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Temporomandibular Disorders: Priorities for Research and Care (2020)

Chapter: 6 Improving TMD Health Care: Practice, Education, Access, and Coverage

« Previous: 5 Caring for Individuals with a TMD
Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
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6

Improving TMD Health Care: Practice, Education, Access, and Coverage

When we began our journey consulting “medical professionals” (dentists, oral surgeons, rheumatologists, physical therapists, chiropractors, etc.), there was lack of knowledge and understanding, lack of standards of care, mixed diagnosis, conflicting treatments options, etc. There was very little (if any) collaboration with other health care professionals, and poor communication.

—Michelle and Alexandra

Our current “system” (for lack of a better word) for treating TMD is not only broken but it’s fragmented, and patients are falling through the cracks and left feeling abandoned and alone.

—Adriana V.

TMD HEALTH CARE PATHWAYS

Current Care Pathways

Individuals seeking care for temporomandibular disorder (TMD)-related symptoms enter the health care system through various entrance points and have a wide variety of experiences in locating health care professionals who are knowledgeable about TMDs and who can provide quality care. For some patients, the initial evaluation and management is performed by a primary care physician or a general dentist. This management is effective for some patients, but for patients whose TMD condition is chronic and does not

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

respond to conservative care, multiple other specialties may be engaged. Patients may seek care from a dentist who focuses on TMDs and orofacial pain, an orthodontist, an oral and maxillofacial surgeon, a physical therapist, a behavioral therapist, a chiropractor, or another type of health care professional. No standardized referral pattern for the escalation of diagnosis and treatment exists. Fragmented and siloed care models may lead to delays in diagnosis and management for some patients and frustration by both patients and clinicians. Health care professionals from different disciplines have varied approaches to TMDs, and even clinicians within the same discipline may have disparate ideas about appropriate care options (Greene and Bertagna, 2019). For example, dentists who hold an occlusal viewpoint might recommend adjustments to the teeth or jaw, while other dentists who follow a biopsychosocial model might opt for conservative treatments and psychological supports, and oral and maxillofacial surgeons may lean toward performing injections or surgery (Greene and Bertagna, 2019). As Table 6-1 demonstrates, an individual may visit multiple types of health care professionals and receive very different treatments from each—some of which may be beneficial and others that may have no added value or be harmful. A challenge for patients with the most serious and complex TMD cases is that currently there is not a medical or dental home for TMD care. TMD and orofacial pain centers of excellence (discussed below) as well as expanded availability of orofacial pain specialists could help address the need for TMD patients to be able to access the expertise and coordinated care they need in bridging the medical and dental divide.

Most health care professionals, including dentists, receive minimal or no training in TMDs or pain management during their entry-level education programs, residency and post-graduate training, or continuing education. Clinicians who have received more intensive training in TMDs and orofacial pain are limited in number. Because there are relatively few clinicians specializing in these conditions, geography may be a barrier; as for many other health issues, patients in rural areas face particular obstacles accessing quality care. Insurance reimbursement for TMD treatments can be complex and difficult to navigate, and the quality of care varies from one clinician to the next. Often there is little collaboration among dentists, physicians, and other health care professionals, so patients may bounce back and forth between multiple professionals without ever receiving a satisfactory diagnosis or treatment.

Qualitative interviews with patients with chronic TMDs have revealed three themes about the current care system (Breckons et al., 2017):

  1. The fluidity of the care pathway: patients move among health care professionals within and between the dental and medical systems as they try to have their pain diagnosed and managed;
Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
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TABLE 6-1 Care Journeys of Some Individuals with a Temporomandibular Disorder Who Contacted the Committee

Patient A

Various physicians and specialists

Oral and maxillofacial surgeon

Dentists

Psychiatrist

Patient B

Physical therapist

Oral and maxillofacial surgeon

Orthodontist

Psychotherapist

Mental health treatment center (for suicidal depression)

Ophthalmologist (cauterizing tear ducts due to nerve damage to eyes, which resulted from temporomandibular joint surgery)

Pharmacist

Patient C

Primary care physician

Orthodontist

Oral and maxillofacial surgeon

Immunologist

Pain management physician

Oral and maxillofacial surgeon

Patient D

Primary care physician

Oral and maxillofacial surgeon

Orthopedic surgeon

Various specialists

Physiotherapist

Patient E

Dentist

Primary care physician

Neurologist

Ear, nose, and throat specialist

Chiropractor

Patient F

Primary care physician

Neurologist

Dentist

Oral and maxillofacial surgeons

Rheumatologist

[Order not specified]:

