It is with a measure of disappointment that I read this editorial (David Psutka, June, 2021). Have we somehow forgotten the lessons of the past? In the mid-80s, someone discovered that they could operate on joints arthroscopically and otherwise. So, joints were operated on with great flair and abandon. Then in the mid-90s it pretty much stopped as surgeons saw how unsuccessful their efforts were. (A billion-dollar class action suit helped, too).
Why was joint surgery so unsuccessful? Simple, really. They were operating on a symptom, not solving the problem.
TMD is first and foremost a problem with the occlusion. It’s muscles trying to protect teeth, little more than that. The other things – joint symptoms, muscle pain, headaches, parafunction, occlusal disease and yes, sometimes even psychological issues, are secondary to the bite problems.
(Yes, there are things like trauma-induced and idiopathic condylar resorption, but that’s a whole separate topic).
Surgical intervention should never be the starting point under any normal circumstances. Joint surgery should be “the Court of Last Resort”. Botox, while sometimes effective, is a stop gap
measure to temporarily paralyze symptomatic muscles but not a cure for anything. Nor does it prevent damage to the hard and soft tissues in the long term.
Having treated thousands of TMD cases with occlusal intervention in over 40 years of general and specialty practice, I can recall none that ever required joint surgery. I’m not special, either. There are many dentists and specialists out there who have made the effort to acquire the knowledge and training (that dental schools nowadays don’t seem to offer) to successfully manage these patients.
Unfortunately, with what seems to be the vast majority of dentists at a loss with what to do for these patients, they get left on the doorstep of the oral and maxillofacial surgeon who typically know even less about occlusion. They are therefore stuck trying to do pain management.
Certainly, some TMD cases are easier and some are more difficult, and one needs a certain skillset with which to treat them. But it’s not rocket science.
But I’m seeing a disturbing trend of joint surgery re-emerging as the treatment of choice, and some even advocating (shudder) joint surgery FIRST before stabilizing the occlusion. And even more disturbing is the aggressive denial on the part of some dentists that occlusion is even important. I could host a ticker tape parade of patients who would gladly tell you otherwise.
I’m approaching the latter stages of my career now. I can at least take some solace in that I have a good young partner who has seen what can be done for these patients and has embraced
management of these cases. He can at least carry the torch forward.
Sincerely,
Dr. Mark Antosz
Calgary
