Patients who develop symptoms of temporomandibular disorders (TMDs), face certain challenges when weighing the benefits and risks of new treatments. Because the TMD field is well known for having diverse opinions, different practitioners may offer a wide variety of treatment options for the same condition. Some of those options may be relatively conservative, while others are rather invasive. This difference is often represented as a choice between reversible and irreversible treatment. In a recent paper, Drs. Greene and Obrez have suggested a novel way of assessing the choice between the proposed treatments. Their paper, entitled “Treating temporomandibular disorders with permanent mandibular repositioning: is it medically necessary?” focuses on a central issue in the TMD treatment controversy: should the position of the lower jaw (mandible) be irreversibly changed as a part of treating these conditions?
It should be pointed out that no other joint in the human body can have its parts permanently repositioned except for the temporomandibular joint (TMJ). Therefore, no such controversy exists in orthopedic medicine. Indeed, like all other joints, the TMJ is constantly undergoing minor changes as we age. But because the arrangement of the teeth can be changed by a variety of dental techniques (bite adjustments, crowns and bridges, orthodontics, and even surgery), it is possible to substantially change the position of the lower jaw (condyle) relative to the skull (fossa).
In their paper, the authors argue that there already exists a lot of evidence that most TMD patients can be successfully treated without doing such invasive procedures. The new element they add to this discussion is described as homeostasis, which refers to the body’s ongoing attempts at maintaining a balance within the systems. In the case of the TMJs, this refers to the balance between the teeth, the muscles, and the joints. This represents a more biological concept that supports the clinical decision-making process. The authors then set up a series of six criteria to determine whether jaw repositioning can meet the test of being medically necessary:
1. The medical condition (i.e., mandibular malposition) is generally recognized as a valid health problem or a disease.
2. The diagnostic tests used to assess whether the patient has this condition are valid with acceptable specificity (getting a correct diagnosis) and sensitivity (avoiding a false positive diagnosis).
3. The patient’s condition will get worse unless a particular procedure is done.
4. The clinical procedure itself has specificity (proven value from good clinical studies) for addressing the patient’s particular problem.
5. The procedure is clinically effective according to evidence-based criteria (i.e., not just a placebo effect).
6. The disease or disorder cannot be resolved by performing a less invasive procedure, thus justifying the invasiveness of the clinical procedure based on its benefit-to-risk ratio.
Their conclusion is that criterion #1 above has not been met, since there is no valid diagnosis called “mandibular malposition.” Therefore, treating TMD with permanent jaw repositioning procedures does not meet these medical necessity criteria, and yet many practitioners may still continue to do some or all of those procedures. For TMD patients, this represents a danger of being over-treated with an irreversible therapy. Therefore, they would be wise to seek second opinions if this approach is being offered to them. If an oral splint is being proposed as part of their treatment, they should ask the dentist whether this will lead to bite-changing and jaw-repositioning procedures afterward.
As the authors state in their final paragraph: “In summary, we have concluded that permanent mandibular repositioning procedures do not fulfill any of the six criteria of medical necessity as the appropriate and medically acceptable treatments or management options for patients with various TMD conditions. This conclusion also has ethical implications, as discussed in the recent paper by Reid and Greene. According to ethical standards, a physician is expected to offer patients the best treatment options with the least risk possible, even if that approach results in less ideal financial returns for the practitioner.”
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