LETTERS TO THE EDITOR Screening for craniomandibular disorders in orthodontic treatment To the Editor:
After reading the article entitled "Occurrence of craniomandibular symptoms in healthy young adults" by Loft, Reynolds, Zwemer, Thompson and Dushku in the September issue (AM J ORTHODDENTOFACORTHOP1989; 96:264-5), I felt scepticism and reservations for its conclusion, which indicated that "because orthodontic intervention was significantly associated with increased reports of the single factor of facial discomfort and pain in female subjects, it is essential for orthodontists to secure a careful patient history and to perform a thorough clinical, radiographic, and laboratory examination for signs and symptoms of craniomandibular dysfunction in each patient before initiating orthodontic treatment." There is no doubt that our specialty will gain benefits from reports dealing with the controversial issue of craniomandibular disorders and its possibly etiological association with orthodontic treatment. On the other hand, distinguished colleagues '-3 and the AAO itself' have clearly pointed out that if any conclusive evidence has to be presented, prospective longitudinal studies and data gathered with appropriate controls must be used. In addition, all conclusions must take into account the complex biologic, physiologic, and psychological aspects of craniomandibular disorders.' My specific questions to the authors are: (a) Is it essential for orthodontists to perform radiographic and laboratory examination for dysfunction's signs and symptoms in each patient before initiating orthodontic treatment? Review of the literature shows that neither excellent radiographic nor sophisticated instrumental nor laboratory examination can be used reliably to separate most patients with craniomandibular disorders from other patients (except in cases of extensive osseous alteration), or to identify different subgroupings of dysfunction? -a It has been recommended that x-ray photographs should be taken only when the patient has facial asymmetries of growth, a continuously changing intermaxillary relationship, no response to the conservative treatment, a history of trauma, drepitation of the joint,' a history of rheumatic disease, '°,'' and internal derangement associated with pain on movement. '2 A thorough history and detailed head and neck examination are the first and in most of the cases only necessary diagnostic procedures. 2.'2.'3 (b) Does the presence of pain, discomfort, or other sensations about the face, eyes, throat, neck, or shoulder (Question 3 on which the conclusions were based) by itself constitute symptoms associated only with craniomandibular disorders? It is well known that pain in these regions has been very often associated with
other disorders, not necessarily of craniomandibular origin. '.''.'~ I also think that the authors cannot characterize the pain in all these different sites as facial pain as they do in the legend of Table III and the discussion section of the article. The fact that some orthodontic patients may have certain signs or symptoms of craniomandibular disorders before treatment, while others may exhibit such problems during the therapy or postreatroent and postretention periods, demands, of course, careful screening, monitoring, and documentation of the craniomandibular functional status of all patients during the various phases of their involvement with our orthodontic office. Management of these problems should be related to their diagnosis and degree of severity? Extensive search of the up-to-day bibliography, '-3 however, does not support the conclusion that orthodontic treatment of any type predisposes patients to craniomandibular disorders. It is my opinion that special attention should be given to reports such as this, which imply a systematic relationship between our specialty and the dysfunction of the stomatognathic system. Athanasios E. Athanasiou, DDS, MSD Associate Professor and Coordinator Postgraduate Orthodontic Education The Royal Dental College Aarhus, Denmark REFERENCES 1. Rinchuse DJ. Counterpoint: Preventing adverse effects on the temporomandibular joint through orthodontic treatment. AM J ORTHOD DENTOFACORTItOP 1987;91:500-6. 2. Greene CS. Orthodontics and temporomandibular disorders. Dent Clin North Am 1988;32:529-38. 3. Gianelly AA. Orthodontics, condylar position, and TMJ status. AM J ORTtlOD DENTOFACORTHOP 1989;95:521-3. 4. Announcement of research support by AAO for evaluation of the relationship of orthodontic treatment and temporomandibular disorders. ANI J ORT/tOD DENTOFACORTtlOP 1988;94:20-1A. 5. Pullinger AG, Hollender L, Solberg WK. Radiographic condyle position: TMI patients and a screened control population (abstract). J Dent Res 1983;62:189. 6. Ryan DE, Collier BD, Messer E, Moloney F. Internal derangements of the temporomandibularjoint. III. Use of bone scanning as an aid to diagnosis. Aus Dent J 1985;30:349-54. 7. Christiansea EL, Thompson JR, Hasso AN. CT evaluation of trauma to the temporomandibular joint. J Oral Maxillofac Surg 1987;45:920-3. 8. Lavigne C, Frysinger R, Lund JP. Human factors in the measurement of the masseteric silent period. J Dent Res 1983;62: 985-8. 9. Examination protocol of the European academy of craniomandibular disorders. J Craniomandib Disord Facial Oral Pain 1987;1:9-10. 10. Larheim TA, Johannessen S, Tveito L. Abnormalities of the temporomandibular joint in adults with rheumatic disease. A comparison of panoramic, transcranial and transpharyngeal radiography with tomography. Dentomaxilofac Radiol 1988; 17: 109-13.
