Overtreatment "Successes"--What Are the Negative Consequences for Patients, Dentists, and the Profession?

AIMS: To describe how some management practices in the field of orofacial musculoskeletal disorders (also described as temporomandibular disorders [TMDs]) are based on concepts about occlusal relationships, condyle positions, or functional guidance; for some patients, these procedures may be producing successful outcomes in terms of symptom reduction, but in many cases, they can be examples of unnecessary overtreatment. METHODS: The authors discuss the negative consequences of this type of overtreatment for both doctors and patients, as well as the impact on the dental profession itself. Special focus is given to trying to move the dental profession away from the old mechanical paradigms for treating TMDs and forward to the more modern (and generally more conservative) medically based approaches, with emphasis on the biopsychosocial model. RESULTS: The clinical implications of such a discussion are apparent. For example, it can be argued that the routine use of Phase II dental or surgical treatments for managing most orofacial pain cases represents overtreatment, which cannot be defended on the grounds of symptom improvement (ie, "successful" outcomes) alone. Similarly, there is enough clinical evidence to conclude that complex biomechanical approaches focusing on the search for an ideal specific condylar or neuromuscular position for the management of orofacial musculoskeletal disorders are not needed to produce a positive clinical result that is stable over time. CONCLUSION: Typically, overtreatment successes cannot be easily perceived by the patients or the treating dentists because the patients are satisfied and the dentists feel good about those outcomes. However, neither party knows whether an excessive amount of treatment has been provided. Therefore, both the practical and ethical aspects of this discussion about proper treatment vs overtreatment deserve attention.

Temporomandibular disorders: current status of research, education, policies, and its impact on clinicians in the United States of America.

Temporomandibular disorders (TMDs) encompass a number of different musculoskeletal disorders often accompanied by pain and dysfunction. Most TMDs are acute, but can become chronic leading to disability and quality of life issues. There is wide variation in treatment of TMDs, including both conservative/reversible therapies as well as invasive/irreversible treatments, which present difficulties for clinicians, patients, and third-party payers as to what constitutes appropriate care. Data sources: A recent report by the National Academies of Sciences, Engineering, and Medicine highlighted a number of deficiencies, most notably in the education of TMDs within United States of America dental schools at both the predoctoral and postdoctoral (dental) levels as well as addressing the historic inconsistencies in both diagnosis and treatment. New areas for research and interprofessional collaboration should assist in the understanding of TMDs, and updated clinical practice guidelines should help reduce variation in the delivery of evidence-based care. Recently, the American Dental Association recognized orofacial pain as a specialty, which should increase the level and availability of expertise in treating these issues. Summary: Based on the current best evidence, this report is an attempt to alert the profession to discontinue irreversible and invasive therapies for the vast majority of TMDs and recognize that the majority of these disorders are amenable to conservative, reversible interventions.

Remarks on "Temporomandibular Disorders: Priorities for Research and Care": how will Chile advance? / Observaciones sobre trastornos temporomandibulares: prioridades de investigación y atención: ¿cómo avanzará Chile?

Temporomandibular disorders (TMDs) are complex multi-system disorders for which common traditional dental-centric approaches to research and care unfortunately continue to prevail. A committee appointed by the National Academies of Sciences, Engineering and Medicine (NAM) of the United States of America summarized important recommendations regarding the urgent need to transform, from the predominantly biomedical model, the research, professional education/training, and patient care for TMDs into the biopsychosocial model that is standard in the rest of pain medicine. The release of the Consensus Study Report identifies eleven short-term and long-term recommendations regarding gaps and opportunities oriented towards the situation in the US, which are equally applicable to the situation in Chile. The first four recommendations focus on basic and translational research, public health research and strengthening clinical research. The next three recommendations concern risk assessment, diagnostics, and dissemination of clinical practice guidelines and care metrics to improve patient care and expand its access. Recommendations eight to ten propose Centers of Excellence for Temporomandibular Disorders and Orofacial Pain Treatment, improving professional school education, and expanding specialized continuing education for healthcare providers. The eleventh recommendation focuses on patient education and stigma reduction. This article highlights the published recommendations and addresses what should be considered by Chilean professionals, as a first step of a major effort to shift TMD research, treatment, and education paradigms for the years to come.

