Updated Statement on TMDs Generates Negative Response

Editor’s Note: On October 6, 2010, JCDA.ca published a Debate & Opinion article about the revision of the American Association of Dental Research’s science information statement on temporomandibular disorders (TMDs). Our intent in publishing the article was to bring the updated statement to the attention of JCDA readers.

We subsequently received over 30 letters from across the globe in response to the article. Due to space constraints, we have selected 5 of these letters for publication. I believe these are a good representation of the replies we received, as many letters touched on similar themes and criticisms.

The authors’ response can be found at the end of these letters.

I am writing in response to information recently published in JCDA¹ that, if unchallenged, could threaten my ability to continue providing the life-changing, scientifically based, neuromuscular dentistry that I currently practise. This same information was also published in JADA² and the Journal of the OOOOE.³

Having practised in Ontario for the past 5 years since returning from the United States, I have firsthand knowledge of the damage that the biased findings of Dr. Greene have had on the profession and on the public’s ability to receive predictable care for chronic pain. Because the foundation of Ontario’s oppressive “guidelines” for treating temporomandibular disorder (TMD)⁴ are derived in part from Dr. Greene’s philosophy, it is worth noting that the Royal College of Dental Surgeons of Ontario were defeated in the Ontario courts when they were put to the test. As far as I am aware, Ontario remains the only jurisdiction in North America to have TMD guidelines that are so out of line with commonly accepted treatment modalities within orthodontics, oral surgery and prosthodontics.

Dr. Greene’s attempts to outlaw the use of electronic instrumentation are well-documented. To allow his proposed TMD guidelines to become the standard of care would cause untold damage, including an increase in the mortality of patients suffering from chronic pain. Dentistry’s management of TMD is probably one of the few remaining (and possibly the only) medical specialties that consistently relies so heavily on a patient’s subjective symptoms to establish a diagnosis and treatment plan. Can you imagine an oncologist not using blood studies, or a cardiologist not using an EKG? It is hard to imagine why Dr. Greene continues to so fervently block the scientifically justified place of instrumentation in gathering objective data to support a physiologically based diagnosis.

It is not my concern if Dr. Greene believes in neuromuscular principles. But it is my grave concern that one person, who is clearly ignorant of the relevant and abundant science in this area, can wield so much influence in such a divided field of dentistry. I treasure the privilege that I have earned with my doctorate degree to make judgments based on the evidence, as well as the diagnostic information that I feel is appropriate to gather on my patients. It is my sincere hope that the passionate outpouring you are receiving will make CDA seriously re-evaluate the due diligence (or lack thereof) that has occurred in allowing this material to be published as fact. If it can be measured, it is a fact. Otherwise, it is simply an opinion.

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I take great offence at the recommendations for a TMD standard of care presented by Dr. Greene and his co-authors.¹ I suffered from a worsening TMD condition for 14 years (1986–2000). As a 1989 graduate of the University of British Columbia dental school, I had access to both academic and practising “TMD experts” who espoused the same theories as Dr. Greene. I was provided with no less than 5 different occlusal splints over this time period, with little to no relief. Instead, my symptoms progressively worsened. I went from clenching and moderate headaches to severe daily headaches, left joint pain and severe neck pain. I took the advice of my instructors and attending TMD experts and tried to “manage” my symptoms. This involved daily use of NSAIDs and, eventually, evening alcohol use. Near the end of this 14-year period, I was prescribed amitriptyline. This eliminated the need for alcohol but left me in a cognitive haze. It was a miserable existence.

In 2001, I received a removable neuromuscular appliance. Within a month, my symptoms were nearly 100% resolved. From time to time, the appliances have required replacement because of the acrylic breaking. When the appliance was being re-fabricated, my symptoms rapidly returned. This led me to have my teeth orthodontically moved into position to support the new orthopedic position of the mandible. I would now consider myself to be cured. I no longer need to “manage” my condition. And, by the way, I would be insulted if anyone suggested that my problem was psychological.

It is time for dentistry to enter the new millennium. Those who are uncomfortable with technological advances should either take adequate training to gain understanding or step aside.

Cite this as: J Can Den Assoc 2010;76:a158

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I appreciate JCDA informing Canadian dentists about the American Association of Dental Research (AADR) statement update on TMD.¹ As JCDA readers probably know, the vast majority of this statement was originally released in 1996. That said, I respectfully question its inclusion in the Debate & Opinion section of JCDA. As a position statement authored by Dr. Greene and colleagues, peer-reviewed and adopted by the AADR, it certainly would be better placed under the “Research” heading. Maybe it will attract more readers where it currently resides, but I for one would hope that, considering the source and the authors, there is very little to “debate.” This is science at its best and, like it or not, very little evidence-based arguments can be made against this statement.

Cite this as: J Can Den Assoc 2010;76:a159

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I am writing to express the disappointment I felt when reading the opinion article by Dr. Greene and colleagues in JCDA.¹ I was very surprised that Dr. Greene has been publishing the same views in JADA² and the Journal of the OOOOE.³ It appears that he has an agenda against contemporary, progressive, physiologic-based dental treatment.

Dr. Greene is apparently a proponent of science and evidence-based dentistry. However, he fails to adhere to these principles when he suggests that it has become widely accepted among pain experts in the medical and dental professions that pain conditions like TMDs must be managed within a biopsychosocial framework. There are no evidence-based, peer-reviewed scientific references accompanying this opinion or the following excerpts from the American Association of Dental Research’s updated policy statement⁴:

"The consensus of recent scientific literature about currently available technological diagnostic devices for TMDs is that, except for various imaging modalities, none of them shows the sensitivity and specificity required to separate normal subjects from TMD patients or to distinguish among TMD subgroups."

