There have been many important advancements in the diagnosis and treatment of patients with temporomandibular disorders, facial pain, and occlusal disturbances, but there are still many deficiencies and unanswered questions. Most of our current understanding of each of these areas is buried in the distant past. Concepts of occlusion are based upon theory that was originally developed by Edward H. Angle in the 19th century, and most of our current therapy for malocclusion is based upon techniques from the middle of the 20th century. During the 19th and 20th centuries most facial pain was ignored. Traditional dentistry has treated TMJ pain as a syndrome, and medicine has been slow to embrace the seriousness of temporomandibular disorders. Nearly all therapy today is based upon "technique dentistry" wherein various theories of occlusal management have competed for acceptance, all the while ignorant of anatomy and imaging.

Most conditions in the body start out from injury or early development of disease. Invariably, with the exception of acute trauma, pain is a late manifestation of progressive disease or pathology. Physicians traditionally have been grounded in diagnosis of a problem before it progresses to pain, and much of modern medicine is preventive in nature. Furthermore, medicine is quick to embrace diagnostic testing or imaging when serious pathology is suspected. Oftentimes patients who delay evaluation until they have pain may already have advanced significantly. Not only does modern medicine treat disease before pain starts, but the resolution of pain, albeit important for patient well-being, is not the typical measure of a cure.

Unfortunately, treating TMJ patients before they develop pain is a novel concept. At the Piper Clinic and PERC we believe that this trend will one day reverse. In fact we have been instrumental in advocating that TMJ patients should be evaluated and treated according to a medical model. Hence examination should diagnose a TMJ disorder before the onset of pain. In both children and adults the first sign of a TMJ injury is the development of an occlusal change, typically resulting in premature contact of posterior teeth with separation of the anterior teeth. Dentistry based upon 20th century concepts would order cause and effect as malocclusion leading to a TMJ disorder. In fact technological imaging advancements of the 21st century would point to exactly the opposite- i.e. injury to the TMJ causes a change in the bite. As the truth settles there will most likely be an admixture of both.

The future of the field will one day embrace these concepts. "TMJ" is not some new mysterious disease nor is it accurate to assume that theories from 125 years ago or treatment from 50 years ago are correct. Most joint problems in the young people are trauma induced- whether that joint is a knee or a temporomandibular joint. Contrary to what many experts propose, the TMJ is not uniquely different from all other joints. Granted the teeth are a part of the support for the TMJ, but our evidence in imaging now more than 10,000 patients points to the fact that all occlusions are based upon joint posture and joint condition. Alteration of either accounts for a malposition of the bite. Based upon our imaged population we find that the prevailing numbers of patients have a joint problem that has caused their malocclusion (Joint Based Occlusion), and the more unusual patient population is that in which the occlusion has caused joint damage.

At this time this new theory of Joint Based Occlusion is not embraced by the majority of dentists. In part that is because very few dentists ever image the joint with even the crudest of radiographs that were developed in the 1930's, let alone with 21st century diagnostic imaging such as CT or MR scans. Instead patients are blamed for non-compliance if orthodontics, restorative dentistry, and bite surgery fails, or dentists stumble to the next fad in occlusal theory believing that someone must have an answer.

The future of the three components of a TMJ patient, namely joint degeneration, pain patterning, and occlusal instability will be understood by larger numbers of dentists as concepts of 21st century diagnosis and treatment are embraced. Fortunately the future is now for those willing to seek the truth.

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