Ethics of a Second Opinion in the TMD Field

The following editorial by Dr. Charles Greene recently appeared in CRANIO®: The Journal of Craniomandibular & Sleep Practice. It explores the ethical responsibilities of providing second opinions in the complex field of temporomandibular disorders and concludes with a dedication to the memory of Terrie Cowley, the TMJA’s Co-founder and president. https://www.tandfonline.com/doi/full/10.1080/08869634.2024.2397326?src=exp-la

“The emperor’s new clothes” – Reflections on the ethics of second opinions in the TMD field

This journal has been around for over 40 years, and as most readers know there has been a recent major change in the editorial management and policies of this publication. A series of editorials has laid out some of the core philosophies as well as some of the current concepts that characterize this new version of CRANIO [Citation1–3]. One of the most recent ones dealt with issues surrounding the title topic: “The professional burden of protecting TMD patients” [Citation4]. This editorial addressed many of the responsibilities we all have to not only provide appropriate care for those patients, but at the same time we must protect them from some of the potentially harmful treatment philosophies that permeate this specialty. In the current editorial, I will address one aspect of “protection” that was not covered in the earlier piece, i.e., the need to provide totally honest second opinions when TMD patients seek to find out if choices previously presented to them are reasonable and appropriate in the 21st century.

Every dentist who is seriously involved in the diagnosis and treatment of temporomandibular disorders (TMDs) has faced the challenge of providing second opinions to patients. Some of those patients may come in early, following a diagnostic visit with another practitioner, while others might come in the midst of a treatment process. Because of the well-known diversity of professional concepts and practices in this field, an astonishing variety of proposed diagnostic procedures and treatment plans may be encountered. The issue to be discussed here is: how should we react to these diverse reports?

The American Dental Association has a Code of Ethics which is quite extensive and is based on a number of familiar ethical concepts [Citation5]. But underlying that code (and others like it in other parts of the world) is an unwritten axiom: “Thou shalt not speak ill about thy brothers.” This means that it might be okay to disagree with what is being reported to you, but you should find a way to convey that opinion without impugning the intentions or reputation of the previous practitioners. The rationale for this approach is usually based on some reasonable, but simplistic, arguments – e.g., you don’t know under what conditions the other person was working; there may be several valid ways to solve a problem; choices were presented, but not all were remembered by the patient; etc.

But I would argue that the TMD field is not analogous to most other areas of dental practice. One can appreciate that a single tooth with a failing restoration could be handled in many different ways, or that a missing tooth could be replaced (or not) in a variety of ways, or that an early periodontal problem could be managed in several different ways. In our field, however, we are dealing with what I would call more complex and significant health problems, including a variety of overlapping pain disorders in many cases. Therefore, the potential for more invasive and irreversible procedures is not only possible, but indeed is a common feature of current TMD management practices. As Greene and Manfredini [Citation6] have written, we have an entire “third pathway” of irreversible dental and surgical interventions that are based on obsolete concepts of occlusal disharmonies and jaw malpositioning. As Turp and Greene [Citation7] have pointed out, we still have a widely accepted Phase 1 – Phase 2 approach to TMD diagnosis and management that requires major dental procedures. Oral surgeons report that preventive discopexy surgical operations are being proposed and performed on both children and adults. Finally, as Greene, Manfredini, and Ohrbach [Citation8] have discussed in a recent paper, current technologies are often being inappropriately used to “create” patients based on various measurement or imaging outcomes.

Therefore, I do not see how a reasonable second opinion can be offered to TMD patients who report these phenomena to us without impugning the professional persons who are advocating such approaches to their orofacial pain and suffering – especially when their condition has become chronic and complicated by overlapping pain conditions. In the end, it boils down to a simple and straightforward question: To whom do we owe the most when providing a countervailing opinion – the patients, or the doctors who have preceded you? I see this as an example of “the emperor’s new clothes”, because nothing less than the outspoken truth will convince the audience that there are serious risks associated with the concepts and practices described above. While we do not yet have all the information we need to successfully manage every TMD patient, there are some conservative guidelines that have been developed and accepted by the expert orofacial community in several countries around the world [Citation9]. Primary care is generally based on a combination of pain control, self-management, and psychosocial support, while chronic conditions also have a variety of non-harmful treatment protocols available.

In conclusion, I recommend that each of us should try to protect patients from potentially harmful or inappropriate treatments by giving them the most honest second opinions we can when they come to us. Despite the absence of absolute certainty about several aspects of TMD conditions, we still can distinguish between good and bad ideas when we hear them, and the patients are depending on us to provide the most ethical and scientifically supported professional care whenever they come into our offices.