American Journal of ORTHODONTICS and DENTOFACIAL ORTHOPEDICS Volume I01 Number 1 January1992
Founded in 1915
Copyright © 1992 by the American Association of Orthodontists
VIEWPOINT
TMJ research: Responsibility and risk Rolf G. Behrents, DDS, MS, PhD, and Ralph A. White, DDS, MS Memphis and Kingsport, Tenn.
T h e purpose of this viewpoint is to recount a research program initiated by the American Association of Orthodontists and to express opinions as to the outcome of that program. It is important to point out that this article does not express the opinions of the American Association of Orthodontists, only those of the authors. A TMJ RESEARCH PROGRAM In the 1980s, articles in various journals and trade magazines suggested that orthodontic treatment might play a role in initiating temporomandibular disorders. On the other hand, it was also claimed that orthodontic treatment might be effective in alleviating the signs and symptoms of temporomandibular disorders. Many of the "findings" that were used to argue either direction were based on uncontrolled observation of clinical phenomena and contrived logic. Day-to-day anecdotal experiences and testimonials were often offered as proof, and biased opinion was portrayed as fact to colleagues, to the media, and to the public. Such activities led to name-calling (the term "quack" was heard a few times), attacks on nonbelievers, disdain for science, deep fear, and harsh feelings. Unfortunately, only a relatively small amount of objective data existed to counter the unsubstantiated claims. The conflict became earnest when results of the now famous Michigan orthodontic/TMJ lawsuit were announced. This litigation turned on the argument that a form of orthodontic treatment had caused the patient's temporomandibular disorder; the six-member jury found in favor of the patient. In posttrial actions, the American Association of Orthodontists (AAO) filed an Amicus Curiae Brief on behalf of the defendant (for a review see Pollackt). Ultimately, the matter was con-
811133721
cluded by the payment of a large sum of money to the patient. While the case was settled, it was clear that the matter was not over. Orthodontists became deeply defensive, and critics became deeply offensive. On the basis of the belief that such issues should be considered dialectically and feeling the need to assist in the generation of additional knowledge in this controversial area, the AAO began a program in the latter part of 1987 to support research on orthodontic treatment as it relates to temporomandibular joint disorders. The Board of Trustees of the American Association of Orthodontists passed a motion "that the A A O immediately initiate a program to conduct documented studies for the purpose of determining the relationship, or lack thereof, between orthodontic treatment and temporomandibular joint disorders." They also moved to form a new task-oriented committee, the Scientific Studies Committee, to conduct the program. Early in 1988, the committee was formed, consisting of persons with recognized knowledge in this area but with differing backgrounds: a prosthodontist, an oral pathologist, a general practitioner, and two orthodontists. A nonvoting AAO board member also attended the meetings. Committee activities produced an announcement calling for research proposals. This announcement, in the spring of 1988, called for "proposals to evaluate the relationship of commonly used clinical orthodontic treatments to temporomandibular disorders" and gave as its objective "to stimulate further research to evaluate the relationship of orthodontic treatments and the health of the temporomandibular joint." This announcement was widely distributed, being sent to the AMERICAN JOURNAL OF ORTHODONTICS AND DENTOFACIAL ORTHOPEDICS, Journal of the American Dental Association, Journal of Dental Education, dental school deans, and orthodontic department chairpersons. The text of the announcement was published in the July
2
Behrents and White
1988 issue of the AAO Bulletin and the August 1988 issue of the AJO/DO. By October of 1988, 23 applications had been received requesting over $300,000 in support. Applications were contributed from specialists and nonspecialists, from the United States and abroad, from novice and experienced researchers, and from practitioners and those affiliated with academics. After committee review, nine proposals were recommended for funding and $106,744.50 was to be distributed to support the research. It should be noted that the A A O allocated additional funds over the original budget on the basis of the committee's recommendations. On January 1, 1989, the funds were distributed, and work began. A listing of the successful applicants was printed in the.April 1989 issue of the AAO Bulletin and the June 1989 issue of the AJO/DO. Progress reports were submitted at the end of 1 year, and a report on the program was presented to the AAO membership