We appreciate Dr. Bucholtz’s interest in our article, although his letter focuses on only one of the points we made—namely, the lack of standardized curricula for teaching predoctoral dental students about temporomandibular disorders (TMDs) in U.S. and Canadian dental schools. Unfortunately, he feels that "[p]erhaps this is a good thing." We could not disagree more, especially after reading his rationale for making that statement.
Like many others before him, he invokes the "chaos argument," which essentially states that the temporomandibular joint (TMJ) and the disorders associated with it are subjects that suffer from a lack of intellectual consensus within the dental community.
In his view, even normal anatomy and function of the TMJ complex are in dispute, let alone the great divide between "those who emphasize a need to recognize and address specific types of physical temporomandibular joint derangements and those who are only interested in relieving pain by palliative therapies." By describing the world we live in with such rhetoric, he creates the illusion of a chaotic situation in which we cannot agree on anything, and, therefore, teaching dental students about TMDs cannot (and probably should not) be done in a systematic manner.
This cynical view of the state of scientific information in the TMD field ignores the considerable amount of consensus and advancement in knowledge that has been achieved by more than 50 years of worldwide research. In fact, the American Academy of Orofacial Pain has developed guidelines1 that address Dr. Bucholtz’s concerns, with new guidelines based on the most current evidence-based research (scheduled for publication later this year).
Despite Dr. Bucholtz’s allegation that "provincialism and politics in TMD research is preventing dentistry from getting to the truth related to the condition’s anatomy, diagnosis and therapy," many of the fundamental issues in this field have been clarified, and several new pathways for future research have been developed.
Dr. Bucholtz states that "TMD definitely can be a multi-factorial disease," but, in fact, there is no single TMD "disease." Instead, there are a number of diseases and dysfunctions that can affect the TMJ complex and neighboring structures in the head and neck. Therefore, researchers are studying this field in a broader context, using a medical biopsychosocial model rather than the historic dental mechanical model.2,3 This novel understanding has led to new and innovative approaches being applied to research involving pain and how it affects both the physiology and the psychology of people who have it.4
In addition, we see a lot of basic-science research looking at the genetic aspects of the predisposition, initiation and perpetuation of pain, as well as clinical trials of new approaches to treatments based on the molecular and cellular biology of joints and muscles.5–7
Meanwhile, we have an obligation to prepare dental students to function in a field that is incomplete (more research is needed) and that also is controversial (some key issues are in dispute), but the situation is far from chaotic. We can teach them to sort out patients with TMD from those who have other orofacial pains, and we can give them foundational knowledge about managing those patients’ problems. As we state in our article, it is the patients who are at risk if they are going to get a different diagnosis and treatment in every dental office, so both experienced and new dentists need to recognize and understand how to handle those patients properly.
In an excellent article, Stohler and Zarb8 argued that the incompleteness of information in the TMD field calls for a low-tech, high-prudence approach, rather than the mechanistic and invasive therapies of the past. We heartily agree with this viewpoint, and in our article we recommend that all dental students should receive an education about TMD that is consistent with those principles and based on the vast amount of scientific data that supports them. It is by teaching this approach to our future dentists, using standardized curricula based on the best available evidence, that we as educators can ensure that their patients will be treated in an appropriate manner.
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