- The harm caused by treatments that lack scientific scrutiny
- How to treat the patient when all conservative methods fail to alleviate pain and dysfunction
Finding the Right Practitioner To Manage Your TMJ Problem - Combining Ethical Principles with Practical Considerations
People who think they have symptoms of Temporomandibular Disorders (TMD) should consult with their medical doctor to rule out other medical conditions that may mimic TMD. Their doctor may then suggest that they see a “dental specialist who deals with facial pain problems.” However, since there are no official American Dental Association-approved specialists in TMD, that referral may lead to many different kinds of dental offices and practitioners, among them are oral surgeons, endodontists, periodontists or even general dentists who claim to be experts on TMD. In some communities, there also may be oral medicine or orofacial pain specialists, who actually have had formal postgraduate training about TMD management in university settings, just as a physician would train to become an orthopedist or cardiologist. Officially, even those dentists are not TMD “specialists,” despite the fact that they generally provide the best care for such problems.
In addition to these possibilities, there are dentists who advertise on their websites or in local media that they welcome “TMJ/TMD” patients in their practice. Since there are no established guidelines for TMD treatment, patients with exactly the same symptoms might receive completely different diagnostic workups and treatment recommendations. As a result, they will have very different experiences, based solely on which practitioner they see. Unfortunately, there is no assurance that the diagnostic process (evaluation) and the treatments proposed will be based on the best available scientific data. Indeed, it is just as likely that the evaluation and treatment recommendations will be rooted in outdated concepts that have been disproven or strongly challenged by contemporary standards of science. These scientifically unproven diagnostics and treatments may lead to invasive, irreversible, and sometimes very costly interventions.
At this time, there are serious controversies within the dental profession about all aspects of TMD. This situation makes it essential that a patient be well informed about what could happen when seeking care for TMD. In this article we hope to heighten awareness of potential pitfalls when seeking care for a painful TMD problem, and to provide information that may reduce the chances of a harmful outcome.
There are over 150 different medical conditions that have been identified in the head and face region that cause pain. This means that individuals who believe they are experiencing TMD pain might actually have some other kind of pain disorder. Many of these need to be managed by a physician rather than a dentist. The professional being consulted needs to make a judgment about whether a TMD diagnosis is the most likely alternative. How is that most reliably accomplished?
Despite all the advances in medical science and technology, the diagnosis of a painful TMD still depends primarily on obtaining a detailed patient history and performing a simple hands-on examination. Some dentists who claim special expertise in TMD believe that certain kinds of diagnostic technology equipment should be used to establish a jaw joint or facial pain diagnosis. The results of their diagnostic testing then dictate a particular kind of treatment. Not only do these technologies not provide a clear diagnosis, but they may in some cases provide a false positive result ─ the test says you have TMD, but you don’t.
Except for certain kinds of X-rays, most of these TMD diagnostic machines have been scientifically proven to be unnecessary; they provide no clear benefit beyond what a well-conducted patient interview and clinical examination would reveal. For example, there is no reputable scientific evidence that TMD patients gain a measurable benefit if dentists employ diagnostic machines that measure jaw muscle activity (EMG), or assess vibrations or noises in the temporomandibular joints (vibration analysis), or record the various motions of the jaw. If the dentist is not aware of this fact or believes otherwise, the patient would be well advised to seek care in another office, since the use of such equipment may lead to complicated and irreversible treatments. If the dentist is aware that a valid and reliable examination may be carried out without these instruments, he or she is ethically obligated to disclose that fact. Because there are dentists who are either not aware of the science or who utilize such equipment anyhow, it falls upon the patient to be as well educated as possible about appropriate diagnostics and treatments for TMD.
There are as many controversies regarding proper treatment of TMD as there are in regard to diagnostics. Simply stated, the main issue is whether a regimen of conservative (non-invasive, simple) treatments can resolve the problem, or whether a treatment plan designed to change the bite or to reposition the jaw is required. There are volumes of evidence generated by many years of scientific research that support the usefulness of conservative TMD treatments. Just as important, there is NO EVIDENCE to demonstrate that invasive and irreversible interventions are more effective or beneficial than those conservative methods. Thus, an ethically justifiable approach to caring for TMD patients should emphasize conservative methods in almost all cases. This is especially true for the early stages of most TMD conditions. Even in later stages there are few indications for needing to use more invasive procedures.
