…and the band plays on

I am celebrating my 9th decade of life on this earth and my 62nd year of membership to the wonderful profession of dentistry. My excitement for our profession has never diminished from the day I received my Doctor of Dental Surgery degree [1]. In my professional lifetime, the extraordinary developments in technology with the explosion of science and accompanying knowledge has advanced our profession of dentistry, including craniomandibular and sleep practice, well beyond the wildest imagination of any member of my graduating dental class of 1957. The same is true of our lifestyle. Just the difference between the 40- horsepower of my father’s 1929 Model–A Ford automobile and the technology of the 340-horsepower twin-turbo engine of my current automobile is well beyond my grasp of understanding, but not my grasp of enjoyment.

Today, technology accompanies us wherever we go. A few weeks ago, my wife and I, at the invitation of our grandson and his wife, attended an event at the Armstrong Auditorium here in our small city of Edmond. The auditorium, a magnificent blend of beauty and function, was designed and constructed for the finest acoustic projections and balance. The ratio comparing the volume of the hall to each seat is more ideal at Armstrong than in Amsterdam’s Concertgebouw, Boston’s Symphony Hall, or Vienna’s Musikverein – the three world standards engineers use to measure acoustic quality [2]. The event we attended was an all Mendelssohn program performed by the 46-piece Mozart Orchestra of New York. The Orchestra or Band, as we in Oklahoma are sometimes known to say, was wonderful, and the acoustic quality of the structure amazing.

The first quarterly issue of CRANIO: The Journal of Craniomandibular Practice was published in 1982 and circulated as Volume 1, Number 1. Dr. Riley Lunn’s goal of presenting a quality publication to “fill the informational void centering around the diagnosis and treatment of TMJ-facial pain patients” became a reality [3]. Dr. Lunn had gathered around him a knowledgeable band of learned friends and colleagues, along with a dedicated staff and supportive family who, at his direction, made this publication possible. Early craniomandibular practice articles focused more on clinical aspects of practice; however ensuing publications were expanded to include research studies with appropriate statistical analyses in response to reader interests [4].

Most of us who were involved in craniomandibular practice early on (I treated my first craniomandibular pain patient in 1964) had a tendency to focus on neuromuscular symptoms being related to irregularity of the dental occlusion, although there were conflicting opinions about the ideal occlusion. Dr. William Farrar, in an essay appearing in the first CRANIO, championed a belief that the temporomandibular joint and dental occlusion are mutually dependent. He also introduced the concept of internal derangement in the temporomandibular joint (TMJ) [5]. He concluded his essay with the following statement, “the author strongly suspects that these disorders of the craniomandibular articulation are a much more significant health problem than anyone has yet dared to suspect [5].”

CRANIO: The Journal of Craniomandibular Practice is now titled CRANIO: The Journal of Craniomandibular and Sleep Practice. Not only was the name changed, but the journal developed a more significant international presence. International authorship has broadened and enriched the journal content, and sleep medicine has provided a vision of welcomed inclusion that is appropriate and necessary for complete patient care. For, “A vision without underlying purpose is just a good idea [6].”

The knowledge base required for craniomandibular practice is expanding quickly, as research, technology, and clinical experience is advancing to address the diverse etiology of symptoms presented. A few examples are:

• The computerized occlusal analysis system, T-Scan®, developed in 1984, continues to evolve, and with it come “new parameters and observations that reveal the dynamic nature of physiologic occlusion [7].”

• Dr. Leonard Feld introduced “a unifying hypothesis” resulting from a mind-boggling discovery, “researchers at the Virginia Commonwealth University School of Medicine have determined that the brain has direct communication with the immune system through meningeal lymphatic vessels that were previously thought not to exist [8].” Prior to this discovery, the cranium was considered a closed system. The unexpected presence of lymphatic vessels raises several questions. Is it possible that craniofacial pain could be the result of blockage of lymphatic vessels? “Is it possible then, that an intraoral orthopedic appliance could relieve an elevated substance P (SP), the neurotransmitter from C fibers that sends pain signals to the brain”? And, “is it coincidence that when an oral orthotic appliance that repositions the mandible in an anterior and vertical position reduces symptoms of fibromyalgia and other co-morbid symptoms of Parkinson’s dementia and motor movement disorders, including sleep disorders? [9]”

• A recent article in the Journal of the American Dental Association explored the “Use of platelet-rich plasma, platelet-rich growth factor with arthrocentesis or arthroscopy to treat temporomandibular joint osteoarthritis [10].” While the results of this systematic review were judged to be at high risk of bias, the sample size small, and results judged to be inconclusive, favorable results were reported in the three treatment groups identified.