Infectious disease specialist

Functional medicine specialist

Geneticists

Pain management

Psychologist

Psychiatrist

Nutritionist

Physical therapist

Naturopath

Acupuncturist

Osteopathic physician

Alternative medicine specialist

Orthopedic surgeon

Chiropractor

Massage therapist

Patient G

Oral and maxillofacial surgeon

Medical device company

Oral and maxillofacial surgeon

Orthodontist

Primary care physician

Patient H

Dentist

Oral and maxillofacial surgeon

Primary care physician

Emergency medical technician

Allergist

Myofascial and precision neuromuscular massage therapist

SOURCE: Public comments to the committee. The study’s public access file is available through the National Academies Public Access Records Office (paro@nas.edu).

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
  1. A failure to progress: despite multiple appointments, patients are frustrated with the delays they encounter in obtaining a diagnosis and effective treatment for their pain; and
  2. The effects of unmanaged pain: the longer that pain is unmanaged, the greater its potential to negatively affect patients’ lives.

Vision of a Patient-Centered Care Pathway

In contrast to the typical care pathway outlined above, in an ideal world a patient who is experiencing symptoms of a TMD would visit a primary health care professional who would be knowledgeable about the basics of TMD just as other health conditions, including what patients can do with self-care and when a referral to a specialist is indicated. Unless there was unusual severity or complexity to the symptoms or examination findings, the initial starting point for many patients would be treatments such as self-management and physical therapy (see Chapter 5). If these initial treatments did not improve symptoms within a defined time period, the patient could be referred to a specialist with more advanced training in TMDs. Ideally, such specialty referrals would be coordinated across disciplines so that referring practitioners would work together to find appropriate treatments.

Specialty care might be provided by an individual health care professional, an interprofessional practice of dentists and physicians, a center for excellence in TMDs and orofacial pain, or another type of collaborative practice. Care from these specialists would be available in person or through telehealth platforms. The collaborative approach would allow a patient to access treatments as varied as rehabilitative exercises, cognitive-behavioral therapy, physical therapy, surgery, medications, or acupuncture, depending on the patient’s preferences and the specialists’ assessment of the patient’s particular condition. The details of these treatments would all be readily accessible to all health care professionals through an integrated health record system, and the patient’s progress would be monitored by a primary health care professional who would serve as a navigator and liaison between the various specialists. Payment for services would be straightforward and consistent, and the role of the primary clinician as navigator and liaison would be fully covered and understood by the payment mechanism.

Moving Toward This Future

The committee identified several barriers that prevent this patient-centered care pathway from becoming reality. These include:

  • a lack of training in TMDs for frontline health care professionals such as general dentists, primary care and internal medicine clinicians,
Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
  • nurse practitioners, and physician assistants, who typically field the initial complaints and manage patients with TMDs;

  • difficulty finding health care professionals with specialized training and education in TMDs and orofacial pain;
  • poor integration between medical and dental practice and insurance coverage, and poor communication and collaboration with other health care professionals and specialists; and
  • medical and dental reimbursement systems that are complex, difficult to navigate, exclusionary (i.e., treatments of the temporomandibular joint [TMJ] are often not covered), and often structured to reward interventions regardless of likely effectiveness.

This chapter highlights ways to address these barriers and to improve care for individuals with a TMD by focusing on making improvements in the following areas:

  • interprofessional collaboration,
  • the education and training of health care professionals,
  • access to specialty care, and
  • payment and coverage.

IMPROVING INTERPROFESSIONAL EDUCATION AND COLLABORATION

As discussed in Chapter 2, TMDs are a set of diverse disorders affecting the masticatory system. The more than 30 disorders in the set of TMDs have varied symptoms and care needs, and thus individuals with TMDs need a variety of management and treatment options. Some patients with a TMD may respond quickly to an initial treatment that is recommended by a general dentist or primary care clinician. Other patients may need more individualized care from specialist health care professionals, such as those in surgery or physical therapy. Still other patients may have a TMD that manifests with symptoms affecting multiple systems; these patients may require care from multiple specialists. As seen in Table 6-1, while some patients seek care from multiple clinicians, this care is often not coordinated between the clinicians. An individual health care professional—whether a dentist, oral and maxillofacial surgeon, or physical therapist—will be most familiar with and likely to recommend treatments that fall within his or her area of training and expertise. If assessment and patient care were coordinated between health care professionals—or, better yet, provided by an integrated interprofessional team—patients could access treatments tailored to their specific needs rather than treatments offered solely by a specific clinician. An interprofessional approach, including physicians, dentists, nurses, mental

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

health professionals, physical therapists, nutritionists, and others, would allow health care professionals to collaborate and communicate about the patient’s needs and to learn more about other professionals’ knowledge about and approach to TMDs.