at the 1990 annual session in Washington, D.C. In 1991, when all the projects were nearly complete, the principal investigators were invited to present their findings at the annual session of the AAO in Seattle. The investigators were also ifivited to submit manuscripts to the AJO/DO. Many expressed a desire to do so (others had already submitted articles to this and other journals) and other TMJ related manuscripts were also available (i.e., not supported by AAO funds). Consequently, it was decided to put together an AJO/DO issue devoted to TMJ research. Beyond the tangible work of the AAO supported investigators, the AAO sought to stimulate other research in this important area. Judging by the number of articles on this topic that have appeared in journals since 1987, whatever the cause, it is apparent that research interest has been stimulated. In the Amicus Curiae Brief filed by the AAO, 17 citations were listed, eight of which pertained specifically to the relationship between orthodontics and the temporomandibular joint. During the course of this research program, a reading list was compiled that pertains to the topic and includes articles arguing both sides of the issue. This bibliography now contains more than 400 references. While it might seem useful to summarize the work of the research described in this journal issue, it is best that the readers draw their own conclusions as they peruse the articles. On the other hand, given the substantial reading and study that has been involved in this whole project, and aware of benefits and caveats of the "hundredth research report phenomenon, ''2 it is tempting to draw some general conclusions from all that has been learned. With this guidance, the weight of the good scientific evidence supports the following conclu-
Am. J. Orthod. Dentofac. Orthop. January 1992
sions: (1) Consistently significant associations (either necessary or sufficient) between structure (dental and osseous) and temporomandibular disorders (TMD) have not been demonstrated. Certainly any relationship that might exist is not simple, frequent, or dramatic. (2) The develOpment of TMJ disorders cannot be predicted. (3) No method of TMJ disorder prevention has been demonstrated. (4) The prevalence of TMD symptoms increases with age; thus TMJ disorders may originate during orthodontic treatment, but not be related to the treatment. (5) Orthodontic treatments per se do not initiate TMJ disorders. (6) Evidence favors the beneficial nature of orthodontic treatment; orthodontics, as a part of the regimen of care, may assist in the lessening of symptoms. (7) Once TMD is present, TMD cures cannot be assumed or assu~ed. RESPONSIBILITY AND RISK
A learned profession fails to substantiate the adjectival tag when it fails to look within; to study its old ways, to create new information, and to look at its problems, as well as its assets. An association of persons dedicated to public health will claim their knowledge, but not substantiate its value until such knowledge is subjected to appropriate, controlled scrutiny. To do otherwise is irresponsible toward the public good. The response of the AAO in creating this i-esearch program was appropriate. They did not establish a legal defense fund to counter their critics; rather, with great spirit, the AAO embarked on a significant, responsible program to, in a sense, investigate itself by supporting research in this important area. With a look askance, some may question whether such can be done: Can an institution investigate itself?. This can be very difficult to do, but great measures were taken in this case to make the scrutiny fair and unbiased. The program was widely announced, the review committee was not stacked; the Association did not meddle with the activities or the recommendations of the review committee; the investigators conducted their own investigations without input from the organization; and they were free to report any of their findings in any manner they wished. They all were invited to submit papers to this peer-reviewed JOURNAL. Every effort was made to find the truth of the matter, and then publish whatever was found. A search for the truth, however, is not without risk. The AAO should be admired for its bravery in conducting this program. Those familiar with "real science" know that properly conducted research necessitates that the investigator is not certain of the outcome before the work is conducted. After the work is concIuded, the investigator may uncover information that supports his
Volume 10l Number l
