Overtreatment "Successes"--What Are the Negative Consequences for Patients, Dentists, and the Profession?

AIMS: To describe how some management practices in the field of orofacial musculoskeletal disorders (also described as temporomandibular disorders [TMDs]) are based on concepts about occlusal relationships, condyle positions, or functional guidance; for some patients, these procedures may be producing successful outcomes in terms of symptom reduction, but in many cases, they can be examples of unnecessary overtreatment. METHODS: The authors discuss the negative consequences of this type of overtreatment for both doctors and patients, as well as the impact on the dental profession itself. Special focus is given to trying to move the dental profession away from the old mechanical paradigms for treating TMDs and forward to the more modern (and generally more conservative) medically based approaches, with emphasis on the biopsychosocial model. RESULTS: The clinical implications of such a discussion are apparent. For example, it can be argued that the routine use of Phase II dental or surgical treatments for managing most orofacial pain cases represents overtreatment, which cannot be defended on the grounds of symptom improvement (ie, "successful" outcomes) alone. Similarly, there is enough clinical evidence to conclude that complex biomechanical approaches focusing on the search for an ideal specific condylar or neuromuscular position for the management of orofacial musculoskeletal disorders are not needed to produce a positive clinical result that is stable over time. CONCLUSION: Typically, overtreatment successes cannot be easily perceived by the patients or the treating dentists because the patients are satisfied and the dentists feel good about those outcomes. However, neither party knows whether an excessive amount of treatment has been provided. Therefore, both the practical and ethical aspects of this discussion about proper treatment vs overtreatment deserve attention.

Temporomandibular disorders: current status of research, education, policies, and its impact on clinicians in the United States of America.

Temporomandibular disorders (TMDs) encompass a number of different musculoskeletal disorders often accompanied by pain and dysfunction. Most TMDs are acute, but can become chronic leading to disability and quality of life issues. There is wide variation in treatment of TMDs, including both conservative/reversible therapies as well as invasive/irreversible treatments, which present difficulties for clinicians, patients, and third-party payers as to what constitutes appropriate care. Data sources: A recent report by the National Academies of Sciences, Engineering, and Medicine highlighted a number of deficiencies, most notably in the education of TMDs within United States of America dental schools at both the predoctoral and postdoctoral (dental) levels as well as addressing the historic inconsistencies in both diagnosis and treatment. New areas for research and interprofessional collaboration should assist in the understanding of TMDs, and updated clinical practice guidelines should help reduce variation in the delivery of evidence-based care. Recently, the American Dental Association recognized orofacial pain as a specialty, which should increase the level and availability of expertise in treating these issues. Summary: Based on the current best evidence, this report is an attempt to alert the profession to discontinue irreversible and invasive therapies for the vast majority of TMDs and recognize that the majority of these disorders are amenable to conservative, reversible interventions.

Centric relation critically revisited-What are the clinical implications?

PURPOSE OF THE ARTICLE: Centric relation is a dental term that has undergone many alterations over the years, which in turn have led to significant clinical controversies. These continuing changes in the meaning of the term CR have not only led to confusion, but they also have resulted in a variety of unnecessary diagnostic and therapeutic procedures. Analysis of the dental literature reveals ongoing misunderstanding and disagreement regarding that term among both clinicians and academic dentists. MATERIALS AND METHODS: A search of the PubMed database was performed with the following search terms: "centric relation", "masticatory muscles", "maxillomandibular relationship" and "condylar position." Relevant literature from the past 70 years until the present day was meticulously scrutinised. RESULTS: As expected, the literature review on the topic of CR revealed a problematic pattern of changing definitions and clinical disagreements, all of which have had a significant impact on the practice of dentistry. CONCLUSION: There are semantic, conceptual and practical reasons for concluding that the term 'centric relation' is flawed. Those flaws have a significant impact on dental practice. Based on our analysis, argumentation is provided to conclude that the term 'centric relation' should be abandoned. Instead, it appears that every individual has a unique temporomandibular joint relationship which cannot be described by any singular term. In healthy dentate patients, this relationship is determined by the maximum intercuspation of the teeth and should therefore be considered as biologically acceptable.

Transitioning to chronic temporomandibular disorder pain: A combination of patient vulnerabilities and iatrogenesis.

BACKGROUND: Based on a variety of studies conducted in recent years, some of the factors that might contribute to the negative treatment responses of some TMD patients have been elucidated. METHODS: This paper describes known vulnerability factors that make individuals susceptible to developing temporomandibular disorders (TMDs), as well as those that contribute to the perpetuation of such problems. In addition, the topic of iatrogenesis is discussed as a major contributor to the negative outcomes that can be seen in this field. RESULTS: At the patient level, anatomical, psychosocial and genetic factors may contribute to individual vulnerability. The anatomy and pathophysiology of muscles, joints, disc and nerves may all be involved in predisposing to TMD symptoms, especially when the patients have pain elsewhere in the body. Among the psychosocial factors, some features may be elucidated by the DC/TMD axis II, while others (eg illness behaviour, Munchausen syndrome, lack of acceptance of non-mechanical approaches) require careful evaluation by trained clinicians. Genetic predisposition to first onset TMDs and to chronification of symptoms has been identified for individuals with certain psychological traits, presence of comorbid conditions and certain abnormal clinical manifestations. Regarding iatrogenesis, sins of omission may influence the clinical picture, with the main ones being misdiagnosis and undertreatment. Joint repositioning strategies, occlusal modifications, abuse of oral appliances, use of diagnostic technologies, nocebo effect and complications with intracapsular treatments are the most frequent sins of commission that may contribute to chronification of TMDs. The patients who present with massive occlusal and jaw repositioning changes combined with persistent severe orofacial pain are not a rarity within TMD and orofacial pain canters; these patients are the most difficult ones to manage because of this horrific combination of negative factors. CONCLUSIONS: The information presented in this paper will help clinicians to understand better why some individuals develop temporomandibular disorders, why some of them will progress to becoming chronic patients, and what the appropriate responses may be.

