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<ul><li><p>134 JADA 144(2) February 2013</p><p>L E T T E R SC O M M E N T A R Y</p><p>I think it is unethical to sub-mit these patients to psycholog-ical and psychiatric evaluationsbefore all of the avenues den-tistry has to offer have beentried. Before I learned aboutneuromuscular dentistry, I hadmany patients like the one theauthors described. I even dis-missed several of them becauseI could not help them with CR-based appliances. When Ibrought those same patientsback for a neuromuscularworkup and orthotic, they allimproved beyond my expecta-tions. You truly dont knowwhat you dont know, unlessyou expand your knowledgebase to include neuromuscularprinciples.Timothy J. Isaacson, DDS</p><p>Bloomington, Minn.</p><p>Authors response:Wethank Drs. Kidder and Solow,Smith and Isaacson for theirinterest in our article. Sincethey share similar concerns, wewould like to respond to theirindividual letters altogether.Their concerns about theproper diagnosis and occlusaltreatment of the patient webriefly reported on illustratethe point that we tried to makein the article. That is, when apatient with occlusal com-plaints and pain presents to thedental practice, one strategythat can occur is to find anocclusal explanation and occlu-sal therapeutic procedure(s) totreat the patients pain com-plaint, even though the cause(s)may not be related to maxillofa-cial structures.We agree with them that, as</p><p>dentists, we are called to ad-dress properly the maxillofacialpathologies, including temporo-mandibular disorders (TMD) aswell as malocclusions, since itis within our scope of practice.However, the purpose of ourarticle was not to cover exten-sively the diagnosis or treat-</p><p>ment modalities for TMD. Theobjective of describing, briefly, areal patient of ours was to illus-trate the many forms of a clin-ical presentation known asphantom bite syndrome (PBS),with concurrent comorbid con-ditions that may mislead clini-cians who perform dental treat-ments, even though multipleprior attempts have failed.As we may see in the afore-</p><p>mentioned letters, when a pa-tient complains about occlusionand pain in the temporoman-dibular area, the first focusadvocated is mostly related tostatic and functional occlusionsuch as a retruded jaw position,narrow envelope of function, CRposition or even mandibular ad-vancement due to sleep apnea.We can reassure the letterwriters that in the patient pre-sented, we performed a compre-hensive dental and medical his-tory and a clinical examinationthat routinely includes assess-ment of the patients occlusion.This assessment then was aug-mented with appropriate im-aging to assist in the differentialdiagnoses process.Finally, the patient then had</p><p>a consultation with the phys-ical therapist and health psy-chologist in our clinic to iden-tify other comorbid conditionsand other potential biopsy-chosocial contributing factors.The letter writers claims of useof specific diagnostic philoso-phies or modalities, such astranscutaneous electrical nervestimulation or anterior depro-grammers, as part of a properocclusal analysis have notbeen rigorously assessed andthus are experimental.Specifically, the National</p><p>Institute of Dental and Cranio-facial Researchs TMD Tech-nology Assessment ConferenceStatement stated that occlusaladjustment is irreversible andshould only be used to identifyand eliminate gross occlusal</p><p>discrepancies such as thosethat may inadvertently occuras a result of restorative pro-cedures.1 Furthermore, a 2003Cochrane review concluded there is no evidence from trialsto show that occlusal adjust-ment can prevent or relievetemporomandibular disorders.It also states, There is anabsence of evidence of effective-ness for occlusal adjustment(OA). Based on these data OAcannot be recommended for thetreatment or prevention of tem-poromandibular disorders(TMD).2The absence of evidence is</p><p>based on the fact that there areinsufficient well-designed clin-ical trials that have addressedthis question. Therefore, if oneis to advocate the use of occlu-sal interventions for the treat-ment of TMD, then the clinicianethically needs to tell patientsthat the treatment has neverbeen shown to be superior toother reversible treatments.As pointed out in our article,</p><p>the clinical manifestation ofPBS originates in the centralnervous system and can bemanifested clinically as dif-ferent peripheral sensations,such as tooth pain, prematureocclusal contact, pressure ortooth lightness. These periph-eral sensations may be accom-panied by other comorbid con-ditions that may camouflagethe central origin of PBS.The presence of myofascial</p><p>pain and temporomandibularjoint arthralgia in our patientwas related to constant day-time and nighttime clenchingand to his habit of keeping themandible in a protrusive posi-tion. Thus, the patient was suc-cessfully treated following pub-lished guidelines.3 The multipleprior attempts by the patient toself-perform occlusal equilibra-tion to reduce the posterior oc-clusal contacts and the long-standing high degree of distress</p><p>Copyright 2013 American Dental Association. All rights reserved.