beliefs. But, if one is true to the scientific method, opposing findings are also possible. Very definitely, risk was present in this program; the investigators could have found that orthodontic treatment was instrumental in the initiation of temporomandibular joint problems. Such would have been a sobering revelation. But, such findings have not emerged. Is this issue settled? Not likely. Regardless of the information contained in this JOURNALissue and others, many will approach the study methods, findings, and interpretations, with tired eyes and biases seeking only to disagree and refute because the information does not correspond to personal beliefs and agenda. Bellicose responses, ex cathedra, are expected from those who seek to vilify, not by scientific inquiry, but on the basis of unfounded, jello-like words like "I just know it ain't so, 'cause I know." Such people fail to learn from anyone who expresses a contrary thought or finding; ego-driven inflexibility is a characteristic of many "experts" but is seldom a productive, admirable quality. Ironically, the AAO has already been praised and libeled by inaccurate accounts of this research program. 3 It also is unlikely that the issue will be settled in the courtroom. Given the situation described by Peter Huber in his article titled "Junk science in the courtroom," the legal profession is developing an awareness of the potential absurdity of some "expert" testimony; unfortunately, awareness has not resulted in remedy. 4 Barratry will continue, no doubt, for some time. Unfortunately, the benefits of continued legal activity fall
Viewpoint
3
to the few participants; the benefits for the specialty are minuscule and, most often, negative. In addition to rhetorically inclined "experts," others will also disagree with the findings, but instead of choosing a word-based attack, they will initiate scientific inquiry in the laboratory or through appropriate clinical trials. While this form of retort may make some uncomfortable, it must be respected for it too is responsible and carries the risk of corroboration or denial when the work is done. Best of all, such continued inquiry will contribute to the fund of knowledge that responsible clinical scientists seek.
REFERENCES 1. Pollack B. Cases of note: Michigan jury awards $850,000 in ortho case: a tempest in a teapot. Ar~l J OR'moo DENTOFACORTHOP 1988;94:358-9. (Reprinted from The National Society of Dental Practitioners Risk Management Newsletter 1988;3(2):6-7.) 2. Englebretsen G. The hundredth research report phenomenon. J Irreproducible Results 1988;33:11-12. 3. Keller DC. Analyzing knowledge about TMD [letter to the editor]. Gen Dent 1990;327-9. 4. Huber PW. Junk science in the courtroom. Forbes July 8, 1991:6872.
Reprint requests to: Dr. Rolf G. Behrents Department of Orthodontics College of Dentistry The University of Tennessee 875 Union Ave. Memphis, TN 38163
Founded in 1915
Copyright © 1992 by the American Association of Orthodontists
VIEWPOINT
TMJ research: Responsibility and risk Rolf G. Behrents, DDS, MS, PhD, and Ralph A. White, DDS, MS Memphis and Kingsport, Tenn.
T h e purpose of this viewpoint is to recount a research program initiated by the American Association of Orthodontists and to express opinions as to the outcome of that program. It is important to point out that this article does not express the opinions of the American Association of Orthodontists, only those of the authors. A TMJ RESEARCH PROGRAM In the 1980s, articles in various journals and trade magazines suggested that orthodontic treatment might play a role in initiating temporomandibular disorders. On the other hand, it was also claimed that orthodontic treatment might be effective in alleviating the signs and symptoms of temporomandibular disorders. Many of the "findings" that were used to argue either direction were based on uncontrolled observation of clinical phenomena and contrived logic. Day-to-day anecdotal experiences and testimonials were often offered as proof, and biased opinion was portrayed as fact to colleagues, to the media, and to the public. Such activities led to name-calling (the term "quack" was heard a few times), attacks on nonbelievers, disdain for science, deep fear, and harsh feelings. Unfortunately, only a relatively small amount of objective data existed to counter the unsubstantiated claims. The conflict became earnest when results of the now famous Michigan orthodontic/TMJ lawsuit were announced. This litigation turned on the argument that a form of orthodontic treatment had caused the patient's temporomandibular disorder; the six-member jury found in favor of the patient. In posttrial actions, the American Association of Orthodontists (AAO) filed an Amicus Curiae Brief on behalf of the defendant (for a review see Pollackt). Ultimately, the matter was con-
811133721