Interprofessional approaches are under way in many areas of pain management. Pain is a “complex sensory and emotional experience” (Klasser and Gremillion, 2013, p. 398). Models of pain management have been developed that focus on the physical, psychosocial, and behavioral aspects of pain management; the involvement of multiple types of clinicians not only ensures a breadth of knowledge and experience, but also contributes “to the integration of that information into a multifaceted team approach” (Klasser and Gremillion, 2013, p. 398). Beginning collaboration early, with interprofessional education during professional school, is essential in fostering understandings between the professions and respect for the roles of other health care professionals (Klasser and Gremillion, 2013). Expansion of these types of educational programs would allow health professionals from many disciplines to prepare for treating a patient in an interprofessional, collaborative team that takes a holistic view of patients and their symptoms.

Dental–Medical Divide

One of the major barriers to effective TMD care is the dental–medical divide (Powers et al., 2017). In most places in the United States, dentistry and medicine have separate education systems, separate practices, and separate financing arrangements. This divide has significant consequences for the health of patients, particularly given the wealth of information available on the impact of oral care on an individual’s overall health. Each year, 108 million Americans visit a physician but not a dentist, and primary care physicians rarely ask patients about oral health signs and symptoms (Atchison et al., 2018). Conversely, each year 27 million Americans visit a dentist but not a physician, and dentists rarely ask patients about preventive health behaviors, such as flu shots, human papillomavirus vaccines, mammograms, or screening for diabetes (Atchison et al., 2018).

For patients with a TMD, this divide can be even more consequential because TMDs can involve multiple systems that are traditionally separated from each other but which are inexorably intertwined. The masticatory system is an integrated system that involves the TMJ, masticatory muscles, and teeth (see Appendix D); that is connected to the body through the head and neck; and that is controlled by the peripheral and central nervous system. The symptoms of TMDs can affect oral, physical, and psychological health and well-being; for example, patients with a TMD can have limitations in dental hygiene, talking, eating, smiling, and sexual activities.

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

However, because of the siloed nature of dentistry and medicine, patients usually either receive care from only one type of health care professional or else must navigate and coordinate care between multiple health care professionals themselves. Many dentists and physicians are likely to focus on the systems and symptoms of TMDs that fall within their specialized area of training, rather than viewing the TMD condition and the patient in a holistic, integrated manner. The financing mechanisms for dental and medical care are also generally separate, making interprofessional collaboration and team care even more difficult.

One approach for bridging the dental–medical divide is to integrate dental and medical practices within the same health system or have them use the same insurance program. For example, Kaiser Permanente in the Pacific Northwest integrates dental and medical care (Kaiser Permanente Dental, 2019). This allows dentists to access medical records and doctors to access dental records, and medical and dental care are often in the same building, allowing for real-time interprofessional collaboration and patient consultation and treatment. One benefit to the integration of dental and medical services is that it allows team members to address care gaps. Kaiser’s patient portal can be used by dentists and dental hygienists to remind patients of medical appointments, needed screenings and care (e.g., vaccines), and follow-up reminders. At some Kaiser locations all patients receive a blood pressure screening at dental exams and are referred to their primary health care professionals if the reading is elevated. This type of model could allow physicians and dentists to work together to address the multiple systems, symptoms, and needs of some patients with TMDs.

Other approaches for bridging the dental–medical divide include:

  • interprofessional education during graduate school that teaches dentists and physicians about the unique knowledge and skills that each brings to the table and prepares them to work together as a team;
  • interprofessional continuing education to bring practicing physicians and dentists together to discuss and explore ways to better collaborate; and
  • formal agreements between dental and medical practices regarding referrals, communication, and collaboration.

