Sir, we are responding to the recent articles TMD and occlusion... by F. Luther (BDJ 2007; 202: E2, E3). While these papers draw on the multi-factorial aetiology of TMD, we know there is overwhelming evidence to suggest that TMD and related chronic oro-facial pain conditions like atypical facial pain are part of a wider spectrum of disorders with common psychological factors.1 Case-control studies2,3 that have examined the role of mechanical and psychological factors associated with TMD found that although cases had significantly increased pain on temporomandibular joint palpation, they also reported pain on palpation of placebo sites twice as frequently.
In addition, although cases had restricted mouth opening and deviation on jaw opening, there was no deterioration in corresponding function associated with these symptoms. Importantly, there were no differences between cases and controls in joint sounds, occlusion, facial trauma, missing teeth, prior dentistry and presence of dentures. The second, more recent case-control study3 found that although mechanical factors like facial trauma and teeth grinding were associated with cases of TMD, equally important was the role of psychological factors like distress, sleep disturbance and aspects of illness behaviour.
Other studies4 have shown stronger relationships with psychological factors and while there was an association with mechanical factors, those such as trauma and third molar removal are not amenable to invasive intervention. Rather, primary care practitioners should recognise this condition early by taking a thorough history which will indicate the presence of other chronic pain disorders and psychological distress.
Patients should be given early intervention in the form of patient focused leaflets and counselling. More severely disabled patients need referral to a tertiary clinic for cognitive behaviour therapy for which there is good quality evidence from randomised controlled trials.5,6 Just as there is no justification for occlusal adjustments,7 there is also insufficient evidence for occlusal splints which do not address the problem in a holistic manner, which is essential.8
References
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Aggarwal, V., Zakrzewska, J. A wider spectrum. Br Dent J 202, 300 (2007). https://doi.org/10.1038/bdj.2007.235
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DOI: https://doi.org/10.1038/bdj.2007.235
