Okeson is graduate of the University of Kentucky College of Dentistry. After graduation he completed two years with the Public Health Service in a rotating dental internship and directing an outpatient clinic. He joined the faculty at the University of Kentucky in The program is a multidisciplinary effort in the management of chronic orofacial pain problems.
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It was with great joy that I accepted the invitation from the Dental Press Journal of Orthodontics to coordinate an interview with Dr. Jeffrey Okeson. I have known Dr. Okeson for over 14 years. All started when I had the fantastic opportunity to be one of his residents for 3 years, and ever since, he has been my mentor and my friend.
Jeffrey Okeson, despite of being a very famous and tremendously talented professional, continues to be an extremely nice and simple person. He is married for 48 years to Mrs. Barbara Okeson, and they have two sons and one granddaughter. Okeson has a twin brother who is also a dentist. He enjoys jogging and has continued to jog for over 40 years. He also enjoys traveling and meeting people.
Okeson has more than professional publications. One of his textbooks, Management of Temporomandibular Disorders and Occlusion, is used in most of the United States dental schools and has been translated into eleven different foreign languages. Okeson has presented more than 1, invited lectures on the subject of TMD and orofacial pain in all 50 U.
Now is time to enjoy reading the interview! Com grande alegria aceitei o convite do Dental Press Journal of Orthodontics para coordenar uma entrevista com o Dr. Apesar de ser um profissional muito famoso e extremamente talentoso, o Dr. Okeson apresentou mais de 1. Daniela Feu. The role of the occlusion and TMDs has been debated for many, many years. In other words, if someone had a dental malocclusion, it would cause a TMD.
Likewise, if a person had a TMD problem, it would be because the occlusion was incorrect. As we progressed into evidence-based dentistry, it became obvious that this association was not nearly as consistent as we once thought. In my opinion, the evidence suggests that there are five well documented etiologic factors that are able to contribute to TMD. These factors present as risk factors for the development of a TMD.
However, there is an additional factor that needs to be considered: the adaptability of the patient. Many patients are exposed to one or more of these etiologic factors and have no evidence of TMD. It seems that many patients have significant adaptability so that less than ideal is well tolerated by them, resulting in no clinical symptoms.
Therefore, in this model, occlusion may have a role in TMD, but it is only one of five potential etiologic risk factors. These are very important questions. When we look at the five etiologic risk factors, orthodontic therapy can only influence one: occlusion. Therefore, from the very beginning, orthodontic therapy has only a minimum effect on TMD. However, it is important that the orthodontist recognizes how occlusion can become a risk factor for TMD.
Where and how the teeth occlude has a very important relationship with temporomandibular joint function. Orthodontists should appreciate that they are truly orthopedists and need to understand the orthopedic stability in the masticatory structures.
It is my belief that the most stable joint position is when the condyles are in their most superior anterior position in the fossae, resting against the posterior slope of the articular eminences, with the discs property interposed. This is an orthopedically stable joint position as determined by the muscles that load these joints.
I believe it is important that in this stable joint position, the patient can achieve a stable occlusal position. The most stable occlusal position is maximum intercuspation. Therefore, orthopedic stability in the masticatory system is achieved by having both joint stability and occlusal stability that coincide.
I believe every orthodontist should have as a final treatment goal to produce orthopedic stability in the masticatory structures. This means, establishing a stable joint position Fig 1 that is in harmony with a stable occlusal position.
It is reasonable to assume that orthopedic stability would reduce risk factors for developing TMD. However, producing this orthopedic stability in the masticatory structures by no means guarantees that the patient will not develop TMD.
Always remember that there are four other etiologic risk factors associated with the development of TMD. I believe it is important that we do not suggest to the patient that orthodontic therapy will prevent TMD. An orthodontist may establish a stable orthopedic relationship and then other risk factors, such as trauma or emotional stress, could precipitate a TMD. Considering the fact that all studies that investigated such relationship analyzed treatments performed by orthodontists specialists , do you think there is a chance that poor orthodontic treatment could lead to a higher risk of developing TMD?
Since there is an increase in treatments involving dental movements performed by dentist without extensive understanding in orthodontics, do you think that new longitudinal studies may start presenting stronger association between orthodontic treatment and TMD? Felipe Porto. I would certainly agree that most studies investigating the relationship of orthodontic therapy and TMD do not suggest a strong association.
Perhaps one of these reasons is related to the discrepancy between a stable joint position and the stable occlusal position.