Conclusion 6-1: Due to education, training, and financing mechanisms, there is often a lack of collaboration between clinicians, particularly dentists and physicians, and this divide can make it challenging for patients with temporomandibular disorders to access and coordinate care.

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

STRENGTHENING EDUCATION AND TRAINING

Although primary care and internal medicine clinicians and general dentists are typically the entry point for patients seeking care, most of these clinicians receive little to no education and training in the diagnosis or treatment of TMDs. Other health care professionals (including nurses, nurse practitioners, psychologists, physical therapists, and physician assistants) also receive little to no education and training in TMDs. A number of approaches could be taken to improve education and training for health care professionals, including adding TMD information to health professional school curricula, adding TMD care as an area tested in licensing exams, expanding post-graduate fellowship and residency opportunities, and improving continuing education. These potential areas for improvement are explored below for the fields of medicine, dentistry, physical therapy, and nursing.

Medicine

Curriculum

Medical education and training currently includes little training about diagnosing and treating TMDs, orofacial pain, or pain management in general (IOM, 2011). The curriculum requirements for U.S. medical schools do not include specific education in TMDs, and neither TMDs nor oral health are included by the Association of American Medical Colleges or the American Association of Colleges of Osteopathic Medicine in their list of most frequently included subjects (AACOM, 2019; AAMC, 2019). Pain also receives inadequate attention in medical school, despite pain being the most common reason that people visit a health care professional (Fishman et al., 2013). Studies of medical schools in Canada, the United Kingdom, and the United States have found that few schools require much, if any, dedicated course time on pain, and students report feeling inadequately prepared to manage patients’ pain (Fishman et al., 2013). However, there is an increasing awareness of the need to improve pain education in medical schools nationwide, and some schools have begun to add additional content on pain management. The committee acknowledges the challenges of adding more content to already full curricula but given the impact of TMDs on health and well-being, the recommendations provided in Chapter 8 urge medical, nursing, and other health professional schools to provide the information that health care professionals need on TMDs.

Furthermore, there is an increasing emphasis on interprofessional education within medical and other health professional schools, with 143 U.S. allopathic medical schools requiring this component as of 2018 (AAMC, 2018).

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

While not specific to TMDs, improving the broad area of pain management education within medical schools could be an initial step toward improving the management of all physicians of TMDs. Consensus-based core competencies in pain management were developed by an interprofessional group of pain experts and have been endorsed by many professional organizations (Fishman et al., 2013). The endorsement and adoption of pain competencies and curriculum guidelines by the American Medical Association would provide an initial step toward recognition by medical schools of the need to improve pain science education within the curriculum. As part of a pain management curriculum, there could be specific recommendations for education on TMDs along with other high-impact pain conditions such as low back pain and fibromyalgia.

Another path for changing curricula would be by changing accreditation standards. Medical schools in the United States are accredited either by the Liaison Committee on Medical Education (LCME) (for M.D. programs), or the Commission on Osteopathic College Accreditation (COCA) of the American Osteopathic Association (for D.O. programs). Neither the LCME nor the COCA accreditation standards detail specific areas of curriculum or specific competencies that must be covered in medical school. Rather, the faculty at a medical school is responsible for defining the competencies to be achieved, and is responsible for the design and implementation of the elements of the curriculum that will enable its students to fully achieve those competencies and objectives (COCA, 2019; LCME, 2019). The LCME provides a few guidelines on general areas that should be covered in the curriculum (e.g., prevention, diagnosis, treatment, and problem-solving skills) (LCME, 2019). COCA states that curriculum must develop the seven core competencies of osteopathy (medical knowledge, patient care, communication, professionalism, practice-based learning, systems-based practice, and osteopathic principles and practice/osteopathic manipulative treatment) (COCA, 2019). However, because the specific curriculum at a medical school is dictated by the faculty rather than through accreditation standards, it is unlikely that changing accreditation standards would be a fruitful way to improve TMD education in medical schools.