• Symptoms of TMD occur in approximately 6 to 12% of the adult population or approximately 10 million individuals in the United States [11]. Approximately 80% of the patients with TMD present with signs and symptoms of joint disease, including disc displacement, arthralgia, osteoarthrosis, and osteoarthritis [12]. For many, replacement of the mandibular condyle is the singular option. Unfortunately, the use of autogenous tissue for grafting or alloplastic materials for replacement have not proven to be ideal for the task [13]. The role of regenerative medicine in creating living, functional tissue to repair or replace diseased tissue or to replace lost function of organs is rapidly developing. Regeneration of the articular surface of a synovial joint in animal studies by cell homing has been successfully demonstrated through placement of an anatomically correct bioscaffold infused with transforming growth factor beta 3 (TGFB3) adsorbed collagen gel. The results show that the entire articular surface of a synovial joint can be replaced by homing of endogenous cells [14]. Stem cells are favored for regeneration of tissue, as they have the capacity for self-renewal and capability of differentiation to various cell lineages [15], and endogenous homing of adult stem cells makes them available in quantities that support the advancement of regenerative medicine. In the near future, it may be possible to successfully reconstruct a bioengineered temporomandibular joint (TMJ) replacement that is compatible with a host, biologically usable and capable of withstanding the physiologic loads required of the TMJ [16]. Regenerative medicine holds potential for developing and refining TMJ applications; however, specific protocol will require much investigation. The flexibility of stem cells is well-documented, and through research being conducted in centers around the country similar to the Oklahoma Center for Adult Stem Cell Research [17], appropriate parameters of application are destined to be identified and refined.

I have heard it said that, “with age comes wisdom,” but It appears that age-related wisdom has passed me by, for I clearly do not understand how the American Dental Association can continue to ignore the overwhelming need for a specialty in craniomandibular practice. The sheer volume of knowledge and experience necessary for practitioners to deliver quality evidence- based patient care in an ethical manner, as fostered by the ADA, clearly dictates that a specialty practice must be recognized for craniomandibular practice. Having served as a faculty member in medical and dental education for over 40 years and Dean of a College of Dentistry for over 20 years, I can attest that there is inadequate room in undergraduate dental education for a quality curriculum in craniomandibular practice that would satisfy the existing call for specialty education. Graduate dental education fosters research and, as in all health care, much research is needed to refine the existing potential for delivery of improved, expected, deserved patient care.

Undergraduate dental education must include an understanding of the craniofacial complex in health, malfunction, and disease. It must provide experience at a minimum level equal to that extended by other dental specialties at the undergraduate level that includes recognition, diagnosis, and basic treatment of craniomandibular dysfunction. My understanding of this knowledge as a necessary qualification for the practice of dentistry makes it impossible to comprehend why the Commission on Dental Accreditation has not established a specific undergraduate standard for dental college accreditation that accesses the undergraduate students’ knowledge of and experience in craniomandibular function and treatment.

I compliment the dental educational institutions that have taken it upon themselves to give students exposure and experience in craniomandibular function through formalized courses and clinical rotations. Some colleges have established Centers for Craniomandibular & Sleep Practice for patient care and education. I am very pleased that the University of Tennessee now has a “William F. Slagle Center for Craniomandibular and Sleep Practice” that serves patients and conducts undergraduate, graduate, and continuing education courses. It is a good start but does not replace the need for specialty education that would enhance clinical research, expand the knowledge base, and elevate the standard of care in craniomandibular & sleep practice.

I congratulate Dr. Riley Lunn for 36 years of CRANIO, a journal that is a quality international publication. Dr. Lunn is greatly appreciated by all who seek enlightenment through knowledge. Maestro Lunn continues to direct. …and the band plays on.

The clock of life is wound but once,

And no man has the power

To tell just when the hands will stop

At late or early hour.

To lose one’s wealth is sad indeed,

To lose one’s health is more,

To lose one’s soul is such a loss

That no man can restore.

The present only is our own,

So live, love, toil with a will,

Place no faith in “Tomorrow,”

For the Clock may then be still.”

-Robert H. Smith