Today I noticed on ResearchGate another author cited my work. Those of you that write and publish know this can be a very big deal. At the very least, it is exciting for the published author to have a sense of recognition. However, after reading the manuscript and double-checking which paper they cited I was disappointed and irritated enough to write this editorial, which will be sent to the editor along with the author. The paper in question is Pop-Jordanova, N., & Loleska, S. On Psychosomatic Problems in Dentistry, PRILOZI, 2020;41(1), 57-63. Doi: https://doi.org/10.2478/prilozi-2020-0023.

The paper is obviously concerned with psychosomatic problems and not organic/physical dental concerns. It is a legitimate topic and I do not oppose writing about it. However, my publication demonstrated in a case presentation manuscript that the patient met the unifying diagnostic criteria for Phantom Bite Syndrome1 (PB), but had an underlying dental occlusal problem that was measured, quantified and ultimately corrected, relieving the symptom. 57% of the total bite force was on the right side and 31% of that pressure was between teeth numbers 2 and 31. When the occlusal concern was corrected the patient no longer reported her bite was off. This case study paper actually cautioned providers from jumping to conclusions that patients could have some rare psychosomatic problem when in fact they might actually have an occlusal problem.2 It is doubtful that by correcting the bite I cured some form of somatoform illness or neurologic deficit. Occam’s Razor is often translated as “all things being equal, the simplest answer is probably the correct one.” I am being cited for their statement, “All of the mentioned symptoms do not have any organic reason, and many doctors believe that these are psychiatric disorders [17, 18, 19].” My citation is number 19 in the Pop-Jordanova paper. Clearly, even the abstract of my paper was either not read, was misunderstood or was mischaracterized. My position was very clear that “This case review of PB is unique from the others found in the literature and diverges away from the hypothesized somatoform disorder model.”2

The authors are certainly entitled to their opinions as long as they are identified as such. They listed twenty other orofacial conditions that in their opinions are due to Somatic Symptom Disorders (SSD) or other neurotic disorders. Their justification was limited to a classification in one book published 40 years ago, not a substantial reference. What they clearly misunderstand within the real biopsychosocial model is that the “bio” must come first. There is no such thing as a “psychosociobio” model. Painful biological conditions routinely produce emotional responses undifferentiable from those of neuroses. Psychiatrists, unlike dentists, understand very well that without eliminating the biological component, it is not possible to separate any purely emotional component. Although a plethora of dental studies have now established correlations between TMD/OFP and the reactions of depression, anxiety and emotional stress, no study has yet demonstrated a curative psychological counselling treatment that would support a psychological or psychosocial etiology. In fact, some attempts to do that have failed.

So, what is the ethical thing to do? Do I keep quiet and not say anything? Should I be glad that I got a citation and watch as my research scores go up even though it was contextually wrong? Am I complicit if a patient is harmed in a treatment and I said nothing? Do I write a commentary and call out the authors and peer reviewers for not doing their respective due diligence? There is a lot to unravel here and this is not an isolated incident.

Two of the most prestigious medical journals are the Lancet and The New England Journal of Medicine. Dr Marcia Angell, former Editor in Chief of NEJM has written, “It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as editor of The New England Journal of Medicine.”3 Richard Horton, former Editor in Chief of the Lancet wrote, “The case against science is straightforward; much of the scientific literature, perhaps half, may simply be untrue.”4 Perhaps it is because researchers today are focused more on obtaining those huge government grants rather than on adding to human knowledge?

In my short tenure as Editor in Chief of the Journal of Advanced Dental Technologies & Techniques I have been witness to events in the literature that undermine the propagation of knowledge. These include censorship, systematic reviews that only contained three citations, a lack of responsibility among some reviewers as well as editors to make the right publishing decision instead of perpetuating their own agenda. Also, some authors of systematic reviews reference papers in non-English languages, claiming that the manuscript supports their position, when in fact it is contradictory. Perhaps they thought no one would get a translated version to challenge their position. My personal favorite is a paper called, “The conceptual penis as a social construct.”5 This was a totally made up paper by authors that made up false names, emails and credentials to test the peer review process. It was published twice. I wish I could say this was a new phenomenon, or at the very least a rare occurrence, but it is not, as evidenced by the many retractions in recent years from elite journals.

