3
134 JADA 144(2) http://jada.ada.org February 2013 LETTERS COMMENTARY I think it is unethical to sub- mit these patients to psycholog- ical and psychiatric evaluations before all of the avenues den- tistry has to offer have been tried. Before I learned about neuromuscular dentistry, I had many patients like the one the authors described. I even dis- missed several of them because I could not help them with CR- based appliances. When I brought those same patients back for a neuromuscular workup and orthotic, they all improved beyond my expecta- tions. You truly don’t know what you don’t know, unless you expand your knowledge base to include neuromuscular principles. Timothy J. Isaacson, DDS Bloomington, Minn. Authors’ response: We thank Drs. Kidder and Solow, Smith and Isaacson for their interest in our article. Since they share similar concerns, we would like to respond to their individual letters altogether. Their concerns about the proper diagnosis and occlusal treatment of the patient we briefly reported on illustrate the point that we tried to make in the article. That is, when a patient with occlusal com- plaints and pain presents to the dental practice, one strategy that can occur is to find an occlusal explanation and occlu- sal therapeutic procedure(s) to treat the patient’s pain com- plaint, even though the cause(s) may not be related to maxillofa- cial structures. We agree with them that, as dentists, we are called to ad- dress properly the maxillofacial pathologies, including temporo- mandibular disorders (TMD) as well as malocclusions, since it is within our scope of practice. However, the purpose of our article was not to cover exten- sively the diagnosis or treat- ment modalities for TMD. The objective of describing, briefly, a real patient of ours was to illus- trate the many forms of a clin- ical presentation known as phantom bite syndrome (PBS), with concurrent comorbid con- ditions that may mislead clini- cians who perform dental treat- ments, even though multiple prior attempts have failed. As we may see in the afore- mentioned letters, when a pa- tient complains about occlusion and pain in the temporoman- dibular area, the first focus advocated is mostly related to static and functional occlusion such as a retruded jaw position, narrow envelope of function, CR position or even mandibular ad- vancement due to sleep apnea. We can reassure the letter writers that in the patient pre- sented, we performed a compre- hensive dental and medical his- tory and a clinical examination that routinely includes assess- ment of the patient’s occlusion. This assessment then was aug- mented with appropriate im- aging to assist in the differential diagnoses process. Finally, the patient then had a consultation with the phys- ical therapist and health psy- chologist in our clinic to iden- tify other comorbid conditions and other potential biopsy- chosocial contributing factors. The letter writers’ claims of use of specific diagnostic philoso- phies or modalities, such as transcutaneous electrical nerve stimulation or anterior depro- grammers, as part of a “proper occlusal analysis” have not been rigorously assessed and thus are experimental. Specifically, the National Institute of Dental and Cranio- facial Research’s TMD Tech- nology Assessment Conference Statement stated that occlusal adjustment is irreversible and should only be used to “identify and eliminate gross occlusal discrepancies such as those that may inadvertently occur as a result of restorative pro- cedures.” 1 Furthermore, a 2003 Cochrane review concluded “… there is no evidence from trials to show that occlusal adjust- ment can prevent or relieve temporomandibular disorders.” It also states, “There is an absence of evidence of effective- ness for occlusal adjustment (OA). Based on these data OA cannot be recommended for the treatment or prevention of tem- poromandibular disorders (TMD).” 2 The absence of evidence is based on the fact that there are insufficient well-designed clin- ical trials that have addressed this question. Therefore, if one is to advocate the use of occlu- sal interventions for the treat- ment of TMD, then the clinician ethically needs to tell patients that the treatment has never been shown to be superior to other reversible treatments. As pointed out in our article, the clinical manifestation of PBS originates in the central nervous system and can be manifested clinically as dif- ferent peripheral sensations, such as tooth pain, premature occlusal contact, pressure or tooth “lightness.” These periph- eral sensations may be accom- panied by other comorbid con- ditions that may camouflage the central origin of PBS. The presence of myofascial pain and temporomandibular joint arthralgia in our patient was related to constant day- time and nighttime clenching and to his habit of keeping the mandible in a protrusive posi- tion. Thus, the patient was suc- cessfully treated following pub- lished guidelines. 3 The multiple prior attempts by the patient to self-perform occlusal equilibra- tion to reduce the posterior oc- clusal contacts and the long- standing high degree of distress Copyright © 2013 American Dental Association. All rights reserved.

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Page 1: NEUROMUSCULAR PROBLEMS: Authors' response

134 JADA 144(2) http://jada.ada.org February 2013

L E T T E R SC O M M E N T A R Y

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 don’t knowwhat you don’t know, unlessyou expand your knowledgebase to include neuromuscularprinciples.Timothy J. Isaacson, DDS

Bloomington, Minn.

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 patient’s pain com-plaint, even though the cause(s)may not be related to maxillofa-cial structures.We agree with them that, as

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-

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-

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 patient’s occlusion.This assessment then was aug-mented with appropriate im-aging to assist in the differentialdiagnoses process.Finally, the patient then had

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

Institute of Dental and Cranio-facial Research’s TMD Tech-nology Assessment ConferenceStatement stated that occlusaladjustment is irreversible andshould only be used to “identifyand eliminate gross occlusal

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

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,

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

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

Copyright © 2013 American Dental Association. All rights reserved.

Page 2: NEUROMUSCULAR PROBLEMS: Authors' response

JADA 144(2) http://jada.ada.org February 2013 135

L E T T E R SC O M M E N T A R Y

associated with these contactssuggest a chronic and complexpresentation rather than asimple case of temporoman-dibular arthralgia or myoge-nous pain.Dr. Smith’s concern that

“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

management of chronic kneeand lower back pain has helpedto advance the knowledge onthe need of multidisciplinarymanagement of chronic jointpain including orofacial pain.

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

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-

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

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

Copyright © 2013 American Dental Association. All rights reserved.

Page 3: NEUROMUSCULAR PROBLEMS: Authors' response

136 JADA 144(2) http://jada.ada.org February 2013

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

patients with PBS for psycho-logical evaluation is not uneth-ical. Although for some clini-cians it may be difficult tomake these referrals—the 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-

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

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.

Vladimir Leon-Salazar,DDS, MSD

Senior ResidentDivision of Orthodontics

Department of Developmentaland Surgical Sciences

Leesa Morrow, PhD, JD, LPClinical Assistant Professor

Eric L. Schiffman, DDS, MSAssociate Professor

and Division DirectorDivision of TMD and Orofacial

PainDepartment of Diagnosticand Biological Sciences

School of Dentistry

University of MinnesotaMinneapolis

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-

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-

facial Pain. Orofacial Pain: Guidelines forAssessment, Diagnosis, and Management.4th ed. Chicago: Quintessence; 2008:316.4. Edwards RR, Cahalan C, Mensing G,

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

Dental Association principles of ethics andcode of professional conduct, with officialadvisory opinions revised to April 2012.www.ada.org/1379.aspx. Accessed Dec. 17,2012.

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Copyright © 2013 American Dental Association. All rights reserved.