cluded by the payment of a large sum of money to the patient. While the case was settled, it was clear that the matter was not over. Orthodontists became deeply defensive, and critics became deeply offensive. On the basis of the belief that such issues should be considered dialectically and feeling the need to assist in the generation of additional knowledge in this controversial area, the AAO began a program in the latter part of 1987 to support research on orthodontic treatment as it relates to temporomandibular joint disorders. The Board of Trustees of the American Association of Orthodontists passed a motion "that the A A O immediately initiate a program to conduct documented studies for the purpose of determining the relationship, or lack thereof, between orthodontic treatment and temporomandibular joint disorders." They also moved to form a new task-oriented committee, the Scientific Studies Committee, to conduct the program. Early in 1988, the committee was formed, consisting of persons with recognized knowledge in this area but with differing backgrounds: a prosthodontist, an oral pathologist, a general practitioner, and two orthodontists. A nonvoting AAO board member also attended the meetings. Committee activities produced an announcement calling for research proposals. This announcement, in the spring of 1988, called for "proposals to evaluate the relationship of commonly used clinical orthodontic treatments to temporomandibular disorders" and gave as its objective "to stimulate further research to evaluate the relationship of orthodontic treatments and the health of the temporomandibular joint." This announcement was widely distributed, being sent to the AMERICAN JOURNAL OF ORTHODONTICS AND DENTOFACIAL ORTHOPEDICS, Journal of the American Dental Association, Journal of Dental Education, dental school deans, and orthodontic department chairpersons. The text of the announcement was published in the July
2
Behrents and White
1988 issue of the AAO Bulletin and the August 1988 issue of the AJO/DO. By October of 1988, 23 applications had been received requesting over $300,000 in support. Applications were contributed from specialists and nonspecialists, from the United States and abroad, from novice and experienced researchers, and from practitioners and those affiliated with academics. After committee review, nine proposals were recommended for funding and $106,744.50 was to be distributed to support the research. It should be noted that the A A O allocated additional funds over the original budget on the basis of the committee's recommendations. On January 1, 1989, the funds were distributed, and work began. A listing of the successful applicants was printed in the.April 1989 issue of the AAO Bulletin and the June 1989 issue of the AJO/DO. Progress reports were submitted at the end of 1 year, and a report on the program was presented to the AAO membership at the 1990 annual session in Washington, D.C. In 1991, when all the projects were nearly complete, the principal investigators were invited to present their findings at the annual session of the AAO in Seattle. The investigators were also ifivited to submit manuscripts to the AJO/DO. Many expressed a desire to do so (others had already submitted articles to this and other journals) and other TMJ related manuscripts were also available (i.e., not supported by AAO funds). Consequently, it was decided to put together an AJO/DO issue devoted to TMJ research. Beyond the tangible work of the AAO supported investigators, the AAO sought to stimulate other research in this important area. Judging by the number of articles on this topic that have appeared in journals since 1987, whatever the cause, it is apparent that research interest has been stimulated. In the Amicus Curiae Brief filed by the AAO, 17 citations were listed, eight of which pertained specifically to the relationship between orthodontics and the temporomandibular joint. During the course of this research program, a reading list was compiled that pertains to the topic and includes articles arguing both sides of the issue. This bibliography now contains more than 400 references. While it might seem useful to summarize the work of the research described in this journal issue, it is best that the readers draw their own conclusions as they peruse the articles. On the other hand, given the substantial reading and study that has been involved in this whole project, and aware of benefits and caveats of the "hundredth research report phenomenon, ''2 it is tempting to draw some general conclusions from all that has been learned. With this guidance, the weight of the good scientific evidence supports the following conclu-
Am. J. Orthod. Dentofac. Orthop. January 1992
sions: (1) Consistently significant associations (either necessary or sufficient) between structure (dental and osseous) and temporomandibular disorders (TMD) have not been demonstrated. Certainly any relationship that might exist is not simple, frequent, or dramatic. (2) The develOpment of TMJ disorders cannot be predicted. (3) No method of TMJ disorder prevention has been demonstrated. (4) The prevalence of TMD symptoms increases with age; thus TMJ disorders may originate during orthodontic treatment, but not be related to the treatment. (5) Orthodontic treatments per se do not initiate TMJ disorders. (6) Evidence favors the beneficial nature of orthodontic treatment; orthodontics, as a part of the regimen of care, may assist in the lessening of symptoms. (7) Once TMD is present, TMD cures cannot be assumed or assu~ed. RESPONSIBILITY AND RISK
