Dr. Uppgaard’s chief criticism of our research relates to the diagnostic criteria we used. In noting that "TMD" encompasses several subclasses, he reiterates a point we have repeatedly made—that it is important to study the most homogeneous subgroups possible, since research may show that treatment and outcome differ for different subtypes.
We did not classify our study subjects according to "internal derangement," just as we did not classify them according to their diabetes or myopia status. This does not imply that these other conditions were not present, only that they were irrelevant to the specific focus of our investigation.
Dr. Uppgaard also notes that insurance companies do not have a diagnostic code for myofascial face pain. While this may be true, his comment implies that our research or clinical standards should be consistent with insurance company practices; we would hope that the opposite would be true.
It appears that, because we neither mention trigger points nor use them for diagnostic purposes in our research, Dr Uppgaard concludes that our research "added little to the literature, only more confusion." Moreover, the author seems surprised that we do not mention the "world-renowned" Drs. Travell and Simon.
The trigger-point concept is a controversial one, certainly not a concept endorsed by the overwhelming majority of practitioners or researchers. It bears reiterating that, despite the clinical impact of Travell and Simons’ work, research data have not supported the relevance of trigger points for differential diagnosis. It has now been shown that, with sufficient training (
Gerwin RD and colleagues. Interrater reliability in myofascial trigger point examination. Pain 1997; 69(1–2):65–73[Medline]
), examiners can achieve almost perfect agreement about the presence or absence of trigger points and associated characteristics.
Regardless, to date, peer-reviewed research has not demonstrated that trigger points differentiate between patients with fibromyalgia and myofascial pain syndrome (
Wolfe F and colleagues. The fibromyalgia and myofascial pain syndromes: a preliminary study of tender points and trigger points in persons with fibromyalgia, myofascial pain syndrome and no disease. J Rheumatol 1992; 19[6]:944–951[Medline]
). Dr. Uppgaard does not support his claim that "chronic myofascial pain could be bodywide, without fibromyalgia being involved."
To provide support for his views, Dr. Uppgaard references the concurring opinion of a well-received author of a book for fibromyalgia patients who is also founder of a patient Web site, Devin Starlanyl. In response to our direct inquiry, she acknowledges that she is not a licensed physician nor is she in medical practice.
Finally, Dr. Uppgaard references a single published editorial whose conclusions do not contradict our own. The rates of current comorbid fibromyalgia in myofascial face pain that he cites (originally from
Plesh O and colleagues. The relationship between fibromyalgia and temporomandibular disorders: prevalence and symptom severity. J Rheumatol 1996; 23[11]: 1948–1952[Medline]
) are not inconsistent with our lifetime comorbid rates of 23.5 percent. When one considers the effect of comorbid fibromyalgia on course and outcome in myofascial face pain, we would argue that this is not a trivial rate.
Dr. Uppgaard argues that the diagnostic criteria used in our research were "vague." This is incorrect. Our diagnostic criteria were clearly described and have been published as part of a comprehensive pain taxonomy system published by the International Association for the Study of Pain. They may not be, however, the diagnostic criteria that [Dr. Uppgaard] uses. Diagnoses are social constructs, continuously evolving. Diagnostic criteria develop (and change) through consensus by a large group of professionals.
The problem with diagnosis of myofascial pain is that different groups of professionals endorse different diagnostic criteria. This is not unique among clinical syndromes. If one considers as valid only the research on disorders in which there is universal agreement about diagnostic criteria, one would be required to reject the overwhelming majority of research on medical and dental disorders.
Dr. Uppgaard’s critique does not direct the critical reader to contradictory evidence but to unsubstantiated opinion. Rather than pointing the JADA readership to Web sites or books intended for laity, we urge the dental profession to take an evidence-based approach to these issues, with evidence best provided by data-based, published articles that have undergone the peer-review process.
