Thank you for the opportunity to respond to the thoughtful letter by Dr Quinn, the current president of the ASTMJS. He raised an important issue that needs to be clarified.
First, I should state that my own background in the TMJ/TMD field dates back to 1965, when I began working with Dr Daniel Laskin in the Oral Surgery Department at University of Illinois, Chicago. Working with him and his colleagues over the next 20 years made me very aware of how a doctor could be both a surgeon and a conservative therapist, and I continue to value the services of my oral surgeon colleagues in the ASTMJS whenever they are needed. I have watched their field evolve from the interventionist days of the 1970s through the 1990s, when condyles were being altered and TMJ disks were being repaired, removed, or replaced, to the modern position described by Dr Quinn as “exhausting all conservative therapy before considering any [surgical] intervention.” I believe him when he says that modern oral surgeons are “committed to an evidence-based approach to surgical interventions now and in the future.”
However, I think Dr Quinn misread both my introductory paragraphs and the actual AADR statement if he believes that they exclude surgical procedures as possible treatment options. He correctly noted that the AADR statement recognizes TMDs as encompassing all possible diagnoses; this means that they definitely include the types of pathology or intracapsular derangements he cited later as possibly requiring surgery. In discussing part of my introduction, however, he expressed concern that having “all TMD-type pain” treated within a biopsychosocial framework means that surgery is somehow excluded, and therefore he is worried that third-party payers will use the AADR statement against surgeons and their treatments. This interpretation is an example of the “either-or” approach to diagnosis and treatment that comes from dividing human ailments into physical vs psychological, or real vs psychosomatic, or even surgical vs medical.
The hallmark of the biopsychosocial approach to chronic pain and illness is the recognition that all such conditions are intimately associated with psychological and social factors that play powerful roles in patients’ illnesses and that profoundly influence their responses to treatment. Thus, the therapist is encouraged to always relate to his or her patients within this framework, because it enhances the outcomes above and beyond the specific medical or surgical procedures used. I’m sure the rheumatologists and orthopedic surgeons mentioned by Dr Quinn would all agree that their surgical procedures do not exist in a vacuum, so the “human factor” in their interactions must include placebo effects, reassurances about prognoses, reduction of anxiety, and even cotreatment by psychotherapist colleagues for many of the chronic-illness residuals that cannot be cured by their operations.
So, I don’t think that the AADR statement either intentionally or accidently implies anything negative about the possibility that surgical treatments are an option. In the second paragraph of the statement, it clearly says “It is strongly recommended that, unless there are specific and justifiable indications to the contrary, treatment of TMD patients initially [emphasis added] should be based on the use of conservative, reversible, and evidence-based therapeutic modalities.” The major concern in the TMD field during the past 20 years has not been so much about escalation to surgery as about escalation to major occlusion and jaw-repositioning treatments. These are almost never appropriate as therapies for either muscular or joint problems, although we acknowledge that certain surgical procedures might be quite appropriate when specifically indicated.
I hope that Dr Quinn and his colleagues in the ASTMJS will be reassured by my response, and I appreciate their contributions to the TMD field.