A learned profession fails to substantiate the adjectival tag when it fails to look within; to study its old ways, to create new information, and to look at its problems, as well as its assets. An association of persons dedicated to public health will claim their knowledge, but not substantiate its value until such knowledge is subjected to appropriate, controlled scrutiny. To do otherwise is irresponsible toward the public good. The response of the AAO in creating this i-esearch program was appropriate. They did not establish a legal defense fund to counter their critics; rather, with great spirit, the AAO embarked on a significant, responsible program to, in a sense, investigate itself by supporting research in this important area. With a look askance, some may question whether such can be done: Can an institution investigate itself?. This can be very difficult to do, but great measures were taken in this case to make the scrutiny fair and unbiased. The program was widely announced, the review committee was not stacked; the Association did not meddle with the activities or the recommendations of the review committee; the investigators conducted their own investigations without input from the organization; and they were free to report any of their findings in any manner they wished. They all were invited to submit papers to this peer-reviewed JOURNAL. Every effort was made to find the truth of the matter, and then publish whatever was found. A search for the truth, however, is not without risk. The AAO should be admired for its bravery in conducting this program. Those familiar with "real science" know that properly conducted research necessitates that the investigator is not certain of the outcome before the work is conducted. After the work is concIuded, the investigator may uncover information that supports his
Volume 10l Number l
beliefs. But, if one is true to the scientific method, opposing findings are also possible. Very definitely, risk was present in this program; the investigators could have found that orthodontic treatment was instrumental in the initiation of temporomandibular joint problems. Such would have been a sobering revelation. But, such findings have not emerged. Is this issue settled? Not likely. Regardless of the information contained in this JOURNALissue and others, many will approach the study methods, findings, and interpretations, with tired eyes and biases seeking only to disagree and refute because the information does not correspond to personal beliefs and agenda. Bellicose responses, ex cathedra, are expected from those who seek to vilify, not by scientific inquiry, but on the basis of unfounded, jello-like words like "I just know it ain't so, 'cause I know." Such people fail to learn from anyone who expresses a contrary thought or finding; ego-driven inflexibility is a characteristic of many "experts" but is seldom a productive, admirable quality. Ironically, the AAO has already been praised and libeled by inaccurate accounts of this research program. 3 It also is unlikely that the issue will be settled in the courtroom. Given the situation described by Peter Huber in his article titled "Junk science in the courtroom," the legal profession is developing an awareness of the potential absurdity of some "expert" testimony; unfortunately, awareness has not resulted in remedy. 4 Barratry will continue, no doubt, for some time. Unfortunately, the benefits of continued legal activity fall
Viewpoint
3
to the few participants; the benefits for the specialty are minuscule and, most often, negative. In addition to rhetorically inclined "experts," others will also disagree with the findings, but instead of choosing a word-based attack, they will initiate scientific inquiry in the laboratory or through appropriate clinical trials. While this form of retort may make some uncomfortable, it must be respected for it too is responsible and carries the risk of corroboration or denial when the work is done. Best of all, such continued inquiry will contribute to the fund of knowledge that responsible clinical scientists seek.
REFERENCES 1. Pollack B. Cases of note: Michigan jury awards $850,000 in ortho case: a tempest in a teapot. Ar~l J OR'moo DENTOFACORTHOP 1988;94:358-9. (Reprinted from The National Society of Dental Practitioners Risk Management Newsletter 1988;3(2):6-7.) 2. Englebretsen G. The hundredth research report phenomenon. J Irreproducible Results 1988;33:11-12. 3. Keller DC. Analyzing knowledge about TMD [letter to the editor]. Gen Dent 1990;327-9. 4. Huber PW. Junk science in the courtroom. Forbes July 8, 1991:6872.
Reprint requests to: Dr. Rolf G. Behrents Department of Orthodontics College of Dentistry The University of Tennessee 875 Union Ave. Memphis, TN 38163