Licensing Exams

Every physician in the United States must pass the United States Medical Licensing Examination (USMLE) or the Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX-USA) in order to practice medicine. The exact questions of the exams vary from year to year, but every year the content covers a wide range of medical knowledge. There has not been a comprehensive study of TMD-related questions on these exams, although study guides do include TMDs as a

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

topic (MedBullets, 2019). However, an evaluation of the scope and nature of pain-related questions on the USMLE, which may be similar to TMD-related questions, indicates that while pain-related questions were common on the USMLE, the focus of most of the questions was on the recognition and assessment of pain, rather than on safe and effective pain management (Fishman et al., 2018). The authors of that paper have used the results to begin conversations with medical school deans and USMLE officials about changing the pain-related content of the exam. A similar study and approach could be used to improve the number and quality of questions about TMDs on the USMLE and the COMLEX-USA.

Post-Graduate Training

After completing 4 years of medical school, physicians go on to complete a residency in their chosen specialty; residencies are usually 3 to 7 years in length. After residency (and possibly additional training in a subspecialty) physicians take the board exam(s) for their specialty. These exams are administered by the American Board of Medical Specialties, the American Osteopathic Association’s Bureau of Osteopathic Specialists, and the American Board of Physician Specialties. Upon passing the exam, the physician is a board-certified specialist in that specialty field. Depending on the specialty chosen, a physician may receive some training on TMDs during residency. Physicians specializing in such areas as pain medicine, otolaryngology, or physical medicine and rehabilitation may receive more training in TMDs than other specialists; however, their training is likely to be limited to their specialty. For example, in pain medicine the specialty training might focus on the pain aspects of TMDs, even though not all TMD patients experience pain. Physicians who specialize in family medicine or internal medicine may receive no training at all on TMDs, despite the fact that many patients first go to their primary health care or internal medicine professionals when experiencing symptoms. The Accreditation Council for Graduate Medical Education lists no specific curriculum requirements for training in TMDs, oral health, or orofacial pain for any primary care specialty.

There are, however, a few specialties in which competency in orofacial pain is required. For example, competency in the diagnosis and management of orofacial pain is a required curriculum component for the pain medicine subspecialty (ACGME, 2019). The United Council for Neurologic Subspecialties requires that trainees in headache medicine understand that secondary headache syndromes (including TMDs) have knowledge about headache classification and diagnosis and about the pathophysiology of headache due to dental disease. However, there is no requirement for training in the evaluation, diagnosis, and management of TMDs.

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

Expanded opportunities for post-graduate training in TMDs and orofacial pain are needed, in coordination with the appropriate accrediting organizations and certifying boards. Where the management of TMDs includes pain management, particularly relating to chronic TMDs, it may be useful to coordinate with the recommendations and efforts related to the Department of Health and Human Services’ National Pain Strategy (HHS, 2016), which seeks to improve both curricula and core competencies for all professionals in the management of pain.

A challenge to the TMD field is to find innovative ways to cross the medical and dental divides in training and in practice and to find opportunities for post-graduate physicians, nurses, and other health providers to become more engaged—through fellowships, continuing education courses, integrative research, and other efforts—in TMD care and research. Given the great strides in care for knees, shoulders, and other joints of the body, the committee urges similar levels of attention to the TMJ and TMDs.

Continuing Medical Education

Continuing medical education on TMDs for physicians is available although much of the TMD-related continuing education is focused on dentists. As discussed below the ready perusal of the syllabi of many continuing dental education courses indicates that an adequate evidence basis is absent; moreover, information from individuals with a TMD suggests that not all diagnosis and treatment recommendations from practitioners conducting these courses are evidence based. Focusing on a biopsychosocial approach to TMDs and emphasizing that TMD care often begins with conservative, non-intrusive treatment approaches is critically important.

Dentistry

Curriculum

General dental education programs may provide some exposure to TMDs, depending in part on whether the dental school has any faculty trained in TMDs or orofacial pain, but there is no national curriculum requirement specifically addressing learning objectives for TMDs or orofacial pain. Currently, the amount of training on TMDs or orofacial pain varies by school. For example, the Harvard Dental School has about 10 hours of didactic education on TMDs over 4 years but no formal clinical training in TMDs, whereas the University at Buffalo School of Dental Medicine offers about 32 hours of didactic education in TMDs and two semesters of rotation in the specialty clinic. Klasser and Greene (2007) conducted a survey of U.S. and Canadian dental schools and found that while predoctoral

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

education on TMDs has improved over the past several decades, the topic is still inadequately addressed by some schools. Of the 53 dental schools that responded to the survey, only 3 reported that their system of teaching TMDs was ideal; the remaining schools reported that their system was fragmented, reported that there were competing viewpoints presented within the curriculum, or did not answer the question. The authors concluded that although progress has been made in predoctoral dental education on TMDs it is “far from optimal, and, in some schools, the teaching effort is too minimal, too outdated, and too narrowly focused” (Klasser and Greene, 2007, p. 236). In contrast to primary care medicine, where almost all primary care physicians will complete a residency prior to entering practice, many dentists begin practice immediately following dental school. Thus, adding training on TMDs and orofacial pain to dental school curricula assumes particular importance. Including discussions on the ethical issues and controversies relevant to TMD care in ethics courses in dental schools is also of critical value.

