It was with interest that I read "Clinical Implications of Sex in Acute Temporomandibular Disorders" by Dr. Gatchel and colleagues (January JADA). This article at first appeared to be a good study. However, on further review and closer reading of the article, I found some discrepancies that I feel should be pointed out to the profession regarding patients with temporomandibular disorder, or TMD.
First, the evaluation and diagnosis of TMD was done by clinical psychology graduate students who had been trained by Edward Ellis III, D.D.S. However, a psychology student is not a dentist, nor a doctor of other professions who would be qualified to make the diagnosis of TMD that would fit to the American Dental Association standard of care. No clinical examinations had been provided by the psychology students, only question-and-answer interviews. The authors’ conclusion stated that dentists may want to do their own psychological testing.
I disagree. This is not under our licensure. The TMJ Scale (Pain Resource Center Inc.) is a screening tool already researched, published and used by dentists for patient referrals, not to diagnose psychological disorders.
Second, the tests used to determine the psychological measures included the Minnesota Multiphasic Personality Inventory-2, or MMPI-2. The appropriateness of this test for chronic pain patient evaluation has been explained in the literature by Dennis C. Turk and Ronald Melzack in their 1992 textbook.1
In the Turk and Melzack articles on page 202 in the chapter about psychological evaluation, it was stated that the MMPI-1 or MMPI-2 is not appropriate for the assessment of chronic pain patients. Their statements were backed by other literature quotes that dated back to 1981 and had five varied citations. Specifically identified in MMPI-1 data as not valid were the items used to evaluate hypochondriasis, depression and hysteria. This also stated that the identified profile patterns of hypochondriasis and hysteria were also invalid in other quotations.
Third, it was unclear in the initial assessment of acute TMD patients as to the cause of their problems. As we know from previous studies by Romanelli and colleagues,2 posttraumatic TMD patients responded to treatment 48 percent of the time, while nontraumatic TMD patients responded 75 percent of the time. Posttraumatic TMD patients also required treatment of many modalities to achieve their healing plateaus. Dr. Gatchel’s article did not evaluate traumatic vs. nontraumatic TMD acute symptomatology.
Fourth, this article did not mention, and apparently did not evaluate, whether the patients reporting with acute TMD also had problems with headaches and varied muscular pain symptoms. Primary symptoms evaluated were preauricular pain, limited mandibular functioning and joint sounds. We all know in our profession that TMD is more encompassing than the above-mentioned few evaluated symptoms. Many patients presenting to the dental office and/ or TMD treatment center with acute TMD problems already have chronic pain problems present in the other areas of the head and neck. The TMD symptoms evaluated may have become an extension to the chronic pre-existing problem.
Fifth, also interesting in the literature was an article by Tauschke and colleagues3 that stated, "There is a longstanding position that pain, and especially chronic pain, may arise from psychological mechanisms of defence. We have compared a group of chronic pain patients with a sample of psychiatric patients attending for reasons other than pain. We conclude that in general the patients with chronic pain had more normal childhoods and more mature defenses than the psychiatric control group. They showed an increase in the diagnosis of depression, attributable to reactive factors. In the sample of patients with pain, the majority of the psychological change cannot be attributed to the operation of primitive psychological defences."
In summary, Dr. Gatchel’s article, which was funded by research grants from the National Institutes of Health, did not consider the above variables. Obviously, further research is necessary in this area.
This article pertains to patients who were evaluated in a paper-and-pencil study and did not receive ongoing treatment. This article did show that it is necessary to treat acute TMD problems to prevent the development of chronic problems, suggest future research on patients with acute TMD who are actually in dental treatment, and indicate that a team approach to TMD is needed to support the patient’s emotional component.
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