I have authored and coauthored multiple ‘Letters to the Editors’ and published editorials in an attempt to combat academic dishonesty and inaccurate conclusions. One could spend a career writing corrections and/or letters of concern to editors regarding substandard publishing. Certainly, tenure requirements and the ‘publish or perish’ mantra contribute to the speed at which some authors publish and sometimes less than honorable intentions to submit work that was rushed or otherwise falls short of any quality mark.

This does not only happen in publishing. A prominent orofacial pain lecturer (who will remain nameless) customarily shows a slide with 3 references to illustrate the position that there is no difference between placebo adjustments (or polishing) vs actual occlusal adjustments. If this is true, why would you ever adjust occlusion for reasons related to orofacial pain or TMD? That is a fair question. The slide touts an odds ratio with a 95 % confidence interval. This sounds impressive and credible. However, if you actually read the papers for yourself and not take out a few cherry-picked sentences, out of context, you have a totally different meaning. The three papers cited that supposedly strengthen this argument are:

  1. Forssell H, Kirveskari P, Kangasniemi P. Effect of occlusal adjustment on mandibular dysfunction. A double-blind study. Acta Odontol Scand. 1986;44(2):63-9. doi:10.3109/00016358609041309

  2. Karppinen K, Eklund S, Suoninen E, Eskelin M, Kirveskari P. Adjustment of dental occlusion in treatment of chronic cervicobrachial pain and headache. J Oral Rehabil. 1999;26(9):715-21. doi:10.1046/j.1365-2842.1999.00448.x

  3. Tsolka P, Morris RW, Preiskel HW. Occlusal adjustment therapy for craniomandibular disorders: a clinical assessment by a double-blind method. J Prosthet Dent. 1992;68(6):957-64. doi:10.1016/0022-3913(92)90558-r

In reading the totality of these manuscripts, specifically the conclusions, a totally different concept emerges. The Forssell paper concludes “It can be concluded that the elimination of occlusal disturbances was an effective treatment for mandibular dysfunction.” Though there was no measured quantification of what was being adjusted it was reportedly a double-blind study.

The Karppinen paper is clear in their statements, “The short-term response to therapy was good in both groups.” (both placebo and treatment). “In the long-term, however, the response was significantly better in the patients who had undergone occlusal adjustment than in the mock adjustment adjusted controls.” Perhaps the subjects needed time to respond before the desired effect was observed? Clearly the presenter is being intentionally dishonest and misleading by omitting part of the information that was introduced. The Tsolka paper actually says what the lecturer in question says it does, but only with respect to removing CO – CR slides and non-working interferences “as far as possible.” Note: Of the 26 patients (92.8 %) in the treatment group that had unilateral contacts in CR pre-treatment, “After the initial occlusal adjustment in the real treatment group, the unilateral contacts in CR were eliminated in only two patients.” Tsolka et al also falsely claimed, “Observations similar to those in our study were presented in the double-blind study of Forssell et al.”

All patients were diagnosed strictly based upon their painful symptoms and the placebo group’s symptoms were significantly different pre-treatment. Even including this doubtful evidence, the original claim lost 66.7% of its support. This was another example of a deceptive presentation accomplished by cherry-picking choice sentences from the manuscript, taken out of context from the totality of the work.

Who pays the price for those that would sacrifice the true facts in lieu of preserving their paradigm and in some cases careers to perpetuate dogma? The doctors who are misled of course, individually and professionally. The patients do as well as they are being treated by those that read literature with good intent but unknowingly don’t have the full story. Reporting the facts as they present themselves will ultimately winnow out the truth even when it may initially be rather inconvenient. This is the direction all evidence-based medicine or dentistry should move towards. At one point, Jean-Baptiste Lamarck and Gregor Mendel both presented competing ideas on the transmission of genetic information. Ultimately, Lamarck was disproven and Mendel’s model was adopted.

Research of any kind is hard. Brutally tough. The problems are real and the answers are not in the back of the book. The scientific literature is filled with holes, contradictions and blatant lies, but it is the best we have. We are all entitled to our opinions when labeled as such, but not to our own set of facts.