As dentists, we have a very mechanical mind and we desire precision in our dentistry for success. Therefore, even very slight discrepancies between a stable joint position and a stable occlusal position has been described as a malocclusion.
In my opinion, most patients have a discrepancy of mm. These discrepancies have not been shown to be significantly correlated with TMD symptoms. However, in mostly epidemiological studies, slides that are greater than 3 to 4 mm from a stable joint position to a stable occlusal position become more significantly correlated to symptoms.
It would seem reasonable that as slides become greater, the demand for adaptability becomes greater, and fewer patients have this capacity to adapt. Another consideration that may have influenced the results of these studies is the fact that most orthodontic therapy is accomplished in young healthy growing adolescents. Often the occlusal condition is finalized before the condyles have fully matured.
When this occurs, a stable intercuspal position allows the patient to function while condyles mature into their stable functional position. Therefore, function encourages development of the condyle into its musculoskeletal stable position form follows function. Significant discrepancies between this position and the stable occlusal position are rarely found.
Another consideration is that most, if not all, the studies that have investigated the relationship between orthodontic therapy and TMD symptoms have been accomplished in graduate orthodontic training programs. It seems reasonable to assume that treatments provided in these teaching facilities are highly supervised and at the highest level of orthodontic therapy. Perhaps orthodontic therapy that is less than ideal may pose increased risk factors, potentiating TMD symptoms.
There may be some orthodontists who reviews these studies and conclude that orthodontic therapy can never influence TMD symptoms.
I believe this is misinterpretation of the data and could place some patients at increased risk. Only time will tell if these new orthodontic technics are associated with TMD risk factors. Is it possible that TMJ disc displacements are results of the orthodontic mechanotherapy, and what would you recommend to the orthodontist in these cases? Lucas Cardinal. Epidemiological studies suggest that clicking is a common clinical finding in the general population. It seems to begin in the teenage years, increasing into the 20s and 30s.
Studies also suggested clicking is not often associated with significant clinical symptoms. Magnuson et al 6 have reported that clicking comes and goes between the age of , usually unrelated to significant clinical symptoms. Therefore, I believe it is important to conduct a history analysis and clinical examination, evaluating masticatory structures, before therapy begins. A simple screening history 1 can be used to determine the presence of any TMD symptoms prior to treatment.
Also, a simple clinical examination consisting of palpating the muscles of mastication and the TMJs, as well as observing the range of mandibular movements, is helpful to determine the presence of any TMD symptoms.
These data serves as a baseline for the presence of TMD symptoms. When symptoms are present, the need for treatment should be assessed. These data are also important if, during treatment, the patient reports symptoms and believes they are a result of your treatment.
Having pre-existing data is important, especially when you have documented that you discussed these findings with the patient parents before starting treatment. In your opinion, what is the ideal treatment sequence: a to treat the TMD first and then initiate the orthodontic treatment; b to treat both conditions simultaneously; c to perform orthodontic treatment monitoring the progression of the TMD? As previously mentioned, I believe it is very important to assess the function of the masticatory system prior to beginning orthodontic therapy.
If signs and symptoms of TMD are present, they should be discussed with the patient parents. If the symptoms are significant, they should be managed before starting orthodontic therapy. This is important because if orthopedic instability is present, it needs to be identified as a potential risk factor for TMD symptoms.
Once the symptoms have been resolved, a stable joint position can be determined so that the orthodontic therapy can provide a sound occlusal position in harmony with this joint position. A stabilization appliance may be helpful during this treatment period. If a stabilization appliance is utilized and the TMD symptoms are not resolved, is likely that the etiologic risk factor s is not malocclusion and therefore the orthodontic therapy will not likely affect the TMD symptoms.
The patient should be aware of this before orthodontic therapy is begun. Achieving improved esthetics is still a possible treatment goal, but reasonable treatment expectations need to be presented to the patient prior to beginning treatment.
Bruno Furquim. Once the TMD symptoms have been resolved, a stable jaw position can be better identified to carry out the extensive dental procedures. Also, eliminating the TMD symptoms first may provide the clinician with insights regarding the appropriateness of the needed dental procedures.
Why do you think this happens? Where does TMD fit the full range of orofacial pain? This is a very sad, but true, statement. In my opinion, the best explanation for this is that these individuals do not have a complete understanding of orofacial pain.
An interview with Jeffrey Okeson
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Jeffrey Okeson, DMD