Los trastornos temporomandibulares son complejos trastornos multisistémicos para los que, lamentablemente, siguen prevaleciendo los enfoques tradicionales odontocéntricos comunes de la investigación y la atención. Un comité designado por las Academias Nacionales de Ciencias, Ingeniería y Medicina de los Estados Unidos de América resumió importantes recomendaciones relativas a la urgente necesidad de transformar, desde el modelo predominantemente biomédico, la investigación, la educación/formación profesional y la atención al paciente para los trastornos temporomandibulares en el modelo biopsicosocial que es estándar en el resto de la medicina del dolor. La publicación del informe del estudio de consenso identifica once recomendaciones de corto y largo plazo respecto a brechas y oportunidades orientadas a la situación en Estados Unidos, que son igualmente aplicables a la situación en Chile. Las primeras cuatro recomendaciones se centran en la investigación básica y traslacional, la investigación en salud pública y el fortalecimiento de la investigación clínica. Las tres recomendaciones siguientes se refieren a la evaluación de riesgos, el diagnóstico y la difusión de guías de práctica clínica y métricas asistenciales para mejorar la atención de los pacientes y ampliar su acceso. Las recomendaciones octavas a décima proponen centros de excelencia para el tratamiento de los trastornos temporomandibulares y el dolor orofacial, la mejora de la formación en los centros profesionales y la ampliación de la formación continua especializada para los profesionales sanitarios. La undécima recomendación se centra en la educación de los pacientes y la reducción del estigma. Este artículo destaca las recomendaciones publicadas y aborda lo que debiesen considerar los profesionales chilenos, como primer paso hacia un gran esfuerzo por cambiar los paradigmas de investigación, tratamiento y educación sobre los trastornos temporomandibulares para los próximos años.

Observaciones sobre trastornos temporomandibulares: prioridades de investigación y atención: ¿cómo avanzará Chile? / Remarks on "Temporomandibular Disorders: Priorities for Research and Care": how will Chile advance?

Los trastornos temporomandibulares son complejos trastornos multisistémicos para los que, lamentablemente, siguen prevaleciendo los enfoques tradicionales odontocéntricos comunes de la investigación y la atención. Un comité designado por las Academias Nacionales de Ciencias, Ingeniería y Medicina de los Estados Unidos de América resumió importantes recomendaciones relativas a la urgente necesidad de transformar, desde el modelo predominantemente biomédico, la investigación, la educación/formación profesional y la atención al paciente para los trastornos temporomandibulares en el modelo biopsicosocial que es estándar en el resto de la medicina del dolor. La publicación del informe del estudio de consenso identifica once recomendaciones de corto y largo plazo respecto a brechas y oportunidades orientadas a la situación en Estados Unidos, que son igualmente aplicables a la situación en Chile. Las primeras cuatro recomendaciones se centran en la investigación básica y traslacional, la investigación en salud pública y el fortalecimiento de la investigación clínica. Las tres recomendaciones siguientes se refieren a la evaluación de riesgos, el diagnóstico y la difusión de guías de práctica clínica y métricas asistenciales para mejorar la atención de los pacientes y ampliar su acceso. Las recomendaciones octavas a décima proponen centros de excelencia para el tratamiento de los trastornos temporomandibulares y el dolor orofacial, la mejora de la formación en los centros profesionales y la ampliación de la formación continua especializada para los profesionales sanitarios. La undécima recomendación se centra en la educación de los pacientes y la reducción del estigma. Este artículo destaca las recomendaciones publicadas y aborda lo que debiesen considerar los profesionales chilenos, como primer paso hacia un gran esfuerzo por cambiar los paradigmas de investigación, tratamiento y educación sobre los trastornos temporomandibulares para los próximos años.

