We would like to thank Dr. Friedman for some of his comments and questions concerning our study. He appropriately notes that patients presenting with acute pain in the masticatory muscles may have associated temporomandibular joint arthralgia, internal derangements, parafunctional habits, etc.
The major point of our study, however, was to demonstrate that, even though we did not stratify patients by the type of temporomandibular disorder (TMD) they presented, patients with acute myalgia respond exceedingly well to biopsychosocial intervention. This is not to say that it is the only treatment that patients should receive.
However, there is a paradigm shift occurring in medicine and pain management toward a stepped-care framework in acute care.1,2 This framework encourages the initial use of the least invasive and least expensive intervention as the first step in improving outcomes. If patients do not demonstrate a favorable outcome, then services are "stepped up," or intensified, to the next level of intervention, which typically is more complex and costly.
Indeed, in our study, we clearly demonstrated good therapeutic outcomes in our acute patients, that were accompanied by fewer health care provider visits for the jaw-related pain during the one year after treatment.
Certainly, one might ascribe the improvement seen in these patients to other treatments they may have concomitantly received along with our biopsychosocial intervention. Approximately 25.6 percent of our patients had some treatment by oral health care professionals during the one-year duration of the study. However, 74.4 percent did not and nevertheless improved over the course of the investigation. Our major conclusion is that most patients’ symptoms improve from this conservative noninvasive biopsychosocial intervention.
Finally, it also should be noted that there was one misunderstanding [in Dr. Friedman’s remarks] concerning denial of treatment, when he stated that "delay of specific treatment for other categories would be clinically irresponsible." As we explicitly noted on page 341 of our article, "During the entire study, we encouraged all the subjects, even those in the NI group, to continue treatment as usual with their outside health care providers if needed ... ." As is evidenced in Table 2 in our article, many of the subjects in both groups did so.
In conclusion, we again want to emphasize that a biopsychosocial approach to acute TMD-related disorders is quite heuristic and can result in the most efficacious and long-term outcomes. Of course, additional research will be required to document its efficacy with various other types of TMD.
Nevertheless, a biopsychosocial approach to both assessment and treatment of acute TMD patients will guarantee the best treatment of patients. It also provides a safeguard against early overtreatment and the unwitting potential for iatrogenic increases in symptomatology.
"It is much more important to know what sort of patient has a disease than what sort of disease a patient has," said Sir William Osler, MD.3
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