To THE EDITOR:
I am critically concerned by the article “Treatment of myofascial pain dysfunction syndrome with occlusal equilibration” by Kerstein and Farrell (J PROSTHETDENT 1990;63:695-700). Their article appears to be an anecdotal summary of the authors’ clinical experience over a period of 4 years, not a scientific study! In this report, there was not a shred of scientific methodology applied, starting with a specific d&no& for each patient, definition of measurable parameters, controls, unbiased evaluation, or statistical analysis of the results. The application of the “catchall” diagnosis of myofascial pain dysfunction syndrome (MPDS) for patients who conceivably could have a specific joint disorder such as disk dislocation, degenerative arthritis, or hypermobility is quite obsolete by the evolving standards establir#hed over the past decade.l Several scientific studies2-6 have not supported a strong correlation between malocclusion or occlusal interferences and TMJ dysfunction symptoms. Dr. Kerstein appears to have a narrow focus with respect to TMD or MPDS disorders in spite of the overwhelming amount of scientific information available in the literature regarding TMJ dysfunction as a multifactorial disorder. Several more recent publications recommend reversible treatment prior to irreversible therapy such as dental equilibration or acclusal modification in the treatment of TMD. After 13 years of extensive personal experience in the management of TMD, I emphatically agree. Although I agree in principle to the equilibration technique used by Dr. Kerstein to reduce or eliminate working and balancing occlusal interferences, this technique should not be applied until the TMD/MPDS symptoms are reduced and stable with “reversible” techniques such as orthotic splint therapy. I cannot accept the authors’ 98% success rate in total resolution of TMD symptoms with equilibration or any single treatment modality. In addition, I cannot accept their statement that their results would stand up under scientific methodology. From my own clinical experience in equilibrating many TMD patients prior to orthotic splint therapy 10 to 13 Iyears ago, few if any of the patients experienced total resolution of their TMJ symptoms over the long run. Some became more symptomatic. The technique I used was essent:ially identical to the technique used by Dr. Kerstein in his report. As a result, I strongly recommend reversible procedures prior to any occlusal alteration. STEPHEN HARKINS, D.D.S. 601 N. WILMOT, STE. 82 TUCSON, AZ 85711
REFERENCES 1. Griffith RH. Report of the President’s conference on examination, diagnosis, and management of tempormandibular disorders. J Am Dent Assoc 1983;106:7.5-7. 2. Greene CS, Marbach JJ. Epidemiologic studies of mandibular dysfunction: a critical review. J PROSTHET DENT 1982;48:184-90.
THE JOURNAL
OF PROSTHETIC
DENTISTRY
3. Laskin DJ, Greene CS. Infbrence of the doctor-patient relationship on placebo therapy for patients with myofascial pain dysfunction (MPD) syndrome. J Am Dent Assoc 1972;85:892-4. 4. Bailey JO, Rugh JD. Effect of occlusal adjustments on bruxism as monitored by nocturnal EMG recordings [Abstract]. J Dent Res 1980;59:317. 5. Rugh JD, Barghi N, Drago CJ. Experimental occlusal discrepancies and nocturnal bruxism. J PROSTHET DENT 1984;51:548-53. 6. Seligman DA, Pullinger AC. Association of occlusal variables among refined TM patient diagnostic groups. J Craniomand Disord Facial Oral Pain 1989;3:227-36.
Reply To THE EDITOR:
In response to Dr. Harkin’s letter regarding “Treatment of myofascial pain dysfunction syndrome with occlusal equilibration” (J PROSTHETDENT 1990;63:695-700), it is necessary to state that this manuscript was prepared as and presented as a clinical report and not a scientific study. This report focuses on a clinical observation, made by the author over a period of 4 years, of the presence of a common occlusal element present in 53 MPDS sufferers. This common element was a lack of true anterior guidance with excessive molar contacts guiding the mandible during function. Upon correction of this element to establish complete anterior guidance,l the common symptoms of MPDS were dramatically reduced in a relatively short period of time. The purpose of this article was to report on these clinical findings and to elaborate on a potential major etiologic component of MPDS. Numerous authors2-4 have reported that occlusal interferences affect the muscles of mastication. Yet others believe that occlusion has little role in the creation of muscular dysfunction. 5,6 The “battle lines” have been drawn regarding this issue and only further research in this area will clearly define the answer. Dr. Harkins wants scientific data and statistical analysis to substantiate the clinical findings in the cited published report.’ Presently, there is a manuscript accepted for publication by the JOURNALof PROSTHETICDENTISTRY, by Kerstein and Wright, that is a scientific study of the effects that complete anterior guidance development has on the masseter and temporal muscles in seven female patients. In all subjects studied, pretreatment elevated-muscle activity was lowered to near resting state values in approximately 1 month by developing complete anterior guidance. These changes are all statistically significant (p < 0.05). In addition, the symptoms of MPDS were resolved across the subject pool in approximately 1 month. All subjects had previously worn splints without symptom reductions. The reported success rate of this treatment in the cited paper of 98 % is actually only slightly higher than the clinical success rate in well over 400 clinical trials since 1983. Compilations of our data reveal that symptom elimination, or dramatic reduction to a nonchronic state, occurs in approximately 89 % of all treated subjects. The other 11%