Temporomandibular disorders (TMDs) are complex multi-system disorders for which common traditional dental-centric approaches to research and care unfortunately continue to prevail. A committee appointed by the National Academies of Sciences, Engineering and Medicine (NAM) of the United States of America summarized important recommendations regarding the urgent need to transform, from the predominantly biomedical model, the research, professional education/training, and patient care for TMDs into the biopsychosocial model that is standard in the rest of pain medicine. The release of the Consensus Study Report identifies eleven short-term and long-term recommendations regarding gaps and opportunities oriented towards the situation in the US, which are equally applicable to the situation in Chile. The first four recommendations focus on basic and translational research, public health research and strengthening clinical research. The next three recommendations concern risk assessment, diagnostics, and dissemination of clinical practice guidelines and care metrics to improve patient care and expand its access. Recommendations eight to ten propose Centers of Excellence for Temporomandibular Disorders and Orofacial Pain Treatment, improving professional school education, and expanding specialized continuing education for healthcare providers. The eleventh recommendation focuses on patient education and stigma reduction. This article highlights the published recommendations and addresses what should be considered by Chilean professionals, as a first step of a major effort to shift TMD research, treatment, and education paradigms for the years to come.

Algal solutions: Transforming marine aquaculture from the bottom up for a sustainable future.

Today's global food production system is unsustainable. Shifting the focus of marine aquaculture down the food chain to algae could help meet projected global nutritional demands while simultaneously improving overall environmental sustainability and ocean health.

A commentary on Temporomandibular disorders: priorities for research and care - bridging from the US to the UK.

In January 2019, the United States National Academy of Medicine initiated a comprehensive study of the status of current knowledge and clinical practices associated with temporomandibular disorders (TMDs). The National Academy of Sciences, which includes the National Academy of Medicine, was chartered by the US Government in the late 1800s as a non-profit institution working outside of government in order to provide unbiased, objective opinions on matters including healthcare. In this brief paper, we will discuss the open access 2020 report Temporomandibular disorders: priorities for research and care, available online. While the main focus of this report was the situation of TMDs in the US, the evidence base, authorship, expertise and literature scope was international and the findings therefore are at least in part generalisable to and important for the UK.The authors of this commentary were directly involved in the National Academy process, with RO a panel member, JD a consultant and CG one of 15 reviewers of the draft report. There was a wide variety of clinical and research fields involved in gathering the evidence and constructing the report. In addition, there was extensive involvement from affected patients with TMDs and their families, which is critical because their perspective is typically omitted in textbooks and professional consensus meetings.

Centric relation critically revisited-What are the clinical implications?

PURPOSE OF THE ARTICLE: Centric relation is a dental term that has undergone many alterations over the years, which in turn have led to significant clinical controversies. These continuing changes in the meaning of the term CR have not only led to confusion, but they also have resulted in a variety of unnecessary diagnostic and therapeutic procedures. Analysis of the dental literature reveals ongoing misunderstanding and disagreement regarding that term among both clinicians and academic dentists. MATERIALS AND METHODS: A search of the PubMed database was performed with the following search terms: "centric relation", "masticatory muscles", "maxillomandibular relationship" and "condylar position." Relevant literature from the past 70 years until the present day was meticulously scrutinised. RESULTS: As expected, the literature review on the topic of CR revealed a problematic pattern of changing definitions and clinical disagreements, all of which have had a significant impact on the practice of dentistry. CONCLUSION: There are semantic, conceptual and practical reasons for concluding that the term 'centric relation' is flawed. Those flaws have a significant impact on dental practice. Based on our analysis, argumentation is provided to conclude that the term 'centric relation' should be abandoned. Instead, it appears that every individual has a unique temporomandibular joint relationship which cannot be described by any singular term. In healthy dentate patients, this relationship is determined by the maximum intercuspation of the teeth and should therefore be considered as biologically acceptable.