The article by Dr. Anna Stowell and colleagues, "Cost Effectiveness of Treatments for Temporomandibular Disorders: Biopsychosocial Intervention Versus Treatment As Usual" (JADA 2007;138[2]:202–8), seems fair in concluding that treatment of acute temporomandibular joint disorder (TMD) with cognitive-behavioral and biofeedback therapies has at least a temporary effect on reducing the chance of chronic orofacial pain associated with some TMD patients.
However, because the study was concluded after one year, it is not known if the lack of further participation in a study will influence a recurrence of acute symptoms or progress into a chronic problem with pain. The study refers to biopsychosocial interventions. However, the study only involves psychological therapy.
The psychosocial nature of TMD is extremely important. These facts influence the pain threshold of the disease. A positive psychosocial nature allows a patient to cope, while a negative nature can produce depressive consequences.
The article does not explain the method used in cognitive-behavior training, nor does it give details of the type of jaw examination used and its relationship to the study criteria. From this study, there does not seem to be any uniformity of patient selection based on biological criteria, such as the existence of muscle pain, the exact orientation of intracapsular soft tissue and osseous problems, or a combination of these factors. In fact, most TMD studies done in the past do not define the exact physical characteristics to make adequate comparisons between patients within the study in establishing the true nature of disease.
Furthermore, this study and others downplay the problems of patients who fail to respond to various therapies, including behavioral therapy. Most TMD is the result of underlying physical change in and around the vicinity of the temporomandibular joint and the failure to make biological adaptation. Some TMD is due to referred influences from other neuropathological sources or from tumors.
Psychosocial behavioral therapy helps with awareness of the problem, social problems and control of habits; massage decreases muscle spasm; physical and chiropractic therapy ease muscle problems and aid in bringing vertebrae in more normal alignment; and drug therapy can be used to reduce muscle spasm, inflammation, neuropathological impulses and depression. However, these therapies do not reverse intracapsular problems. These treatments only lessen the awareness of intracapsular derangements.
Conservative dental treatment should be directed toward all these areas of concern—biological and psychosocial—thus reducing mechanical stress in the TMJ area and allowing displaced or otherwise affected structures to reorientate to normal positions, reduce muscle spasm or allow adaptive healing.
This article also notes that "because of the multifactorial nature of these disorders, medical and dental insurance carriers typically pass the liability of TMD to each other, resulting in a situation in which both carriers refuse to pay." Who can blame them? We have such disagreement in the area of TMD, and the insurance carriers rightfully refuse to pay when confusion overrules consensus.
