Bracha, Adam S.

Bracha, Dr. Stefan

Person, Dr. COL. MC Donald A.

Ralston, Tyler C.

Williams, Andrew E.

Yamashita, Jennifer M.

English

CogPrints Cognitive Sciences Eprint Archive

Reevaluating the Management of Chronic 
Temporomandibular Pain 

Are We Treating PTSD with Debridement and Lavage?

Cognitive Sciences ePrint Archive

In 2002, researchers from the Hous-
ton VA Medical Center, Houston,
TX published findings from their
randomized, controlled trial demon-
strating that sham arthroscopic sur-
gery is as effective as arthroscopic
lavage or arthroscopic debridement
in treating osteoarthritis of the
knee.1 According to the research-
ers, the cost of such surgeries ex-
ceeds $3 billion a year in the United
States alone.1 Beyond the specific
implications for patients with os-
teoarthritis of the knee, these find-
ings highlight the importance of
maintaining an ongoing dialogue
between research and clinical prac-
tice in order to control health care
costs and improve the health of
both veterans and the general civil-
ian population.
We believe such an evidence-
based approach is needed in an-
other area of health care: the
management of temporomandibu-
lar disorders (TMDs). Although it’s
likely that TMDs rarely are inquired
about or addressed by primary care
physicians, these chronic pain dis-
orders are second only to odontal-
gia (tooth or periodontal pain) as
the most common problem pa-
tients report to their dentists.2 In
our experience, they are extremely
common in both active-duty mili-
tary personnel and veterans with
posttraumatic stress disorder
(PTSD)—especially the latter. Ac-
cording to a National Institutes of
Health (NIH) Technology Assess-
ment Conference Statement, how-
ever, no data from randomized
clinical trials support any of the
current dental interventions for
TMDs.3 While the overall cost of
craniomaxillofacial and orthodon-
tic procedures used to treat or pre-
vent TMDs in the United States is
unknown, it may well approach
those for arthroscopic debridement
and lavage of the osteoarthritic
knee. 
In this article, we suggest that
the current prevailing approaches
to TMD treatment may be mis-
guided. To achieve optimal treat-
ment, it may be necessary to
change the way we view these dis-
orders. In the following brief re-
view, we endeavor to establish the
need for more clinical research in
this area in order to validate the
emerging theories we present here
and to translate them into practical
clinical advice. 
A TRADITIONAL APPROACH
DISCREDITED
In the past, the constellation of
conditions involving pain in the
muscles of mastication, the tem-
poromandibular joints, and other
associated orofacial structures
were known variously as Costen
syndrome, temporomandibular joint
dysfunction, or craniomandibular
disorders. Because the muscles of
mastication (the masseter and tem-
poralis muscles)—rather than the
temporomandibular joint—most
commonly are involved in these
conditions, however, the American
Dental Association has adopted the
more general term, temporomandi-
bular disorders.2,4,5
PRACTITIONER FORUM
H. Stefan Bracha, MD, Andrew E. Williams, MA, 
Donald A. Person, MD, COL, MC, Tyler C. Ralston, MA, 
Jennifer M. Yamashita, MA, and Adam S. Bracha, BA
Reevaluating the Management of Chronic
Temporomandibular Pain
Are We Treating PTSD with Debridement and Lavage? 
Dr. Bracha is a research psychiatrist at the National
Center for Posttraumatic Stress Disorder (PTSD), VA
Pacific Islands Health Care System, Spark M. Mat-
sunaga Medical Center, Honolulu, HI. Mr. Williams is
a statistician and a graduate student in psychology at
the University of Hawaii at Manoa, Honolulu, HI.
COL Person is a physician in the department of clini-
cal investigation and pediatrics at Tripler Army Med-
ical Center, Honolulu, HI. Mr. Ralston is a graduate
student in psychology at Argosy University/Honolulu,
HI and a research assistant at the National Center for
PTSD. Mrs. Yamashita is a graduate student in psy-
chology at the University of Hawaii at Manoa, Hon-
olulu, HI and a research assistant at the National
Center for PTSD. Mr. Bracha is a biomedical research
consultant in Honolulu, HI.
