Temporomandibular disordersBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h1154 (Published 12 March 2015) Cite this as: BMJ 2015;350:h1154
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I read with interest this article on TMJ Disorders. I found it unfortunate that very little attention was given to surgical treatment for temporomandibular disorders, which is important in those patients in whom conservative treatments are ineffective. There is enough evidence from the literature that fairly simple procedure like arthrocentesis or arthroscopy of the TMJ can alleviate the pain and restricted mouthopening in these patients. As a maxillofacial surgeon I practise arthroscopy of the TMJ on a regular basis with excellent results. The UK has an excellent reputation on treatment of TMJ Disorders. All surgeons with an interest in this topic are members of the British Association of Temporomandibular Disorders and I refer to their website for further information.
Competing interests: No competing interests
We thank Hua et al (1) for their compliments on our paper (2).
In response to Hua et al’s constructive critique of our portrayal of the evidence related to the role of orthodontics and occlusal equilibration in Temporomandibular disorders we would contend that we have presented this evidence as they request, but have done so in a manner different to that which they request.
All the evidence in the intervention section of our review was paraphrased at the beginning of the section by stating that the recurring theme of our systematic search was that “well designed pragmatic randomised controlled trials using standardised and patient based outcome measures in TMD are urgently needed”. Further to this we also stated that there was a “lack evidence to support” the use of orthodontics or occlusal equilibration which is consistent with the current evidence base. The supplementary table of the systematic reviews that accompanies our article also clearly summarises the outcomes of those reviews pertinent to orthodontics and occlusal equilibration for the reader.
We believe, however, that given the current evidence base it is difficult to justify more invasive and irreversible interventions as first line management techniques for patients in the absence of objective pathology when reversible and conservative management techniques are so successful in the majority of cases(3).
Over the forthcoming years perhaps through better designed randomized controlled trials that employ homogenous samples, and or further data from the ongoing OPPERA study on the pathophysiology of TMD, we may start to be able to better determine the indications for specific interventions in TMD as opposed to using a “blunderbuss” approach of reversible therapies in the first instance. We must, however, be careful over the forthcoming years to take a wide, as opposed to a discipline- or profession-specific, perspective so as to not to limit our conceptualization of TMD and ensure science in the area moves forwards(4).
1. Hua F, Xiong H, Hong H. TMD and orthodontics: the importance of emphasising “more research is needed”. 2015. http://www.bmj.com/content/350/bmj.h1154/rr. Last accessed 20/03/2015.
2. Durham J, Newton-John TR, Zakrzewska JM. Temporomandibular disorders. BMJ. 2015;350:h1154.
3. Greene CS. The etiology of temporomandibular disorders: implications for treatment. J Orofac Pain. 2001;15:93-105; discussion 106.
4. Stohler C. Orofacial pain disorders – linking phenotype to genotype. In: Zakrzewska JM, ed. Orofacial pain. Oxford: Oxford University Press; 2009:173-182.
Competing interests: Authors of the review this correspondence relates to.
Facial pain continues to challenge clinicians in all specialties. Awareness of potentially life threatening conditions presenting with atypical facial pain, is of vital importance.
We read with interest the article on “Temporomandibular disorders “by Durham et al.  The authors outlined a number of red flags that may masquerade as temporomandibular disorders (TMD), including temporal arteritis.  The pain associated with jaw claudication in temporal arteritis can mimic musculoskeletal pain associated with TMD. The former is caused by arteritis of maxillary artery which results in ischemia of masticatory muscles. 
Another important consideration is atherosclerotic disease of the carotid artery which is usually asymptomatic, but can have more serious manifestations including amaurosis fugax, transient ischemic attacks, cerebral infractions, retinal arterial occlusions and ocular ischemic syndrome.
Jaw claudication could also rarely result from carotid atherosclerotic occlusive disease.
Venna et al reported a case presenting with classic symptoms of giant cell arteritis including jaw claudication. However, this proved to be caused by complete atherosclerotic occlusion of the external carotid artery secondary and the symptoms relieved following endarterectomy procedure. 
Another case of bilateral jaw claudication due to bilateral severe external carotid artery stenosis was described by Janssens et al. In this case, the symptoms disappeared completely after unilateral endarterectomy. 
A review of literature reveals additional reports of jaw claudication secondary to severe atherosclerotic disease of ECAs that were successfully managed with either conservative approach or revascularization of the external carotid artery stenosis [5-7]
There have also been cases of jaw claudication following external carotid artery stenting or ligation of the artery. [8, 9]
In conclusion, occlusive atherosclerotic disease of the external carotid artery should be considered as a possible differential diagnosis of patients presenting with jaw pain. Revascularisation surgery can be regarded as an option in selected cases with debilitating symptoms.
