
- – women with acute TMD: Group I, 31.4 percent; Group II, 43.1 percent; Group III, 45.1 percent;
- – women with chronic TMD: Group I, 67.1 percent; Group II, 38.8 percent; Group III, 51.8 percent.
Although women were diagnosed more frequently with Group I and Group III disorders than men, there were also trends from acute to chronic in both men and women as discussed in our article. In addition, differences were found within the groups of disorders as described in our article.
Group II disorders were not omitted from analysis. However, they were not presented in Table 2 simply because only significant findings were included. There were no significant differences between groups on this variable. It became impossible to try to include every variable examined. Thus, for the sake of space, if a variable had no significant findings it was not included in the tables.
Dr. Marbach also expressed concern that "proportions of each TMD group, broken down by sex and chronicity, in no category totaled 100 percent (see Table 2)." We should point out that each percentage represented in both Table 1 and Table 2 is its own separate entity and represents separate groups of patients and separate variables.
For example, in Table 2, 67.1 percent of women with chronic TMD are diagnosed with a muscle disorder. That implicitly means that 32.9 percent of women with chronic TMD did not have a muscle disorder diagnosis.
Regarding Dr. Marbach’s concern that studying groups by gender or by chronicity is not as accurate as looking at groups by RDC diagnosis, we agree that TMD is heterogeneous and that differences exist between men and women; that is a primary reason why we conducted this study.
Moreover, although this heterogeneity exists in the groups as we chose to divide them, we feel that it is important to examine the biopsychosocial differences expressed by men and women. This should serve as the basis for further research, perhaps looking at the sexes by group of RDC disorder, and it should serve as a beginning guideline for establishing an understanding of the difference between men and women with acute or chronic TMD.
Given the fact that RDC grouping was taken into account in our analyses, we feel confident that the differences reported in our study are not merely "the result of differences in the prevalence of the different disorders by sex and not sex itself." This was not borne out in the prevalences noted among groups in this study.
Furthermore, we feel that to suggest that sex is a "demographic classification variable" that serves as a "proxy" for the more important variable of TMD subtype is also inaccurate. Again, after separating by sex, we also examined differences in subtype of TMD and compared those findings between acute and chronic groups. As our data revealed, there were some important differences in grouping that existed not only between men and women but also between acute and chronic patients.
We feel that such differences are important to study. Yes, the resulting psychological findings could at least partly be attributed to differences in prevalence of different TMD groupings. However, we also feel that being a man or woman plays a role in the psychological presentation of a person with any form of TMD. So while it may be more accurate to decide on the use of different physical treatments based on the subtype of TMD, our research suggests that it may be more accurate to decide on the use of different psychologically based treatments based on sex.
Dr. Marbach’s final point is that the article did not present "evidence for the reliability of either TMD or psychiatric examination procedures. This is especially important given that a clinical psychology graduate student conducted both the TMD diagnostic examinations and, apparently, the psychiatric examination."
We would refer the reader to Dr. Gatchel’s response to Dr. Olson’s letter to the editor (April JADA) regarding the use of the RDC in this study. Regarding psychological assessments, most of the measures used are self-report in nature and do not require a trained administrator.
The Structured Clinical Interview, or SCID, was administered by graduate students who had been trained in its administration. Interrater reliability was checked by the psychologists involved in the study and was found to meet the standards noted in the literature on the SCID.5–7 Furthermore, studies have indicated that both clinically experienced interviewers and newly trained people display good interrater reliability and accuracy in diagnosis using this measure.8
We hope that these responses have answered Dr. Marbach’s concerns and have helped clarify issues not totally crystallized in our article. (Les différences entre les hommes and les femmes sont importantes!)
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