50 • FEDERAL PRACTITIONER • APRIL 2004
TMDs have been associated
with jaw clenching and tooth grind-
ing and with sleep bruxism, but the
precise etiology of these disorders
remains unclear. One theory that
has had a substantial influence
over approaches to preventing and
treating these disorders in the past
has been the idea that dental mal-
occlusion plays a major role in
their development. 
Based on this hypothesis, costly
occlusal adjustments frequently
have been initiated after detection
of clenching-grinding or bruxism in
order to prevent progression to
TMDs. In 2003, however, Koh and
Robinson concluded by meta-
analysis that such procedures are
ineffective for treating or prevent-
ing TMDs.6 Likewise, after a major
literature review, Vanderas and
Manetas concluded that early treat-
ment of malocclusion to prevent
clenching-grinding is not supported
by longitudinal studies and is not
scientifically justified.7
EMOTIONAL DISTRESS, 
ANXIETY, AND TMDs
Accumulating evidence supports
a connection between anxiety
disorders such as PTSD; the den-
tal conditions of clenching-grind-
ing, bruxism, and TMDs; and the
difficult-to-classify illnesses of fi-
bromyalgia (FM) and chronic fa-
tigue syndrome (CFS).5,8 Patients
with these disorders share common
key symptoms and underlying psy-
chophysiologic mechanisms. Fur-
thermore, as evidence supporting a
temporal relationship between
emotional distress, clenching-grind-
ing, TMDs, FM, and CFS accumu-
lates, the idea of a cascade of
disorders with increasing severity
becomes increasingly plausible.5
The best known disorder in the
clenching-grinding spectrum is
sleep bruxism. In one epidemio-
logic survey of about 13,000 Euro-
peans aged 15 and older, 4.4% of
the participants met the Interna-
tional Classification of Sleep Dis-
orders’ criteria for sleep bruxism
and 8% met the less restrictive cri-
teria for a diagnosis of tooth grind-
ing.9 This survey found an elevated
risk of sleep bruxism among par-
ticipants reporting anxiety, heavy
alcohol consumption, or a “highly
stressful life.”9 Sleep bruxism and
presumably other clenching-grind-
ing behaviors peak between the
ages of 25 and 44 years,8 which is
similar to the peak prevalence of
most anxiety and stress disorders.
Moreover, recent research increas-
ingly documents the role of neuro-
biological factors in the etiology of
clenching-grinding, bruxism, and
related disorders.10–12
Results from other recent studies
strongly suggest that both extracap-
sular (muscular) and intracapsular
joint TMDs share many clinical
features with FM and CFS. For ex-
ample, researchers working in hos-
pital-based clinics have shown that
patients diagnosed with TMDs, CFS,
or FM share such common symp-
toms as heightened pain sensitivity
and difficulties in concentration.5 In
addition, PTSD, irritable bowel syn-
drome, and chronic pelvic pain ap-
pear to coexist frequently with
TMDs.5
BEYOND CURRENT 
MANAGEMENT OF TMD 
According to the NIH Technology
Assessment Conference State-
ment, nonsteroidal anti-inflamma-
tory drugs and opiates are “the
mainstay of pharmacologic pain
treatment” for this and other
types of musculoskeletal pain.
Benzodiazepines and, increas-
ingly, very low dose antidepres-
sants and anticonvulsants also
are used.4 Patients with TMDs,
however, are being referred regu-
larly to craniomaxillofacial sur-
geons for invasive therapies.
These include injections of lubri-
cants and corticosteroids into the
joint, laser irradiation of the tem-
poromandibular joint and mus-
cles, temporomandibular joint
lavage and debridement, and
eventually bilateral total joint re-
placement. These invasive thera-
pies have not proven efficacious
in treating this condition.13,14
When craniomaxillofacial surgi-
cal procedures fail or worsen the
pain, opiates are used widely as
salvage therapy.4
What is needed is a consensus to
direct clinicians away from these in-
vasive, irreversible procedures that
are unsupported by hard scientific
data and toward a more rational,
evidence-based approach empha-
sizing conservative, nonsurgical in-
terventions. Such an approach
likely would have a substantial im-
pact on health care in the federal
