I have treated temporomandibular joint disorder (TMJD) patients in my general practice since 1979.  It has been a unique and rewarding experience.  This area of dentistry has been fraught with disagreement and controversy over the causes of TMJD and the best treatment methods for as long as I have been involved in dentistry.

I do not consider myself an expert on TMJD and I certainly am not a known entity.   However, I have been able to eliminate pain for over 90% of the patients I have treated over the last 25 years.  The foundation for my treatment is based on my training at the L D Pankey Institute for Advanced Dental Educations and a belief that no permanent dental changes should be made until the patient is comfortable and stable.  

Based on my experiences, I believe treating TMJD is the hardest area of dentistry to deal with.  I have found that following well-established routines gives me highly predictable results in all areas of dental care-well over 90%.   TMJD has no well-established routines.  When I follow a routine I believe will work well for a TMJD patient, my results are frequently inconsistent.   My “standard protocol” works about 60% of the time.  When it doesn’t work as I expect, I have to go into “improv” mode, which means trying different therapies based on my observations of and conversations with the patient and an intuitive sense about how to proceed.  This intuitive sense has been developed over time and is not an easily or quickly teachable process.

I plan to retire from active practice within the next three years and would like to pass on to other dentists the knowledge I have gained.  I am not aware of any dentists in my area who consistently and effectively treat TMJD patients, although there is not a network for communication as far as I know.  It is an area where dentists get frustrated because of inconsistent outcomes and discontinue treating patients.  I have been there and understand the frustrations.  I was fortunate to make changes that resulted in a significant improvement in results.  I believe many dentists can do what I did with appropriate training.

What follows is a brief explanation of my early experiences which will help you understand my journey to this point.

From 1979-81, I used the protocols I learned at the Pankey Institute for treating TMJD patients.  I did not achieve the level of success I anticipated.  In the early 1980’s, the treatment of TMJD was probably the hottest topic in dentistry, with many speakers on the lecture circuit.  Many books were written.  I took most of the courses and read most of the books.   Among the presenters I heard were Pete Dawson, Harold Gelb, Terry Tanaka, John Witzig, Niles Guichet, Daniel Laskin, Mariano Rocabado, Charles McNeil, Bernie Williams, Jim Guinn, and Trip Owen.   I incorporated many of their therapies into my routine including ultrasound, physical therapy, electrogalvanic stimulation (EGS), biofeedback, stress management, nutritional supplements, radiographic analysis of joint relationships, and equilibration.  

I would estimate my success rate from 1979-85, was 30-40 % if one uses the elimination of pain as the criteria.  Those are not great numbers.  I felt success was just around the corner and if I did what was taught “just a little better” the numbers would go up dramatically.  After all, those lecturers were successfully treating their patients, weren’t they?  I was too intimidated to ask them. 

Feeling very discouraged in 1985, I stopped throwing treatment at patients long enough to actually think about ways I might improve the numbers.  I wondered if the patients that I had “successfully” treated might teach me what was missing.  So, I brought in 10 patients and examined them.    I saw changes in the occlusal relationships of all those patients that were not what I had been taught to expect.  Based on those observations I changed my treatment protocol.  I noticed significant changes in results almost immediately.   Instead of pain disappearing gradually over a 7-8 week period in 30-40% of the cases, it was resolving over 1-3 weeks at an 80% rate.   This was a change that could not be attributed to chance.    I have followed the same protocol since then and the results have remained the same and have improved somewhat with refinement.

I have always used an appliance as the primary form of treatment, since it is a reversible therapy with no long-term adverse consequences.  However, I think the use of appliances is poorly understood, poorly taught, and consequently often ineffective.  I was initially taught 5 different designs, based on what the patient’s problem was.  That is complex.

I believe that a dentist who is a good interviewer and listener will be more effective that one who is not.  This ability will make a difference in difficult cases, perhaps 10-15% of the time.   Regardless, the learning is mostly through experience.