Is It a Shot in the Dark?
On March 24, 1989, the ABC television program 20/20 aired a segment on TMJ disorders. It presented a picture of suffering patients who may spend thousands of dollars with numerous doctors of various disciplines without getting a cure, and of lack of agreement within the dental profession on how to treat TMJ pain. There was more than a suggestion that even at universities the various disciplines are groping in the dark, and that in private practice charlatanism and greed are spurred on by dentists' lack of busyness.
The program concluded that those treating TMJ pain should start conservatively with heat, massage, pain medication, and soft food before even considering irreversible therapy such as surgery.
One views a program like this one with mixed feelings. In 15 minutes it certainly got to the heart of the problem. However, it is unfortunate that all health-care professionals were daubed with the same brush. In emphasizing the dark side of the TMJ problem, the program failed to show that there are many dental practitioners who are striving to find out how to separate the patients who are going to get better spontaneously and those who have a more deep-seated problem, many who are practicing ethically, many who are not making a fortune on TMJ.
There is irony in the probability that the dentist with the TMJ practice who was presented in a somewhat unfavorable light on the TV broadcast is adored by a large majority of the people he treats. If he, as it appears, treats everyone with TMJ symptoms, he probably is treating many people who have muscle problems that would respond spontaneously, as the program implied; and he probably is getting good results, as he says, in 80-90% of his cases.
The national exposure of disarray in the diagnosis and treatment of TMJ disorders, and the increasing jeopardy of malpractice suits--and the two are not unrelated--raise some real questions about the public perception of the integrity of orthodontics and the effect that may have on the behavior of practicing orthodontists.
The specialty of orthodontics is not responsible for the lack of definitive answers to TMJ problems. It is not a black mark on orthodontics that it has not yet produced the cure of TMJ dysfunctions and disorders. We are a group of clinicians trying to do the best we can with what we've got. We must be careful that we are not like the TMJ specialist who sees a TMJ case in every click, that we do not see an orthodontic case in every TMJ dysfunction.
This is not a time for handwringing nor for finger pointing. It is a time for practicing orthodontists to take a look at the adequacy of their diagnostic procedures, their case presentation and other patient education procedures, and their evaluation of treatment results.
With regard to diagnostic procedures, instrumentation of various kinds has recently been developed to track jaw movements, to diagnose joint behavior, to record muscle activity. The problem that the practitioner faces is that a considerable investment of time and money is needed to use such equipment, with no assurance that it is the answer or that some new development will not make it obsolete. Those practitioners who do invest the time and money--the risk-takers--are to be commended. However, they also run the risk of having so much time and money invested in one idea that they can't abandon it for another.
It is not to the credit of the research community--if there is a research community--that it has not sorted out the value of the instrumentation that has been developed so far or pointed a direction for progress in that area. It has been left to the Jankelsons and the Slaviceks to develop the equipment and the rationale for its use, and to try to interest practicing orthodontists in both.
X-rays and arthrography have not been widely accepted as routine diagnostic tools; perhaps magnetic resonance imaging may prove more useful. However, the expense of the equipment and the need to develop good scientific data will likely delay the application of this technology. There may be some interesting information from arthroscopic surgery, and it may assume a greater role in TMJ diagnosis and treatment as more experience is gained with it. Three-dimensional computer models are also a key that will be tried in the TMJ door.
One good thing to come out of the national spotlight on TMJ is that sufferers may be more patient about demanding a cure, more reluctant to spend their money on unconventional or unscientific methods, and more questioning about proposed treatment. And doctors may be more prone to improve their own education, to spend more time on patient education, and to document the TMJ condition of patients whose treatment they do undertake.
Practicing orthodontists must dispel the image of being willing to take a shot in the dark and, like so many Inspector Clouseaus, bumbling accidentally upon a solution.