Moving TMJ Research into the 21st Century – At Last!

Background

The National Advisory Dental & Craniofacial Research Council meets periodically to receive state-of-the-Institute reports from the National Institute of Dental and Craniofacial Research (NIDCR) Director, other staff, and guest scientists to learn about proposed new policies, activities, and research concepts in a public session. In a closed session, Council provides a secondary review of the research project grant applications the Institute proposes to fund. Concurrence by a majority of the Council is needed for implementation of grant funding and for approval of new policies and concepts.

The TMD IMPACT Concept Proposal

On January 25, 2022, the 229th meeting of the Council convened to review a series of “Concept Clearances,” research initiatives deemed to be of high priority to the Institute. One proposal was to establish a TMD Collaborative for Improving Patient-Centered Translational Research (TMD IMPACT). What followed was an outline of research goals and projects to: “advance Temporomandibular Disorders (TMD) basic and clinical research, research training and translation to evidence-based treatment and improved clinical care – through the establishment of a national, interdisciplinary, trans-NIH, patient centered research Collaborative.” This proposed Collaborative would include relevant research areas from tissue engineering and regeneration, TMD pain, disease prevention, building the evidence base for existing treatments, and developing scientifically based new treatments.

The Concept was presented by Melissa Ghim, PhD, Director of the Institute’s Extramural Neuroscience, Orofacial Pain and Temporomandibular Disorders Program. She emphasized the multidisciplinary nature of the Collaborative as well as the multidisciplinary composition of the teams that would carry out the research, which would include consideration of co-occurring pain and non-pain conditions associated with TMDs. Implicit in that statement is the Institute’s recognition that TMDs are complex multifactorial disorders, not dental conditions mainly treated by dentists.

Equally important, Dr. Ghim went on to say that the proposed Collaborative will be patient-centered, recognizing the extent of the problem and the pressing need to find effective treatments for TMD patients.

Dr. Ghim acknowledged that research on the temporomandibular joint and TMDs has lagged behind research of other musculoskeletal conditions and also noted the slow pace of development of TMD therapies/pain drugs.

TMD Research Opportunities

Overall, she said the proposed Collaborative offered opportunities to:

  • Build a coordinated multi- and interdisciplinary platform to support largescale studies, which integrate across studies and projects, and provide a cohesive research strategy/agenda
  • Employ systems biology and whole-person approaches, including biopsychosocial factors and comorbidities
  • Coordinate data repositories and centralize data resources
  • Develop teams of multi- and interdisciplinary investigators

Specific TMD Research Projects

Following those broad aims Dr. Ghim went on to list specific research projects that may be pursued to:

  • Understand the mechanistic underpinnings of TMD for specific patient subgroups and phenotypes and to identify and validate etiologic targets
  • Establish best practices for integrated clinical management in the context of co-occurring pain conditions and comorbidities
  • Develop tools and technologies to facilitate access to the temporomandibular joint and associated tissues to improve upon current diagnostics and quantitative measurement
  • Use artificial intelligence, machine learning, and deep learning to integrate data from animal studies, basic and clinical research to aid in the development of individualized clinical decision making and predict patient outcomes
  • Strengthen the evidence base for treatments and interventions
  • Develop evidence-based early diagnosis and prevention strategies

Possible Organization of a TMD Collaborative

Dr. Ghim touched briefly on how the proposed Collaborative might be organized. In one configuration a series of centers would be established each with interdisciplinary teams, all tied to a central coordinating hub. A second possibility would be to have clusters of specialized interdisciplinary centers, each tackling different parts of a comprehensive TMD research agenda. The basic point of adopting a center approach, she said, was the belief that the whole was greater than the sum of its parts: that bringing together complementary resources and disciplines and diverse ways of thinking can deliver over and beyond what single investigators can do.

Comments by Advisory Council Members

She then turned discussion of the proposal over to two members of Council who had been previously briefed on the Concept and tasked with providing comment. Dr. Clark Stanford, Dean of the University of Illinois at Chicago College of Dentistry noted that the proposed Concept reflected the recommendations from the comprehensive report of the National Academy of Medicine (NAM) – Temporomandibular Disorders: Priorities for Research and Care, specifically “to create and sustain collaborative and multidisciplinary research on TMDs …through a national collaborative research consortium.” He said he had been co-chair of the multi-council working group which was tasked to respond to the NAM report. He also paid tribute to the late Dr. William Maixner who directed the multi-centered Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) epidemiological study of TMDs for generating the most significant findings about the disorders to date. He enthusiastically supported the collaborative Concept, making an especially strong case for including Patient Advocacy groups from the start. Their voice needs to be heard, he said, not only in terms of outcome measures, but also, given the power of social media, in getting the correct scientific messages out to the public. “And so patient-related communication is something I would strongly recommend be included in the design of the Consortium from Day One. Another key element is the training needed for investigations in complex areas like chronic pain and the disabilities that can be associated with TMD, and that is why the Concept of a Consortium is critically important, in my opinion, to move forward, and I strongly urge Council to endorse it.”

The second Council member to comment was Dr. Kathryn Albers from the Center for Neuroscience, University of Pittsburgh School of Medicine. She agreed with everything Dr. Stanford had stated and added, “There is such a strong need in terms of clinical outcomes and at the basic science level. We just don’t know enough about this complex joint and how often these conditions intersect with other inflammatory conditions in the body. So, this would be an opportunity to determine what types of patient subgroups are out there and relate back to basic science studies to develop effective approaches to deal with the subgroups. I know several people with TMD and I have asked them if they were treated and did the treatment help. And the answers were No! and No! So, I am strongly in support of the Concept.”

Discussion of the Concept was then open to comments and questions from other Council members. This elicited a comment from one member who recommended that sleep problems be included in the TMD research agenda. He was aware that treatment for sleep disorders like sleep apnea could ameliorate some TMD issues and could also reduce bruxism.

With no further discussion the Council voted unanimously to approve the Concept.

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