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What Allen Told the Committee

  • Jun 20, 2019

Allen Cowley addressed the second open-to-the-public meeting of the National Institute of Medicine's (NAM) Committee on Temporomandibular Disorders (TMD) held on March 28, 2019 in Washington, DC. No stranger to the world of TMD, Dr. Cowley is the husband of TMJA's President, Co-founder and TMD patient, Terrie Cowley. Dr. Cowley has had a long and distinguished career as professor and chair of the department of physiology at the Medical College of Wisconsin and as an innovative multi-grant winning researcher in the field of hypertension (high blood pressure). He has also played a principal role as chair of the planning committees for TMJA's science meetings.

"I was appalled when I started to look at the literature in this field," Dr. Cowley told the committee in a talk which reviewed the history and the state of research and funding on TMD. "In the year 2000 there was no coherent body of knowledge or even a common clinical definition of TMD." That was one of the findings from TMJA's first scientific meeting held that year, co-sponsored with components of the National Institutes of Health (NIH). Importantly, the meeting resulted in a fundamental change in perspective: TMD was to be recognized " as part of a complex system, rather than a problem of jaw dysfunction and pain in the jaw joints." That view was voiced by Dr. Lawrence Tabak, then Director of the National Institute of Dental and Craniofacial Research. In keeping with that perspective, it was further proposed that there be a multi-disciplinary integrated patient care and research effort.

TMJA, in partnership with NIH, has continued to hold scientific meetings with the eighth meeting in 2016, Dr. Cowley said. All have as their goals an analysis of the state of the science with the intent to bring new ideas and perspectives to the field. All also have asked the scientists attending to formulate recommendations to NIH regarding the gaps and consequent opportunities in TMD basic and clinical sciences.

One of the most important aspects of the meetings has been the participation of patients to provide real-world examples so that the professionals can focus on the priorities only patients can identify, or, as Dr. Cowley said, "The patients have educated all of us. That's what has driven all of the meetings we've had."

Dr. Cowley went on to describe the formation of the TMJ Patient-led RoundTable in 2016, whose mission is to bring together all stakeholders concerned with TMD and who share the goal of improving the health care of patients. The RoundTable is structured into Working Groups with Working Group 1 concerned with the science. They have identified nine gaps/opportunities in the basic sciences related to TMD. "Gaps" are crucial areas to be addressed, while "opportunities" are directions for research to fill in the gaps, providing needed information for accurate, consistent diagnosis and treatment for TMD and related diseases/disorders:

Gaps & Opportunities.

  1. Molecular genomics and epigenetics
  2. TMD and data science informatics
  3. Mechanisms underlying chronic TMD pain and joint-specific pain
  4. Sex differences
  5. Neuro-endocrine system interactions
  6. Immune-inflammatory mechanisms (CNS/Systemic)
  7. TM joint tissues and mechanics
  8. TM joint tissue engineering and disk displacements
  9. Animal models

Each of the nine has been defined in precise terms to guide the development of research in the area. The guiding principle, echoing that first scientific meeting's observation, is that "TMD must be studied as a complex disorder determined by interacting and redundant systems."

Dr. Cowley emphasized that past practices based on only one perspective on the origin/causes of TMD have failed. He stated, "This is where the whole field of research ought to come together." What is needed is information obtained from all related scientific fields.

So where are we now? Where do we stand regarding the funding for the research deemed crucial to answer the needs for diagnosis and effective treatments of TMD?

Fact # 1. Funding for TMD research at the National Institute of Dental and Craniofacial Research is 3-4% of their budget ($11.2 million vs.a total of $371 million). It is important to remember that TMJ affects some 36 million people in the U.S.

Fact #2. There is a disconnect between dental and medical schools in basic and translational research: In particular:

  • There is little collaboration between medical and dental schools in basic research.
  • NIDCR funding for TMD basic research is limited, even in the top 5 research ranked dental schools.
  • Aggressive efforts to stimulate an integrated approach to TMD are lacking. The science and funding siloes are a great impediment to progress.
  • There is little evidence of efforts to integrate cell/tissue specific functions with those of the whole organism.

In summary, Dr. Cowley reiterated points he had earlier emphasized: TMD basic and translational research must be extended beyond the narrow province of dentistry to include the basic and clinical disciplines appropriate to this complex disorder. Basic research in dental schools would greatly benefit from collaborations with medical schools, schools of engineering, pharmacy and a sharing of core facilities.

To coordinate advances in the basic sciences related to TMD Dr. Cowley proposed

-a trans-Institute agency research planning group to set goals based on exciting scientific and clinical missions that will attract basic, clinical, translational scientists and engineers to the field.

And to facilitate these approaches, he again nominated patients whose expertise should be sought to identify and help focus research areas to encompass areas of greatest relevance to them...

...adding a final caveat:

Every aspect of basic and clinical TMD research needs a significant increase in funding to attract scientists from those disciplines essential to develop teams of experts to address obvious gaps in the field. As things stand now, "TMD research is so far behind that it has been left in the dust, behind other scientific fields. This is a disorder in trouble in terms of research funding and lacking a critical mass of scientific expertise required to address the underlying mechanisms related to the etiology of this complex disorder."

Click here to view Allen's slides

Click here to watch Allen's presentation

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