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American Pain Society
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Joan Wilentz, MA, Department Editor
Joan Wilentz, MA
Controversy attends almost every aspect of temporomandibular disorders (TMDs)—the umbrella term used to describe conditions of pain and dysfunction involving the tissues in or around the jaw joint. Even the term TMDs invites the wrath and scorn of some patients, providers, and researchers. In the hope of shedding more light than heat, the National Institute of Dental Research, in collaboration with the National Institutes of Health (NIH) Office of Medical Applications of Research (OMAR), convened a Technology Assessment Conference on the Management of TMDs from April 30 through May 1 of this year on the NIH campus. Cosponsors included the National Institute of Neurological Disorders and Stroke, the National Institute of Nursing Research, the National Institute of Arthritis and Musculoskeletal and Skin Diseases, and the NIH Office of Research on Women's Health.
Interestingly, this meeting was billed as a technology assessment conference—a term OMAR adopts for meetings in which the state of the science may not be mature enough to achieve the level of agreement among the experts that attends OMAR's other type of meeting, a consensus development conference. The format for both types of meetings is the same: An invited panel of scholars (which includes members of the public) acts as an impartial reviewer of findings presented by experts in the field. The panel addresses a set of questions posed by a planning committee and, during the course of the conference, questions the speakers and takes part in a general discussion with the audience. In addition, the TMD meeting included formal testimony presented by representatives of professional and patient groups. The panel then meets in closed session to draft a document addressing the questions that have been posed and making recommendations. It presents the highlights at a press conference held on the last day.
The TMD conference was noteworthy for being the best-attended OMAR meeting in history-more than 1,000 people were in the audience-and also one in which deliberations were among the lengthiest. Panel members completed their draft at 4 am of the last day.
And no wonder it took so long. During the course of the conference panelists heard viewpoints ranging from investigators who decried the lack of solid diagnostic criteria and controlled clinical trials to providers who had no doubts as to the causes of TMD and the effectiveness of their treatments. Indeed, it was the intent of the organizers to have all points of view represented and thus to open a dialogue. Some told the panel that stress was the ultimate culprit and that patients' problems could be solved by teaching them not to lean on their jaws or subject the mandible to other kinds of stress; others contended that a form of occlusal therapy in childhood involving grinding the surfaces of the teeth would prevent a TMD in maturity; still others spoke to the success of orthodontic procedures or surgery. Of course, there were various combinations of the points listed above, along with a range of pharmacological approaches.
Not surprisingly, the panel's conclusions were eminently cautious, calling for much-needed research, particularly randomized controlled clinical trials. “The absence of reliable scientific data has led to confusion among dentists and physicians regarding when and how to treat TMD,” said panel chair Judith E.N. Albino, PhD, president emerita and professor of psychiatry at the University of Colorado Health Sciences Center in Denver, in a postconference press release. “The good news, however, is that for most people initial TMD pain is not a signal that a serious problem is developing. Only a small percentage will develop significant, long-term symptoms,” she said.
The panel accepted the estimates of epidemiologists that more than 10 million Americans have symptoms associated with TMD, and that most often, the problem is seen in women who are between 20 and 40 years old. The panel recommended that the initial work-up of a patient should include a thorough medical and dental history, in addition to a physical examination, which could include laboratory analyses, imaging, and a consideration of psychosocial factors. An assessment of the level of pain and dysfunction and the extent to which they interfere with or diminish the patient's quality of life is also important. This initial work-up may uncover systemic disease, such as arthropathies, or overt joint disease, such as cancer, which may dictate a course of treatment.
Because most cases of TMD are self-limiting, however, and as a number of therapies result in improvement in symptoms, the panel cautioned against invasive or irreversible treatments in the initial management of TMDs. Noninvasive approaches would include pharmacologic pain control, physical therapy, and the use of (reversible) intraoral appliances, along with supportive patient education.
For those patients in whom symptoms persist, the panel again urged caution, recommending analgesic management consistent with what is done in the case of other serious chronic pain conditions. In the absence of data from randomized controlled clinical trials, the panel offered no recommendations with regard to specific kinds of surgical intervention (arthrocentesis, arthroscopy, arthrotomy/arthroplasty, condylotomy, and orthognathic surgery). It was also mindful of the unremitting pain, dysfunction, and systemic complications that have commonly occurred as a result of surgery in which the joint was replaced with an alloplastic implant that failed.
Patients and patient advocacy representatives in the audience responded favorably to the panel's statement with its urging of caution and recommendations for extensive research (not only in terms of clinical trials, but in basic research on etiology and pathogenesis, the need to develop better diagnostic methods and a valid classification system, and the importance of conducting natural history and epidemiological studies). Some who espoused specific causes or treatments were less satisfied, and some questioned the panel's impartiality. But for many in the audience, the very fact that the planning committee assured the presentation of a wide range of divergent views spoke to the fairness of the conference. That controversy persists points to the need to broaden and deepen communication between the research and practitioner communities and between them and the public. In that sense, the TMD conference has made a significant contribution.
The complete text of the panel statement is available on the NIDR home page on the World Wide Web—http://www.nidr.nih.gov (click on News, Publications & Health Information and then on News & Announcements).
Joan Wilentz is chief of the planning and legislative branch in the office of the director of the National Institute of Dental Research. Note: Opinions expressed in this department are those of the department editor; they do not necessarily reflect the views of the National Institute of Dental Research.
