The American Society of Temporomandibular Joint Surgeons (ASTMJS) is a multidisciplinary organization of clinicians, oral and maxillofacial surgeons, ear, nose, and throat surgeons, oral medicine specialists, orthopedic surgeons, and radiologists. Over the past quarter century, we have attempted to define a rational approach to a small subset of patients in the broader “temporomandibular disorder” classification who might ultimately need appropriate surgical intervention. As experts in this field, we were disappointed to read Dr Charles Greene’s guest editorial calling the American Association of Dental Research (AADR) guidelines for the treatment of temporomandibular disorders a new “standard of care” (Greene CS. Managing patients with temporomandibular disorders: a new “standard of care.” Am J Orthod Dentofacial Orthop 2010;138:3-4).
We agree that the vast majority of patients with myofascial complaints should have treatment “based on the use of conservative, reversible and evidence-based therapeutic modalities” (AADR guidelines). Dr Greene, in his article, quotes the AADR statement: “The AADR recognizes that temporomandibular disorders encompass a group of musculoskeletal and neruomuscular conditions that involve the temporomandibular joints (TMJs), the masticatory muscles, and all associated tissues.” Clearly, this can be interpreted as an all-encompassing family of diagnoses. The ASTMJS guidelines for diagnosis and management of disorders involving the TMJs and related musculoskeletal structures concentrate more on internal derangement because we believe that, again, only a small proportion of those patients might ultimately require a surgical approach. Our guidelines also recognize that “non-surgical treatment should be considered for all symptomatic patients with internal derangement or osteoarthritis.” Furthermore, we applaud the AADR for taking a clear stand against the still-too-common use of diagnostic or therapeutic modalities lacking even reasonable plausibility, let alone scientifically validated clinical utility.
What is concerning is to give the impression that all “TMD-type pain should be managed within a biopsychosocial framework.” This would be akin to saying that all orthopedic disorders should be treated within the same biopsychosocial framework. In the United States alone, there are close to 900,000 hip and knee replacements every year, and I think it would be difficult to find a rheumatologist or an orthopedic surgeon who thinks that all of these should have been dealt with in a nonoperative fashion. It is difficult to conceive that the most used, and probably the most complicated, joint in the body would not be prone to diseases that cannot be treated with conservative medical care. Like every other joint in the body, the TMJ is subject to degenerative disorders that might require surgical intervention.
I have had the privilege of being a member of a multidisciplinary TMJ and Facial Pain Clinic at the University of Pennsylvania for over 20 years. Our operative intervention rate (arthroscopy and/or open joint surgery) is less than 3% of our patient population. We use the standard Wilkes classification for all patients and exhaust all conservative therapy before considering any intervention. We clearly recognized the overuse of surgical treatments at times in the past, and we are comitted to an evidence-based approach to surgical interventions now and in the future. In the last month alone, we had surgical patients with diagnoses that included traumatic osteoarthritis, rheumatoid arthritis, synovial chondromatosis, and a malunited condylar fracture. It is naïve and somewhat irresponsible for the authors to think that these guidelines will not be used by third-party insurers to deny treatment to patients with TMJ disorders that are not amenable to a conservative approach. When you search the Internet using “temporomandibular joint disorders,” 2 prominent websites (WEBMD and Wikipedia) both include references to surgery (arthrocentesis, arthroscopy, and open joint surgery) as appropriate when conservative therapy fails or when the initial diagnosis would dictate that approach. If even public websites acknowledge a broader “orthopedic” approach to TMJ disorders, it would be less confusing for patients if professional organization guidelines were as inclusive of all treatment modalities.