READERS’ ROUND TABLE

To THE EDITOR: We feel compelled to reply to the position paper of the

American Academy of Craniomandibular Disorders (J PROSTHET DENT 44:434, 1980).

Their accepted treatment seemed to cover only disorders of nonarticular, functional disturbances; the physical, medical treatment plan was lacking in modern knowledge and logical approach.

In the diagnosis section, injections of local anesthetics

and refrigerated sprays are referred to as a diagnostic tool and “sometimes” as a treatment for muscle spasms. Injec- tions are a treatment for myofascial triggerpoints and splinting, never for spasms. The range of injectable local anesthetic agents available today is very broad, but the article fails to mention that the solutions that degrade to PABA are the only anesthetics that were suggested by the originators of this treatment modality. Although 1 to 5 cc of 0.5% or 0.25% chloroprocaine or procaine hydrochloride is a poor excuse for an anesthetic, it is clinically much more effective on a long-term basis than lidocaine or other available injectables.

The authors limited the utilization of intraoral devices to the treatment of tooth occlusion dysfunctions. In our speciality of physical medicine, orthotics is very important. Orthotics, as applied to articular disturbances, are devices to relieve pressure, to support the damaged or diseased joints of the body, and to assist the weakened and malfunctioning myofascial components in movement. We have personally used intraoral orthotic devices in numer- ous patients with (TMJ) rheumatoid arthritis, traumatic arthritis, and other articular disturbances with great success. Orthotics are used as the primary modality in treating articular disturbances. They were not designed for, nor were they in any manner intended for use in, tooth occlusion problems.

No physical medicine specialist was listed as a co-author or consultant, which may account for the misconceptions

which could cause great pain or irreversible physical harm to patients treated in this way.

In recent publications, ultrasound is contraindicated in treating joint inflammation and some myofascial pain syndrome types. Ultrasound, being merely a “type” of penetrating heat, can increase symptoms of joint inflam-

mation, exacerbate pain, and further limit motion. In the presence of limited joint motion from connective tissue scarring, ultrasound is used as an adjunct to stretching exercises to assist in increasing motion. It is used with great success in our hospital in those patients.

The authors further suggest using sedative-hypnotics and tranquilizers integrated with other forms of treatment. These drugs are often prescribed with a lack of proper indication or familiarity with their depressive effects. All patients with chronic pain suffer from some form of physiologic and/or psychologic depression. When patients are withdrawn from depressive drug therapy, their symp- toms are usually greatly reduced. On the other hand,

THE JOURNAL OF PROSTHETIC DENTISTRY

initiation of sedative-hypnotics and tranquilizer therapy often increases their problems. Controlled use of these drugs in a hospital situation is quite different from treating ambulatory patients as we do in private practice.

The authors do warn of the possible degenerative changes from repeated intraarticular injections of steroids, but they state that an initial injection may by “beneficial in reducing inflammation in an acutely inflamed joint.” How many repeated injections cause degeneration? Those of us who treat pain have seen patients who have had “only one injection,” and severely damaged joint struc- tures have resulted. The TMJ lacks the dense, wear- resistant hyaline cartilage surfaces found in most joints of the body. Steroids can, in themselves, cause great irrever- sible harm to these joints and should never be indicated in any treatment plan of TMJ inflammation because of their osteolytic effect on joint structures. This is not to say that intraarticular injections of steroids in any joint arc bad, but a joint such as the TMJ cannot be safely infiltrated with steroids.

It would do us all good to stop and think before we do something we cannot reverse. A proper, well-planned physicabtheraputic approach can give instant relief to the patient in violent pain without causing harm. The patient can then be kept comfortable until orthotics or other safe treatment modalities are initiated.

BARRY N. TILDS, D.D.S., CONSULTANT

FL L. JOYNT, M.D., MEDICAL DIRECTOR REHABILITATION 1~s~rrn.r~

DETROIT MEDICAL CENTER

261 MACK BLVD.

DETROIT, MI 48201

Reply TO THE EDITOR:

On behalf of the American Academy of Craniomandib- ular Disorders I would like to thank Drs. Tilds and Joynt for their interest in the position paper. As previously stated in a response to comments made regarding the paper, the primary purpose of the paper was to classify the disorders of the craniomandibular complex. A cursory discussion of possible treatments was included to make the paper more interesting.

The Academy hopes to publish a much more in-depth paper on “Accepted Treatment Modalities” in the near future. We most certainly agree with the use of orthopedic apphances (orthotics) for treatment of craniomandibular disorders, including treatment of the neuromuscular sys- tem and articular tissues.

Our hope would be that practitioners in the field of physical medicine will join with us to properly describe treatment modalities in their area of expertise.

CHARLES MCNEILL, D.D.S. 1802 SAN MICUEI. DR.

WALNUT CREEK, CA 94596

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