Thank you for the opportunity to respond to Dr. Shulman’s letter. He appears to be challenging anecdotal reports of occlusal treatment for patients with "TMD" problems and attempting to make a case for nonocclusal treatment of TMD. He refers to "a multitude of epidemiologic and controlled laboratory studies published in refereed journals showing that occlusion plays little if any role in the variable complex of physical and psychological causes" and "the prevalent contrary view based on published studies."
There is a large volume of research indicating that occlusion has no effect on the TM joints or the muscles of mastication. The fatal flaw with most of this research centers on the fact that the researchers were not capable of taking an occlusal equilibration to its end point, of adjusting a splint definitively, of load testing the joints or of determining the condition of the joints prior to the study.
How can research say a treatment doesn’t work when the researchers are incapable of rendering the treatment appropriately? Epidemiologic research is of little use when evaluating treatment modalities in clinical dentistry. Of least value are the literature reviews that total up statistics from flawed studies and get published as research.
On one hand, Dr. Shulman denies the cause-and-effect relationship of occlusal problems and TMD problems. On the other hand, in his own study he treats occlusal prematurities because they trigger bruxing habits. That same inconsistency exists in much of the "antiocclusion" literature that is so frequently cited.
The dental literature is very clear regarding occlusion and the TMJ as well as occlusion and muscular symptoms. Williamson and Lundquist (1983), Kerstein and Wright (1991), Ramfjord and Ash (1983), Dawson (1974), Ziebert and Donegan (1979), Bakke and Moller (1980), Murayama and colleagues (1982) and Riise and Sheikholeslarn (1980, 1983), along with numerous others, demonstrated the intimate relationship between teeth, joints and muscles.
I have been addressing occlusion as a primary issue for over 20 years. The positive effects on muscles, joints, teeth and periodontium that my patients experience, combined with solid scientific proof, have led me to believe this is more than coincidence. I don’t know if Dr. Shulman or other psychosocial/ behavioral advocates will be convinced, but there is an ever-growing number of clinical dentists who have committed to the work necessary to obtain the skills and who, along with their patients, are reaping the rewards.
This debate has continued for as long as I can remember. I suspect the only way to resolve it is to refine our diagnostic skills to the point where we don’t have to use terms like TMJ, TMD, MPD syndrome or CMD.
When we all do complete examinations to diagnose and differentiate TMJ disorders, masticatory muscle disorders, occlusal disease and orofacial pain issues, my hope is that treatment protocols will become more universal, and we will all be in the same camp.
