THE EDITOR'S CORNER
When orthodontists are asked to list subjects they would like to know more about, temporomandibular joint generally tops the list. This is not surprising, considering the deficiency of knowledge that has been available to orthodontists in courses and in the literature concerning the diagnosis and treatment of TMJ dysfunctions and disorders. We are in the dark ages of TMJ science and the simple quest for knowledge spurs us on to higher accomplishment in this area. A more mundane prodding comes from the courts which, rightly or wrongly, in recent decisions have begun to forge a link between alleged orthodontic sins of omission or commission and subsequent TMJ problems. Without arguing the merits of the legal case, there is ample reason to give an urgent priority to TMJ study.
Voids tend to be filled. The difficulty or inability to make an accurate differential diagnosis among head, neck, and back pains, the tentative nature of the treatment, and the lack of a cure at the hands of a variety of professionals and semiprofessionals has driven the victims to seek help anywhere and everywhere. This has elevated certain relatively unrecognized and maybe under-recognized therapies. It may be important not to rule out unconventional modalities out of hand, but to immediately take them seriously is not a mature scientific approach.
The field is so beset with lack of solid information and with disagreement over causes and cures, that a practitioner finds it virtually impossible to make a differential diagnosis among the occlusal, muscular, traumatic, pathologic, psychological, and neurological contributors to TMJ problems. There is insufficient evidence to support a contention that most of the treatment systems can dbe applied in specific instances and predictably effect a cure. Thus the tendency to use several modalities at a time. There is confusion as to whether treatments are effective physiologically or psychologically and whether their effect may be temporary.
It is one thing to recognize that physical asymmetries and muscular imbalances are universal, but the expectation of correcting these by creating perfect balance is unrealistic and overlooks the ability of the body to compensate for imbalances. Also, the habit of considering all the signs and symptoms related to the TMJ area as part of one syndrome is probably a deterrent to more specific and effective diagnosis and treatment approaches. We need a serious scientific research effort to sort out fact from fiction and verifiable "truth" from belief.
There have been a fair number of books published on TMJ. Usually, these have multiple authors, with a different one for each chapter. This approach has led to an exaggeration of the fragmentation that exists in TMJ information. Each specialist tends to advance a diagnostic and treatment approach related to his field. Thus, a dentist equilibrates, a surgeon operates, a psychiatrist emphasizes the emotional or psychosomatic aspect.
Many who attempt to treat TMJ symptoms tend to apply the same treatment procedures to all patients. They are gratified when the treatment is successful. When it is not, they may try something else, or dismiss the patient as not being in their realm, or refer to another specialty. We need a lot stronger relationship between identified cause and selected treatment, and the ability to do both.
One could make an educated guess that the professional who knows the most about the teeth and jaws might be expected to be the one who could best be entrusted with the keys to TMJ. The dentist could be the most likely diagnostician of TMJ disorders and general manager of the treatment effort. Indeed, dentists--general dentists, periodontists, oral surgeons, prosthodontists, and orthodontists--have been involved in this way. But, evidence is lacking that dentistry has expanded its horizons to include current knowledge in nerve, muscle, and bone physiology and anatomy to a depth that would permit a combination of medical, dental, psychological, and surgical diagnostic procedures and an optimum evaluation of TMJ problems.
There is room for specialization in TMJ or in head and facial pain. A dentist might require additional education, perhaps an MD degree, but I have no doubt that such an individual would be a valuable professional in his community, overwhelmed with work, and able to make valuable contributions to the advancement of patient care in TMJ and in head and facial pain.