1. Paraskevas KI, Boumpas DT, Vrentzos GE, et al. Oral and ocular/orbital manifestations of temporal arteritis: a disease with deceptive clinical symptoms and devastating consequences. Clin Rheumatol. 2007 Jul;26(7):1044-8. Epub 2006 Dec 16.
2. Durham J, Newton-John TR, Zakrzewska JM. Temporomandibular disorders. BMJ 2015;350:h1154.
3. Stroke. 1986 Mar-Apr;17(2):325-7.Temporal arteritis-like presentation of carotid atherosclerosis.Venna N, Goldman R, Tilak S, Sabin TD.
4. Janssens MA, Van Thielen TH, Van Veer HG. Jaw claudication as a result of carotid artery disease. Acta Chir Belg. 2008 Jul-Aug;108(4):438-40.
5. Lewis RR, Beasley MG, Maclean KS. Occlusion of external carotid artery causing intermittent claudication of the masseter. BrMed J, 1978, 2 (6152) : 611.
6. Shiller A., Schwartz U, Schuknecht B., et al. Successful treatment of cold-induced neck pain and jaw claudication with revascularization of Severe Atherosclerotic External Carotid Artery Stenoses. J Endovasc Ther, 2007, 14 : 304-306.
7. Argentino C, Idecola C, PIistolese G. R., et al. Ischaemic intermittent claudication of the masticatory muscles. It J Neur Sc, 1979, 1 : 269-274.
8. Chen H, Kougias P, Lin PH, et al. Jaw claudication in the era of carotid stenting. J Vasc Surg. 2011 Aug;54(2):526-8. doi: 10.1016/j.jvs.2010.12.057. Epub 2011 Mar 11.
9. Motamed M1, Farrell R, Philpott J, et al. Claudication on mastication following bilateral external carotid artery ligation for posterior epistaxis. J Laryngol Otol. 1998 Jan;112(1):73-4.
Competing interests: No competing interests
We think that this review , based on a systematic literature search, is very well-written. As orthodontists we have some humble opinions on the paragraph regarding orthodontics and occlusal equilibration, as well as some other related issues.
There have been many discussions on the cited AADR statement. [2-5] Opinion is also divided over its recommendation concerning “irreversible care”. [5, 6] We believe that a more objective and neutral narrative review, generally introducing both sides of the debate, would be more helpful for readers to see the bigger picture and form a more balanced view. In light of this, the two cited Cochrane reviews’ conclusions [7, 8] could be summarised as “there is a lack of evidence to support or refute the use of these approaches” and “more research is needed”.
Of more concern for orthodontists worldwide is a long-lasting debate on articulator mounting in orthodontics, [9, 10] between the so-called “gnathologic orthodontists” and “nongnathologic orthodontists”.  In June 2014, the Beijing Stomatological Association of China hosted a national academic public debate over this issue. We were honoured to be invited to participate as debaters. After this event, we realised that the reason for this controversy’s existence lies in an undoubted lack of high-quality research, mainly well-designed and well-conducted RCTs comparing the effectiveness (functional, aesthetic and psychological), harms and costs of two treatment modalities. We hope that relevant experts and stakeholders with different opinions can agree upon the need for more studies, and start to make joint efforts to ensure the quality and reliability of them.
Fang Hua (Doctoral Student) 1,2;
Hui Xiong (Associate Professor) 1;
Hong He* (Professor and Chair) 1.
1. Department of Orthodontics, School & Hospital of Stomatology, Hubei-MOST KLOS & KLOBM, Wuhan University, Luoyu Road No.237, Wuhan, 430079, China.
* E-mail: email@example.com
2. School of Dentistry, University of Manchester, UK.
1. Durham J, Newton-John TR, Zakrzewska JM. Temporomandibular disorders. BMJ 2015;350:h1154.
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7. Koh H, Robinson PG. Occlusal adjustment for treating and preventing temporomandibular joint disorders. Cochrane Database Syst Rev 2003(1):CD003812.
8. Luther F, Layton S, McDonald F. Orthodontics for treating temporomandibular joint (TMJ) disorders. Cochrane Database Syst Rev 2010(7):CD006541.
9. Rinchuse DJ, Kandasamy S. Orthodontic dental casts: the case against routine articulator mounting. Am J Orthod Dentofacial Orthop 2012;141(1):9-16.
10. Martin D, Cocconi R. Orthodontic dental casts: the case for routine articulator mounting. Am J Orthod Dentofacial Orthop 2012;141(1):8-14.
11. Williams RE. No progress without change. Am J Orthod Dentofacial Orthop 2006;129(6):719.
Competing interests: No competing interests