There are two factions within the dental field that appear to have differing opinions regarding the etiology, diagnosis and treatment of temporomandibular disorders (TMD). One faction believes TMD is primarily a biopsychosocial issue that will respond to medication, psychological stress intervention, and lifestyle modifications.1 The other faction, represented by the American Alliance of TMD Organizations (AATMD), of which the Sacro Occipital Technique Organization (SOTO) -USA has been a member since 2005, believes that dental occlusion, condylar position, and airway space play and important part in the etiology of TMD2 and therefore need to be addressed in a dentist's diagnosis and treatment.
SOTO -USA is the only chiropractic-based member of this essentially dental alliance representing more than 15,000 dentists that treat TMD conditions nationally. As a chiropractic representative, my focus has been on developing co-treatment models for dentistry and chiropractic in the treatment of TMD conditions. In attending AATMD meetings, I have learned things I believe are of value to the chiropractic profession.
Founded in 1995 on behalf of patients' well-being, the AATMD's mission is to support and protect the right and freedom of clinicians to practice in the field of TMD within the scope of their care, skill, judgment, and scientific information. The organization's mission is to represent the broad interests of professional organizations and their member practitioners who understand the importance of effective diagnosis and treatment of craniofacial disorders.
Treating TMD: Two Different Approaches
If we look at the evidence, the problem is that there is relatively good research in both camps, so when one side is challenged, they cite their supportive articles and either ignore or find fault in the other side's articles. This makes for a bit of an untenable situation, since there are reasons why some dental authorities would prefer the biopsychosocial approach.
In my opinion, the American Dental Association (ADA) appears to have a preference for the biopsychosocial approach. Why would this be the case? For years, general dentists and orthodontists have been filling cavities, placing crowns and changing the way teeth touch one another (occlusion). If changes in occlusion affect the position of the mandibular condyle and airway space, then logically the dental profession would be held accountable if a patient develops TMD from "correct" dental care that didn't take TMD dynamics into account. The ADA has the obligation to protect its members as well as the public, and this may create a possible conflict of interest in terms of this treatment approach.
TMD and Insurance Reimbursement
As I chiropractor, I had not really considered how just about every joint in the body is covered by health insurance if it is traumatized, sprained, has muscle dysfunction, and/or becomes inflamed and painful. There is only one joint for the dental field that is not covered, and that is the temporomandibular joint (TMJ). Chiropractors and allopaths can treat the TMJ and be covered for this treatment, but not so with dentists at this time.
How Are Dentistry and Chiropractic Similar?
One thing most chiropractors feel confident about is that chiropractic helps their patients. Likewise, the predominantly dental members of the AATMD also feel confident their care helps patients with TMD. But which chiropractic or dental technique is the right one to treat TMD? This is the huge challenge for both chiropractic and dentistry.
At this time, we both can say that our care helps clinical outcomes, but we have not studied our methods in a comparative way to determine which technique or intervention is best. Part of the problem is that spinal balance and TMJ function are extremely multifactorial, leading to varied diagnoses and treatment options. The "lens" the doctor looks through when examining the patient will inadvertently guide their diagnosis and subsequent treatment.
The Potential for Co-Treatment
With multifactorial conditions such as those relating to the spine or TMJ, some patients may have varied pain thresholds or levels at which they become symptomatic. Some subsets of patients may well respond to specific chiropractic techniques for their spinal condition or specific dental methods for their TMD; but it is also likely that many patients may well respond to multiple types of care and not have conditions that are technique or method specific. As we study our methods in greater detail, we all hope to have more answers.
From a chiropractic perspective, it seems to me self-evident that if we see our bodies as a neuromusculoskeletal kinematic chain, that the TMJ and its function is important. Since posture3,4 has been found to have an effect on dental occlusion, condylar position, and airway space; and dental occlusion,5 condylar position,6 and airway space7 have been found to have an effect on posture, the two seem to be linked kinematically.8
Chiropractic is beginning to open the doors to possible dental/chiropractic co-treatment of TMD and at the 2009 chiropractic research conferences (ACC-RAC9 in Las Vegas and the WFC Biennial Congress /FCER International Conference on Chiropractic Research10,11 in Montreal), there were papers presented discussing how the dental and chiropractic fields can work together to help patients presenting with TMD.
- Green CS, Mohl ND, McNeill C, et al. Temporomandibular disorders and science: a response to the critics. Am J Orthod Dentofacial Orthop, 1999 Oct;116(4):430-1.
- Simmons HC III, Talley RL, Kilpatrick SR; American Academy of Craniofacial Pain Specialty Committee. Craniofacial pain as a dental specialty: a white paper by the American Academy of Craniofacial Pain. Cranio, 2001 Oct;19(4):302-4.
- Fink M, Wahling K, Stiesch-Scholz M, Tschernitschek H. The functional relationship between the craniomandibular system, cervical spine, and the sacroiliac joint: a preliminary investigation. Cranio, 2003 Jul;21(3):202-8.
- Nicolakis P, Nicolakis M, Piehslinger E, et al. Relationship between craniomandibular disorders and poor posture. Cranio, 2000 Apr;18(2):106-12.
- Bergamini C. Dental occlusion and body posture: a surface EMG study. Cranio, 2008 Jan;26(1):25-32.
- Olmos SR, Kritz-Silverstein D, Halligan W, Silverstein ST. The effect of condyle fossa relationships on head posture. Cranio, 2005 Jan;23(1):48-52.
- Cuccia AM, Lotti M, Caradonna D. Oral breathing and head posture. Angle Orthod, 2008 Jan;78(1):77-82.
- Sakaguchi K, Mehta NR, Abdallah EF, et al. Examination of the relationship between mandibular position and body posture. Cranio, 2007 Oct;25(4):237-49.
- Blum CL, Panahpour A. TMD - chiropractic and dentistry: two case reports. J Chirop Ed, 2009;21(1): 104.
- dal Bello F, Borilli F. "Research on the Effects of the Chiropractic Treatment on Individuals With Malocclusion as an Aid to the Orthodontic Treatment." WFC'S 10th Biennial Congress. International Conference of Chiropractic Research, Montreal, Canada, Apr 30 - May 2, 2009.
- dal Bello F, Borilli F. "Pain Alterations on the Temporomandibular Joint in Individuals With Malocclusion After Chiropractic Treatment." WFC'S 10th Biennial Congress. International Conference of Chiropractic Research, Montreal, Canada, April 30 - May 2, 2009.
The 2009 SOTO-USA Clinical Symposium (Oct. 22-25) features a "Dental Chiropractic TMD Co-Treatment Approach" course track.
Dr. Charles Blum, a graduate of Cleveland Chiropractic College - Los Angeles, is a past president of SOTO-USA and the organization's representative to the AATMD.