system and worldwide, decreasing
morbidity and mortality and reduc-
ing health care costs.
Recent studies have begun to
build a foundation of evidence for
this type of approach, but more re-
search clearly is needed. Using well
designed studies, investigators must
probe further into the connections
between the disorders described
here as being part of a spectrum,
the common role of premorbid
emotional distress in the etiology of
these pain disorders, and the opti-
mal psychopharmacologic and psy-
chotherapeutic treatments for these
related disorders. As in the case of
arthroscopic surgery for knee os-
teoarthritis, the VA health care sys-
tem is uniquely suited to serve as a
setting for this clinical research. ●
APRIL 2004 • FEDERAL PRACTITIONER • 51
Continued on next page
This material is based upon
work supported in part by the Of-
fice of Research and Develop-
ment, Medical Research Service,
VA Pacific Islands Health Care
System, Spark M. Matsunaga
Medical Center. Support also was
provided by a National Alliance
for Research on Schizophrenia
and Depression (NARSAD) Inde-
pendent Investigator Award and
the VA National Center for PTSD.
The authors wish to thank COL
Norman A. Flaxman, DMD for
his helpful discussions.
The opinions expressed herein are
those of the authors and do not
necessarily reflect those of Federal
Practitioner, Quadrant HealthCom
Inc., the U.S. government, or any
of its agencies. Please review com-
plete prescribing information for
specific drugs or drug combina-
tions—including indications, con-
traindications, warnings, and
adverse effects—before adminis-
tering pharmacologic therapy to
patients.
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52 • FEDERAL PRACTITIONER • APRIL 2004
PRACTITIONER FORUM
Continued from previous page
The authors wish to acknowledge
the  contributions and assistance
of Ed Alelyunas, Rita Brueckner,
Jai Liu, Kathleen Dunn, Catherine
Cone, Ann Nawarskas, Larry
Lavezo, Nina Resch, Mark Rodgers,
and Otis Solomon, Jr. Portions of
the material contained in this arti-
cle were presented at the American
Society of Health-System Pharma-
cists Midyear Clinical Meeting,
New Orleans, LA, December 5,
2001, and at Western States Con-
ference for Pharmacy Residents,
Fellows, and Preceptors, Pacific
Grove, CA, May 6, 2002.
The opinions expressed herein are
those of the authors and do not
necessarily reflect those of Federal
Practitioner, Quadrant HealthCom
Inc., the U.S. government, or any
of its agencies. Please review com-
plete prescribing information for
specific drugs or drug combina-
tions—including indications, con-
traindications, warnings, and
adverse effects—before adminis-
tering pharmacologic therapy to
patients.
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Continued from page 44
DECENTRALIZED CLINICAL PHARMACISTS


An economic analysis of a randomized, controlled, multicenter study of clinical pharmacist interventions for high-risk veterans: The IMPROVE study. Impact of Managed Pharmaceutical Care Resource Utilization and Outcomes in Veterans Affairs Medical Centers.

Automation Inc. web site. Available at: www.mckessonautomation. com/wt /auto/tech_forpharmacy_acudoserx.

Early switch from intravenous to oral antibiotics: Guidelines and implementation in a large teaching hospital.

Err is Human: Building a Safer Health System.

Implementation and pharmacoeconomic analysis of a clinical staff pharmacist practice model.

Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group.

Interrelationships among mortality rates, drug costs, total cost of care, and length of stay in United States hospitals: Summary and recommendations for clinical pharmacy services and staffing.

Medication Administration System. Falls Church, VA: Health Care Reengineering Program, TRICARE Management Activity;

Pharmacist influence on economic and morbidity outcomes in a tertiary care teaching hospital. Am J Health Syst Pharm.

The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group.

Reevaluating the Management of Chronic Temporomandibular Pain Are We Treating PTSD with Debridement and Lavage?

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