Am. J. Orthod. Dentofac. Orthop. February 1990
"I6A Letters to the editor
11. Larheim TA, Bjornland T. Arthrographic findings in the temporomandibular joint in patients with rheumatic disease. J Oral Maxillofac Surg 1989;47:780-4. 12. Tanaka IT. Recognition of the pain formula for head, neck and TMJ disorders. Oral Health 1985;75:79-85. 13. Solberg WK. Temporomandibular disorders: data collection and examination. Br Dent J 1986;160:317-22. 14. Block SL. Differential diagnosis of craniofacial-cervical pain; differential diagnosis of masticatory dysfunction. In: Samat BG, Laskin DM, eds. The temporomandibularjoint: a biological basis for clinical practice. Springfield: Charles C Thomas, 1980:348421. 15. Sternbach RA. The psychology of pain. New York: Raven Press, 1978.
Reply To the Editor:
In response to the letter from Athanasios E. Athanasiou of Aarhus, Denmark which you kindly shared with us we heartily endorse his conclusion that "the fact that some orthodontic patients may have certain signs or symptoms of craniomandibular disorders before treatment, while others may exhibit such problems during the therapy or posttreatment and postretention periods, demands of course careful screening, monitoring and documentation of the craniomandibular functional status of all patients . . . . " Furthermore, we concur with his recommendation that "prospective longitudinal studies and data gathered with appropriate controls must be utilized." Both of these points, of course, constituted the discussion of our short article. "The presence of pain, discomfort, or other sensations about the face, eyes, throat, neck or shoulder" obviously do not "constitute symptoms associated only with craniomandibular disorders." That is precisely the reason for a careful patient history and differential diagnostic examination that may well include radiographic and laboratory components--particularly in the present litigious environment here in the United States. Gerald H. Loft School of Dentistry Medical College of Georgia Augusta, Ga.
has failed to realize the shortcomings of many university programs, especially in regard to orthodontic training. Dr. Vig is very critical of the nonuniversity continuing educational system. Yet, the fact that so many practitioners are seeking continuing education outside the realm of a university setting should drive the message home that universities refuse to teach what we as practitioners want and/or need to know. Why should it always be necessary for the practitioner to discontinue practicing and go to school fulltime in order to advance his education? Other professions welcome such students of higher learning. It's very common for some professionals to obtain a Masters degree or Ph.D while they are still employed. Yet, our dental schools refuse to allow such practice. Granted, they may offer an afternoon course entitled, "Orthodontics for the General Practitioner." These are usually a waste of time and money and are spent trying to discourage anyone from becoming involved. This, Dr. Vig, should be termed educational malpractice, and it's occurring right under your nose in the university setting. On the other hand, you staff your orthodontic departments with many "part-time" faculty members. I find it ironic that this is an acceptable procedure, and yet, the part-time student's pursuit of an advanced degree is beyond the scope of your understanding. Because the serious practitioner is also devoted to being a continuous student, there are many acceptable programs available whereby one can obtain additional training. Not all of these programs fall into your so-called "educational malpractice" category. Furthermore, if we really want to provide the concerned care for our patients of which you speak, then the state and local dental societies should establish standards of care that must be adhered to. This should be our ultimate concern, not from whom one has learned the subject matter. C. Gordon Simpson, BS, MS, DDS Blackfoot, Idaho
Support for Douglas view on extractions in orthognathic surgery To the Editor:
"Educational malpractice" letter prompts Idaho response To the Editor:
It was interesting to read Dr. Vig's description of educational malpractice in the October issue (AMJ ORTHOD DENTOFAOOFITHOP1989;96:27A-28A). Unfortunately, he
I was quite surprised and very happy to read Dr. Bruce L. Douglas's letter to the editor in the September issue (AM J OnTHOD DENTOFAC ORTHOP 1989; 96:22A-23A). It is quite rare indeed and very pleasing when I find myself in complete agreement with anyone when it comes to extractions and orthognathic surgery. He divides the context of his letter into two specific types of problems, which I also will address. The first problem is that of extracting teeth. Certainly there are