Sir, in the BDJ of 8 January a short abstract was provided of a study on the role of anxiety and depression in patients with temporomandibular pains (TMD).1 It is no surprise that depression plays a role in TMDs as there is also ample evidence in the chronic pain literature to show that depression is common in these groups of patients and affects outcomes. TMD in many instances is associated with other chronic pain as it appears these patients have an increased vulnerability to pain as shown by case control studies linking TMDs with migraines, fibromyalgia, post traumatic stress and back pain.2 Prognostic studies have shown that poor outcomes are to be expected in patients with concomitant psychological factors.2 However, in the recent article in the BDJ in the series on risk management in clinical practice on TMDs3 there is no mention either of the importance of eliciting co-morbidities and psychological factors in the history, or highlighting the role of psychosocial techniques in management. Gray's and Al-Ani's article3 continues to stress a mechanical approach to a problem which has genetic, environmental, behavioural and psychological risk factors. As Stoher4 points out, splints need to be regarded as placebos but patients cling to them as they have few adverse effects and it seems dentists tend to prefer a mechanical rather than a biopsychosocial approach. I am consistently amazed at patients' (who have been wearing splints for months) complete lack of knowledge about the anatomy and functioning of the masticatory apparatus and their relief when this is explained through the use of a model. It is precisely because these broader issues are not taken into account that patients fail to improve and then instigate complaints. Ohrbach has recently extensively reviewed how disability should be assessed in patients with TMDs which is achievable in general practice.4