We appreciate Dr. Bucholtz’s reaffirmation that cognitive-behavioral and biofeedback therapies have a positive effect on reducing pain associated with temporomandibular joint disorder– (TMD–) related disorders (for related literature citations, refer to Stowell and colleagues,1 Gatchel and colleagues2 and Wright and colleagues3). As we proposed, this adjunctive intervention for acute pain is efficacious and cost-effective.
However, we must disagree that the one-year findings in our studies demonstrated only "temporary" pain relief. To continue to experience symptom reduction at one year would hardly be considered temporary by our patients. With that said, we agree that longer-term follow-up will be ground-breaking for the research literature in this area and, consequently, we have begun related data collection.
We further disagree that the intervention was purely "psychological therapy." Readers were referred to our one-year treatment effectiveness study,2 in which the intervention was described at length. Contrary to standard psychological therapy, which may be grounded in other theoretical orientations, our intervention was based on a cognitive-behavioral orientation (for specific descriptions, refer to Mishra and colleagues,4 Gardea and colleagues5 and Lewinsohn6).
Additionally, we derived other skill components from various pain-management programs known to us, as we have, combined, more than 45 years of experience in the diagnosis and treatment of pain conditions from a biopsychosocial perspective.
This method of therapy was functionally oriented and had a significant educational component regarding coping with a specific disease process (that is, pain and the prevention of the progression from acute to chronic pain). Furthermore, divergent from traditional psychotherapies, our study incorporated a strongly biological/physical component by relying on the use of biofeedback training for the identification of tension, and subsequent training of muscle relaxation for increased muscle control.
Dr. Bucholtz also indicated that this therapy "downplays the problems of patients who fail to respond to various therapies, including behavioral therapy." However, recall that the participants in this study were acute pain patients (symptoms of six months or less). Many had not progressed to significant diagnostics and advanced therapies but, rather, were following treatment as usual from their standard sources of care. Hence, in our study, participants were randomly assigned to intervention or nonintervention (standard care). No participants were discouraged from seeking other treatments/diagnostics; participation in the study was an augment to whatever other treatment they sought or was recommended by their outside providers.
We do not disagree that additional therapies, including some of the ones Dr. Bucholtz mentioned, are helpful for these patients. Rather, we aim to make providers aware of the beneficial role of biopsychosocial intervention early on in the treatment process, rather than later, as an intervention of last resort, as is unfortunately more typical for all diagnoses within the pain spectrum.
In an earlier article,3 we gave providers a "snapshot" of when to consider referral for adjunctive therapy, such as ours, to aid in the prevention of progression to chronic pain (for example, initial presentation of extreme self-reported pain levels and the presence of anxiety, and rigid, compulsive characteristics). Traditional approaches assume these symptoms will remit as patients respond to traditional dental-only treatment. Based on our findings, providers were encouraged to direct these individuals to specific care for such symptoms—a proactive treatment choice.
Lastly, in regard to insurance coverage, we agree that it is a sad state of affairs that medical and dental carriers pass the liability of coverage from one to the other. However, we believe the rationale is more financially motivated on the part of the carriers than based on scientific evidence of treatment. Clearly, a variety of treatments, including our intervention, are efficacious and cost-effective for patients with acute or chronic pain.
The decision is for third-party payers to recognize the class of disorders on the whole as a coverable condition and then, based on scientific evidence, cover care for conservative and typically less expensive noninvasive treatments prior to the more costly invasive treatments.
In conclusion, we have shown that a biopsychosocial intervention is not only effective in terms of treatment outcomes in patients with chronic TMD-related pain,4,5 but also in patients with acute TMD-related pain.2 Furthermore, we have demonstrated the cost-effectiveness of the intervention at one-year postintake and are in the process of collecting two- to five-year outcomes; both outcome studies are a first in the literature for patients with acute TMD-related pain.
TOP
REFERENCES
