Having seen Dr. Spahl’s letter, I am not surprised that he read my recent commentary with consternation rather than with enlightenment, because it is obvious that he missed the point. He agrees that there has been confusion and sloppy terminology in the past, but feels that it can be easily remedied by more careful use of existing definitions. That is the whole idea; if dentists used these terms correctly, there would have been no need for my commentary! The truth is that improper use of these terms has confused the literature, as well as resulted in instances of incorrect patient treatment.
Dr. Spahl also seems to be concerned about my statement that there is no good evidence to support the concept of a relationship between "TMD" and occlusion. This is not "‘old guard scientific spin,’" but rather a scientific fact. I do agree that an internal derangement of the TMJ (disk displacement) is not an imaginary condition. However, it is due to trauma or chronic parafunction and is not an occlusal disharmony.
On the other hand, condylar decompression is an imaginary concept, because the TMJ is a third-class lever. The references that he cites in support of his viewpoint relate to disk recapture by anterior mandibular repositioning appliances and not to appliances that supposedly decompress the joint.
Dr. Spahl is correct that symptoms do not constitute a diagnosis. However, terms like "myositis," "myospasm" or "hyperkinesia" are not symptoms; they are diagnoses. The patient with myositis may complain of pain, swelling or tenderness, but he or she will not complain of myositis! Moreover, it is not clear to me how selecting specific diagnoses rather than using umbrella terms adds to, rather than reduces, confusion. It should also be noted that the diagnoses listed in my commentary are indicated in the legend as examples, and not as a complete list of possible conditions. Finally, a diagnosis does not need to define an etiologic agent or condition. For example, we do not know what specifically causes degenerative joint disease or myofascial pain, and yet we are able to successfully treat many of these patients.
The one area in which Dr. Spahl and I definitely agree relates to his statement that "academic leadership has failed to step up and get the job done." If dental schools did a better job of teaching the diagnosis and evidence-based management of the various diseases and disorders of the temporomandibular complex, patients would not be subjected to questionable forms of therapy and their care would be greatly improved.