"Studies of the natural history of many TMDs suggest that they tend to improve or resolve over time."

Dr. Greene’s inflammatory article compelled me to write my first letter to a dental journal in 27 years of practising dentistry. Despite losing battles at the American Dental Association and Food and Drug Administration levels, Dr. Greene has been pursuing a flawed political agenda for over 25 years. He has repeatedly presented a handful of flawed research papers as “evidence” against neuromuscular devices, choosing to ignore in his biased JCDA article a significant body of peer-reviewed literature in support of neuromuscular devices and technologies.

Cite this as: J Can Den Assoc 2010;76:a160

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I read with great alarm the opinion piece by Dr. Greene and colleagues,¹ which tries to set a ‘standard of care’ in the treatment of patients with TMDs. However, the article was not about standard of care treatment. It was primarily an attempt to discredit the use of noninvasive, independent, objective instrumentation (e.g., electromyography, computer mandibular scanning, sonography) and to brand these technologies as being below standard of care.

I realize that there is still much to be done with respect to research in the use of these technologies, such as the K7 instrumentation by Myotronics which I favour. But to completely discredit this methodology is self-serving, and may even be criminal.

Over the last 9 years, I have had the good fortune to work successfully with patients with orofacial, head and neck pain conditions, the vast majority of these conditions resulting from trauma. The independently verifiable, non-biased K7 instrumentation has been crucial in helping me to conservatively assist these patients in returning to their life as it was before the trauma. I have always taken a team-based approach to wellness, using reversible, nondrug, nonsurgical treatment, including intraoral orthotics, physiotherapy, massage therapy, chiropractics, kinesiology and psychology (where indicated). The goal is to get our patients off heavy medication use and back to a normal life.

The biopsychosocial approach Dr. Greene touts as being a standard of care is deeply flawed, as it recommends drug therapy to manage pain and the psychological effects of living with chronic pain, and time to wait for the body to adapt to a pathologic state. How can you call that a standard of care? How can that be in the best interest of our patients?

I am also disappointed with the editor of JCDA for publishing this opinion piece. It has also been published simultaneously elsewhere.^2,3 Although you publish a statement saying that the authors’ opinion is not necessarily that of the Canadian Dental Association, you give the appearance of support by allowing it to be published at a time when it appears in other journals. This is unprecedented in the academic world. Shame on you!

The American Association of Dental Research (a very small organization of about 300 members worldwide, not to be confused with the International Association for Dental Research) is trying to set a standard of care. I strongly oppose its efforts. In my practice, I could not successfully perform my conservative, reversible, noninvasive therapy without the K7 instrumentation that supports my diagnosis and treatment implementation. My K7 only provides data. What I do with the data assists my patients in restoring their lives. Why are you, Dr. Greene et al., afraid of the data this instrumentation collects?

Cite this as: J Can Den Assoc 2010;76:a161

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Response from the Authors

Numerous letters have been sent to JCDA criticizing our article¹ regarding the recent revision and update of the American Association of Dental Research (AADR) statement on temporomandibular disorders (TMDs).² We would like to thank JCDA for giving us an opportunity to provide a general response to all of these letters.

Because one of the major themes in these letters was a criticism of the AADR itself, we felt that JCDA readers would appreciate knowing more about this organization and its process for the development of its science information statements.

The AADR is the largest division of the International Association for Dental Research, and it has more than 3900 members in the United States. Its mission is: (1) to advance research and increase knowledge for the improvement of oral health; (2) to support and represent the oral health research community; and (3) to facilitate the communication and application of research findings. To fulfill the third mandate of its mission, the AADR has developed policy statements on a variety of topics related to oral health, including fluoride, amalgam and sealants. These statements are intended to inform the public and the health care community about the scientific status of various issues in oral health.

In 1996, the AADR published its first policy statement regarding TMDs. This statement was based on a consensus of opinion among the members of the AADR Neuroscience Group—the group that specializes in scientific issues related to sensory and motor disorders, including various orofacial pain conditions. In 2008, the AADR Neuroscience Group determined that the 1996 TMD statement required an update in light of recent scientific developments. The officers of the Neuroscience Group appointed a subcommittee of 3 members to review the literature on diagnosis and treatment of TMDs, with the task of developing an updated policy statement incorporating supporting references. The updated statement was reviewed by the Neuroscience Group and then submitted to the AADR Science Information Committee for review and revision. The updated statement was ultimately approved by the full AADR Board and Council.

The purpose of our recent JCDA article was to provide background information about the statement revision as it was developed and approved by the AADR. After a brief introduction about the lack of a standard of care in diagnosing or managing TMDs, our article identifies controversies in the TMD field and provides evidence about what the current scientific literature states regarding these topics. We provide a brief discussion of the AADR statement and analysis of the specific points that were updated, showing the supporting references that were used to produce revisions from the 1996 to the 2010 version. Finally, our article presents the complete text of the new AADR statement, which is the document as approved by the AADR. The article is presented without personal opinion. Rather, it takes the reader on a journey through the logistics of updating a scientific policy statement within a major research organization. Furthermore, as with any scientific article published in JCDA, it was subjected to the rigours of the JCDA editorial review process.

We hope this clarifies the intent of publishing our article about the AADR statement on TMDs in JCDA—the appropriate forum for Canadian dentists to learn about statements developed by leading organizations that impact upon dental care. We leave it to the readers’ discretion to decide whether the information we present is helpful to them and their TMD patients.

Cite this as: J Can Den Assoc 2010;76:a162