Since many dentists continue to propose only the more aggressive forms of TMD treatment, it is again up to the patient to be as educated on TMD as possible. As both a consumer and a patient, it will be necessary to probe, inquire and even challenge what is being proposed before agreeing to the recommended treatment. Obviously, seeking second or even third independent opinions in such cases is highly recommended.
Because patients are vulnerable and lack the education or training of a dentist, they are likely to assume that the dentist is acting solely on the basis of their welfare. This assumption arises from the ethical covenant that the healing professions have with society. It bears emphasizing that dentists who do not provide comprehensive information about the rationale, goals, risks, benefits, and alternatives to their preferred methods of diagnosis and treatment are violating several ethical obligations to which they are committed by virtue of licensure. Failure to do so is an abdication of a health care professional’s commitments to do good for patients (beneficence), to avoid harming patients in any way if possible (non-maleficence), and respect for autonomy (a patient’s ethical right to make informed choices based on his or her own values and goals). Society has historically trusted that healthcare professionals will act in the best interest of those who seek their care. As a result, society confers professional autonomy on dentistry as a profession, permitting it to be self-monitored. Dentistry may be said to have a contract with society that acknowledges patient vulnerability and is rooted in trustworthiness.
As a practical matter, the care-seeking patient would be wise to inquire about the dentist’s formal training and treatment philosophy. Patients should ask whether the proposed treatment will be conservative and reversible, or invasive/irreversible such as bite-changing or jaw repositioning, before consenting to treatment. This is especially important if an oral appliance (a splint) is being proposed as part of the treatment plan. Under a conservative philosophy, these appliances are intended to help reduce pain without permanently altering the bite or the position of the lower jaw, and so they are a temporary form of therapy similar to a back or knee brace. Alternatively, splints that supposedly put the jaw in what is referred to as the “right or ideal position” may be proposed; this is a concept that has long been refuted and one with no contemporary scientific validity. This approach most often requires long-term day-and-night use of the appliance that will result in a significant alteration in the position of the lower jaw and a change in how your teeth fit together. Thus, this approach must be followed by irreversible dental procedures, since the teeth no longer come together in a functional manner, and now an “ideal” bite must be established. This philosophy is the basis for doing orthodontics, bite adjustments, or even major crown work for addressing the original TMD pain issue.
We strongly discourage this approach not only because it is irreversible, but also because it is expensive, most often unnecessary, and potentially even harmful. Again, it is important to emphasize that there is no compelling evidence to demonstrate that invasive treatments for TMD are more beneficial than non-invasive treatments. Unless the scientific evidence can unequivocally establish that invasive, irreversible, and highly expensive treatments will provide better outcomes than those that are simpler and mostly reversible, then those dentists who routinely choose invasive intervention for TMD are violating their ethical obligations.
Patient Autonomy and Responsibility
There is no doubt that as consumers of health care, we are all more knowledgeable and engaged in our health care decisions than the generations before us. Our grandparents and parents may have never questioned the authority or decisions of physicians or dentists. Back then, the doctor’s opinion was firmly rooted in authority, not to be questioned. The doctor-patient relationship has evolved from that paternalistic and authoritative one to one of shared decision making based on patient values, preferences, and understanding of recommended treatments. Shared decision making is rooted in the ethical concept of respect for persons or respect for patient autonomy in the case of health care. Informed consent is based on this concept, which is less about the doctor avoiding legal liability and more about educating and facilitating patient choice. This is an obligation that applies to all health professionals to help people understand the reasons for the recommendations they are making. Based on this information, the patients ─ not the providers ─ can make an informed decision that is consistent with their own values and preferences.
When patients seek an evaluation and treatment for what may be a TMD problem, they are likely to do so with a sense of trust in the professional person they have selected. They do not base this trust simply on recommendations or because of personal factors; rather, their trust is based on the idea that the profession has held itself out to be trustworthy. However, if the dentist presents a limited perspective as if it were the only choice, the patient is likely to receive a treatment that is more grounded in an economic benefit for the dentist than patient welfare. The discerning patient would do well to seek at least two independent opinions, avoid unnecessary diagnostic modalities, and steer clear of invasive treatment methods involving jaw repositioning and bite changes. A large number of longitudinal and multi-continent studies have shown that many cases of TMD are self-limiting ─ that is, they frequently tend to resolve over time, or at least to respond well to conservative treatments. Therefore, patients should anticipate a good result if they find a dentist who follows the ethical principles discussed here, and who offers to treat them conservatively.