I am writing in response to Dr. Robert Gatchel and colleagues’ March JADA article, "Efficacy of an Early Intervention for Patients With Acute Temporomandibular Disorder–Related Pain: A One-Year Outcome Study" (
JADA 2006;137:339–47
).
Based on the title and results presented, an early biopsychosocial intervention appears to be recommended for all temporomandibular disorder patients with pain. No distinction—or even recognition—is made between trigger points associated with bruxism, temporomandibular joint (TMJ), inflammation or a closed lock (an anteriorly displaced TMJ disk blocking condylar translation).
If the investigation was confined to the first category, it would be more logical. Delay of specific treatment for the other categories would be clinically irresponsible. If an acute TMJ inflammation or a closed lock were denied appropriate treatment for a year, permanent damage could easily result.1,2
The article states, "Finally, the findings of this study are limited to pain of muscular origin." If the TMJs were not palpated for tenderness, and no relevant history obtained (that is, clicking, episodic locking and a presenting restricted jaw opening), how could the study rule out pain—often from secondary muscle involvement—from TMJ inflammation or a closed lock?
Palpation of 20 muscle sites can be clinically confusing regarding myofascial pain. Are the authors aware that the main jaw-opening muscles cannot be palpated?3,4 If isometric muscle testing is not used, inflamed lymph nodes, an inflamed TMJ or referred pain from other sites or conditions can encourage incorrect conclusions.5
Study patients were encouraged to "continue treatment as usual with their outside health care providers if needed." Since the authors "distributed fliers at local universities and placed advertisements in newspapers," many study participants were not undergoing "usual treatment." Therefore, ongoing treatment for some subjects could confuse the study results. An obvious example: wouldn’t it be relevant for the examiners to be aware of study participants’ usage of prescribed narcotics, nonsteroidal anti-inflammatory drugs or muscle relaxants?
This is the only area of the body where it is inferred that joint and muscle problems are mainly psychological, and the only body area that is diagnosed and treated by dentists, who receive only limited training in muscle and joint diagnosis and treatment.
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