</p></li><li><p>JADA 144(2) February 2013 135</p><p>L E T T E R SC O M M E N T A R Y</p><p>associated with these contactssuggest a chronic and complexpresentation rather than asimple case of temporoman-dibular arthralgia or myoge-nous pain.Dr. Smiths concern that</p><p>there is no medical model fortreating any other painful jointin the body primarily with psy-chiatric treatment regardingthe biopsychosocial model forthe treatment of painful jointsis not accurate, especially as itrelates to chronic pain. And thepatient we described hadchronic pain.Specifically, research on the</p><p>management of chronic kneeand lower back pain has helpedto advance the knowledge onthe need of multidisciplinarymanagement of chronic jointpain including orofacial pain.</p><p>The claim that stabilization ofthe joint in the most healthyposition for healing is true inprinciple but is oversimplistic,and is not in accordance withcurrent concepts in pain man-agement.4 Moreover, as healthcare providers, we need to re-member that the focus of ourtreatments are the individuals,not the disease. This is espe-cially important in the manage-ment of patients with chronicpainful conditions with concur-rent behavioral and psychoso-cial contributing factors.Our patient had been seen by</p><p>multiple practitioners and hadmultiple unsuccessful treatmentattempts to reduce his percep-tion of a light occlusal contact inhis posterior teeth. These treat-ments were performed followingdifferent occlusally based treat-</p><p>ment philosophies. According toour assessment, there was noreason to believe that improperdental treatment was performedby the several previous dentists.Instead, the complexity of theclinical presentation that in-cluded multiple episodes ofdental self-mutilation, dispro-portionate distress related to hisocclusal concern and chronicpainful TMD probably made itdifficult to identify the cause ofthe occlusal complaint.The presentation of these</p><p>phantom perceptions mediatedby the central nervous system isnot new and has been exten-sively documented in other med-ical disciplines. Practitionersshould be aware that PBS canbe challenging to detect becauseof the presence of associatedpain. However, the multiple</p><p>Copyright 2013 American Dental Association. All rights reserved.</p></li><li><p>136 JADA 144(2) February 2013</p><p>failed treatment attemptsshould raise red flags. For theprivate practitioner, it is impor-tant to recognize PBS as a com-plex condition before initiatingfurther dental treatment.Finally, the proper referral of</p><p>patients with PBS for psycho-logical evaluation is not uneth-ical. Although for some clini-cians it may be difficult tomake these referralsthe lackof assessing for PBS in the dif-ferential diagnosis for patientswith these types of complaintscontributed to the excessivedental intervention that thesepatients received before beingproperly identified. Unfortu-nately, it also leaves the pri-mary, root condition of PBSuntreated.The principle of nonmalefi-</p><p>cence in the ADA Code (Section2.B) clearly states that one ofour obligations is to know ourown limitations and when torefer to a specialist.5 As sug-gested in our article, we believethat in patients of chronic pain</p><p>with comorbid behavioral andpsychosocial contributing fac-tors, such as the patient withPBS, the proper referral in-cludes psychological and/or psy-chiatric evaluation and, if indi-cated, treatment. Since thedirect referral to these profes-sionals may put the dentist andpatient in an uncomfortable sit-uation, the initial referral maybe to a pain center that has amultidisciplinary team.</p><p>Vladimir Leon-Salazar,DDS, MSD</p><p>Senior ResidentDivision of Orthodontics</p><p>Department of Developmentaland Surgical Sciences</p><p>Leesa Morrow, PhD, JD, LPClinical Assistant Professor</p><p>Eric L. Schiffman, DDS, MSAssociate Professor</p><p>and Division DirectorDivision of TMD and Orofacial</p><p>PainDepartment of Diagnosticand Biological Sciences</p><p>School of Dentistry</p><p>University of MinnesotaMinneapolis</p><p>1. Management of temporomandibular dis-orders: National Institutes of Health Tech-nology Assessment Conference statement.JADA 1996;127(11):1595-1606.2. Koh H, Robinson PG. Occlusal adjust-</p><p>ment for treating and preventing temporo-mandibular joint disorders. Cochrane Data-base Syst Rev 2003;(1):CD003812.3. De Leeuw R, American Academy of Oro-</p><p>facial Pain. Orofacial Pain: Guidelines forAssessment, Diagnosis, and Management.4th ed. Chicago: Quintessence; 2008:316.4. Edwards RR, Cahalan C, Mensing G,</p><p>Smith M, Haythornthwaite JA. Pain, cata-strophizing and depression in the rheumaticdiseases (published online ahead of printFeb. 1, 2011). Nat Rev Rheumatol 2011;7(4):216-24. doi:10.1038/nrrheum.2011.2.5. American Dental Association. American</p><p>Dental Association principles of ethics andcode of professional conduct, with officialadvisory opinions revised to April Accessed Dec. 17,2012.</p><p>ADA ANNUAL SESSIONS</p><p>2013 Oct. 31-Nov. 5, NewOrleans2014 Oct. 9-14, San Antonio2015 Nov. 5-8, Washington2016 Oct. 20-23, Denver2017 Oct. 19-22, Atlanta2018 Sept. 27-30, SanFrancisco</p><p>L E T T E R SC O M M E N T A R Y</p><p>Copyright 2013 American Dental Association. All rights reserved.</p><p>L E T T E R SETHICS AND LAWTHE NEXT DENTISTSHAPING DENTALRE SEARCHMORE ABOUT RESEARCHUNDERSTANDING OCCLUSIONAPPROPRIATE EVALUATIONNEUROMUSCULAR PROBLEMSADA ANNUAL SESSIONS</p></li></ul>