153
I am critically concerned by the article “Treatment of myofascial pain dysfunction syndrome with occlusal equilibration” by Kerstein and Farrell (J PROSTHETDENT 1990;63:695-700). Their article appears to be an anecdotal summary of the authors’ clinical experience over a period of 4 years, not a scientific study! In this report, there was not a shred of scientific methodology applied, starting with a specific d&no& for each patient, definition of measurable parameters, controls, unbiased evaluation, or statistical analysis of the results. The application of the “catchall” diagnosis of myofascial pain dysfunction syndrome (MPDS) for patients who conceivably could have a specific joint disorder such as disk dislocation, degenerative arthritis, or hypermobility is quite obsolete by the evolving standards establir#hed over the past decade.l Several scientific studies2-6 have not supported a strong correlation between malocclusion or occlusal interferences and TMJ dysfunction symptoms. Dr. Kerstein appears to have a narrow focus with respect to TMD or MPDS disorders in spite of the overwhelming amount of scientific information available in the literature regarding TMJ dysfunction as a multifactorial disorder. Several more recent publications recommend reversible treatment prior to irreversible therapy such as dental equilibration or acclusal modification in the treatment of TMD. After 13 years of extensive personal experience in the management of TMD, I emphatically agree. Although I agree in principle to the equilibration technique used by Dr. Kerstein to reduce or eliminate working and balancing occlusal interferences, this technique should not be applied until the TMD/MPDS symptoms are reduced and stable with “reversible” techniques such as orthotic splint therapy. I cannot accept the authors’ 98% success rate in total resolution of TMD symptoms with equilibration or any single treatment modality. In addition, I cannot accept their statement that their results would stand up under scientific methodology. From my own clinical experience in equilibrating many TMD patients prior to orthotic splint therapy 10 to 13 Iyears ago, few if any of the patients experienced total resolution of their TMJ symptoms over the long run. Some became more symptomatic. The technique I used was essent:ially identical to the technique used by Dr. Kerstein in his report. As a result, I strongly recommend reversible procedures prior to any occlusal alteration. STEPHEN HARKINS, D.D.S. 601 N. WILMOT, STE. 82 TUCSON, AZ 85711
REFERENCES 1. Griffith RH. Report of the President’s conference on examination, diagnosis, and management of tempormandibular disorders. J Am Dent Assoc 1983;106:7.5-7. 2. Greene CS, Marbach JJ. Epidemiologic studies of mandibular dysfunction: a critical review. J PROSTHET DENT 1982;48:184-90.
THE JOURNAL
OF PROSTHETIC
DENTISTRY
3. Laskin DJ, Greene CS. Infbrence of the doctor-patient relationship on placebo therapy for patients with myofascial pain dysfunction (MPD) syndrome. J Am Dent Assoc 1972;85:892-4. 4. Bailey JO, Rugh JD. Effect of occlusal adjustments on bruxism as monitored by nocturnal EMG recordings [Abstract]. J Dent Res 1980;59:317. 5. Rugh JD, Barghi N, Drago CJ. Experimental occlusal discrepancies and nocturnal bruxism. J PROSTHET DENT 1984;51:548-53. 6. Seligman DA, Pullinger AC. Association of occlusal variables among refined TM patient diagnostic groups. J Craniomand Disord Facial Oral Pain 1989;3:227-36.
Reply To THE EDITOR:
In response to Dr. Harkin’s letter regarding “Treatment of myofascial pain dysfunction syndrome with occlusal equilibration” (J PROSTHETDENT 1990;63:695-700), it is necessary to state that this manuscript was prepared as and presented as a clinical report and not a scientific study. This report focuses on a clinical observation, made by the author over a period of 4 years, of the presence of a common occlusal element present in 53 MPDS sufferers. This common element was a lack of true anterior guidance with excessive molar contacts guiding the mandible during function. Upon correction of this element to establish complete anterior guidance,l the common symptoms of MPDS were dramatically reduced in a relatively short period of time. The purpose of this article was to report on these clinical findings and to elaborate on a potential major etiologic component of MPDS. Numerous authors2-4 have reported that occlusal interferences affect the muscles of mastication. Yet others believe that occlusion has little role in the creation of muscular dysfunction. 5,6 The “battle lines” have been drawn regarding this issue and only further research in this area will clearly define the answer. Dr. Harkins wants scientific data and statistical analysis to substantiate the clinical findings in the cited published report.’ Presently, there is a manuscript accepted for publication by the JOURNALof PROSTHETICDENTISTRY, by Kerstein and Wright, that is a scientific study of the effects that complete anterior guidance development has on the masseter and temporal muscles in seven female patients. In all subjects studied, pretreatment elevated-muscle activity was lowered to near resting state values in approximately 1 month by developing complete anterior guidance. These changes are all statistically significant (p < 0.05). In addition, the symptoms of MPDS were resolved across the subject pool in approximately 1 month. All subjects had previously worn splints without symptom reductions. The reported success rate of this treatment in the cited paper of 98 % is actually only slightly higher than the clinical success rate in well over 400 clinical trials since 1983. Compilations of our data reveal that symptom elimination, or dramatic reduction to a nonchronic state, occurs in approximately 89 % of all treated subjects. The other 11%
153