Treating Temporomandibular Disorders in the 21st Century: Can We Finally Eliminate the "Third Pathway"?

Within the orofacial pain discipline, the most common group of afflictions is temporomandibular disorders (TMD). The pathologic and functional disorders included in this condition closely resemble those that are seen in the orthopedic medicine branch of the medical profession, so it would be expected that the same principles of orthopedic diagnosis and treatment are applied. Traditional orthopedic therapy relies on a "Two Pathway" approach involving conservative and/or surgical treatments. However, over the course of the 20th century, some members of the dental community have created another way of approaching these disorders- referred to in this paper as the "Third Pathway"-based on the assumption that signs and symptoms of TMD are due to a "bad" relationship between the mandible and skull, leading to a variety of irreversible occlusal or surgical corrective treatments. Since no other human joint is discussed in these terms within the orthopedic medicine communities, it has become progressively clear that the Third Pathway is a unique and artificial conceptual creation of the dental profession. However, many clinical studies have utilized the medically oriented conservative/surgical Two-Pathway model to diagnose and treat TMD within a biopsychosocial model of pain. These studies have shown that TMD comprise another domain of orthopedic illness that requires a medically oriented approach for good outcomes while avoiding the irreversible aspects of the Third Pathway. This review presents historical and current evidence that the Third Pathway is an example of unorthodox medicine that leads to unnecessary overtreatment and further proposes that it is time to abandon this approach as we move forward in the TMD field.

The evolution of temporomandibular disorders: A shift from experience to evidence.

After over 80 years of much obsession as well as avoidance of the subject of temporomandibular disorders (TMDs), the dental profession is still divided over what they are and how to deal with them. Over this period, nearly every discipline in dentistry has played some role in the development of this field. Unfortunately, a significant amount of this information has been based on personal opinion, experience-based philosophies, or poorly conducted research. Furthermore, each dental specialty has been responsible for contributing to the concepts of the etiology and management of TMDs with their own professional bias; for example, orthodontists describe these problems in orthodontic terms and offer orthodontic treatments or solutions for their patients. As various treatment approaches were found to be effective at least some of the time, this has further led to misinformation and confusion within the profession. Advances in research from diverse fields, including neurophysiology, pain pathophysiology, genetics, endocrinology, behavioral sciences, and psychology, have significantly altered our understanding of TMDs and how they should be managed. The rigid mechanical and dental-based model of the past has been gradually replaced by a biopsychosocial medical model for the diagnosis and treatment of TMDs as well as other acute and chronic pain disorders. This paper discusses the evolution of our understanding of TMDs since they were first described 85 years ago. Contemporary scientific findings and their implications are presented in some detail for clinicians who wish to provide the appropriate management for their orofacial pain patients.

Seeking treatment for temporomandibular disorders: What patients can expect from non-dental health care providers.

The dental profession has long been the primary source for clinical management of patients with temporomandibular disorders (TMDs). However, patients with a facial pain problem may seek diagnosis and/or treatment from other health care providers. These providers may be physicians or other professional-level practitioners, or they could be members of various allied groups, such as physical therapists or occupational therapists. However, little has been written about what patients might experience if they seek care outside of the dental profession. This article reports the results of an Internet survey of non-dental professionaland allied health care professionals to learn what they might offer to patients who may be seeking treatment for TMDs. The official organizational websites for all groups, as well as the websites of individual practitioners in each group, were reviewed. Most of the official websites had little or no information about TMDs, but some members of every group surveyed were offering to treat TMDs in their offices. The variety of treatments being offered went far beyond the boundaries of appropriate TMD management in the 21st century. These results are presented with a critical discussion of each concept or practice, as well as advice for both dentists and patients to deal with this situation.

Evidence-based dentistry or meta-analysis illness? A commentary on current publishing trends in the field of temporomandibular disorders and bruxism.

The field of temporomandibular disorders (TMDs) and bruxism research has recently witnessed a publishing trend leaning towards an overuse of systematic reviews (SRs) that contribute little or nothing to current knowledge. The majority of these seem to be more methodological exercises than manuscripts prepared to provide clinicians and researchers with up-to-date information to advance knowledge. In addition, given the increasing number of researchers who have been reviewing the dental literature on various topics without seemingly having any specific clinical or scientific background in the topic under review, the ultimate value of some SRs is questionable. Some of them end up producing meta-analyses (MAs) to give "numbers" (eg, risk measures and strength of association) that do not have a biological basis, due to the clinical heterogeneity of the articles being reviewed. Based on the above, the present commentary discusses this ongoing publishing trend that is affecting the TMD and bruxism field, which does not align well with the core principles of evidence-based dentistry (EBD). Ideally, EBD should be derived from a combination of literary, clinical and patient-centred information, but relying only on the bibliographic aspects could potentially expose less expert clinicians and other readers who merely browse the literature to incomplete, misdirected or even incorrect conclusions.