Curricula at dental schools are largely determined by the dean and faculty of each school; however, the curriculum—and the competencies of graduates—must meet the accreditation standards of the Commission on Dental Accreditation (CODA). CODA is responsible for the accreditation of all accredited dental schools in the United States and has detailed requirements for accreditation, including areas in which dental school graduates must be competent. One way to increase TMD education and training would be for CODA to include TMD knowledge in its list of required competencies (“must” statements) for graduates. Currently, CODA standard 2-24 requires that dental school graduates are competent in the following areas:

  • patient assessment, diagnosis, comprehensive treatment planning, prognosis, and informed consent;
  • screening and risk assessment for head and neck cancer;
  • recognizing the complexity of patient treatment and identifying when a referral is indicated;
  • health promotion and disease prevention;
  • local anesthesia and pain and anxiety control, including consideration of the impact of prescribing practices and substance use disorder;
  • restoration of teeth;
  • communicating and managing dental laboratory procedures in support of patient care;
  • replacement of teeth, including fixed, removable, and dental implant prosthodontic therapies;
  • periodontal therapy;
Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×
  • pulpal therapy;
  • oral mucosal and osseous disorders;
  • hard and soft tissue surgery;
  • dental emergencies;
  • malocclusion and space management; and
  • evaluation of the outcomes of treatment, recall strategies, and prognosis (CODA, 2019).

Dental schools are free to add to these competencies, and some have added competency in management of TMDs. For example, the University of Washington School of Dentistry has added “the management of TMD as it presents in general dental practice” to the list of competencies that a graduate must have (University of Washington, 2019). TMD knowledge is also a part of the American Dental Education Association’s (ADEA’s) competencies for the new general dentist, which state that dental school graduates must be competent to “prevent, diagnose, and manage temporomandibular disorders” (ADEA, 2008). However, it is not mandatory for dental schools to follow ADEA competencies; rather, they serve as non-binding guidance.

Some have called for CODA to change its accreditation standards to add competency in TMDs and orofacial pain. Klasser and Greene (2007) called for the implementation of minimum time and content standards for orofacial pain education in predoctoral programs and proposed that TMDs and orofacial pain be included among accreditation standards for predoctoral dental education. Revisions to the CODA accreditation standards have been proposed including the addition of the phrase “screening, risk assessment, prevention, and early intervention of temporomandibular disorders” to Standard 2-24.1 In August 2019, CODA approved putting this proposal out for public comment. Adding TMDs and orofacial pain to the required competencies of predoctoral dental programs would help ensure that all dentists—regardless of specialty or further training—are equipped with the core knowledge of how to assess and manage patients with TMDs.

Licensing Exam

Another option for improving the preparation of dentists on the subject of TMDs would be to have more TMD-specific questions on the National Board Dental Examination (NBDE), which every dentist must pass in order to be state licensed. Until recently the NBDE was given in two parts, one after the second year of dental school and the other between the third and

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1 Chen, H. 2019. Letter to CODA. May 31. Available through the National Academies Public Access Records Office (paro@nas.edu).

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

fourth years. Questions about the TMJ did appear on the exam; Part I included questions about the TMJ in the areas of gross anatomy, oral histology, and masticatory physiology and biomechanics, while Part II included questions about the diagnosis and management of orofacial pain, TMJ pain and surgery, anxiety and pain control, and TMJ dysfunction. The NBDE has been completely revised and will now be called the Integrated National Board Dental Examination; the content is under development. Adding more TMD-specific questions to the new licensing exam would emphasize the health impacts and clinical importance of these disorders and necessitate changes to dental school curricula in order to make sure that students are prepared to help patients with TMDs. Exam questions on the national boards drive the educational content taught in dental and medical schools. If there is a greater emphasis of questions on TMDs, that will drive increased educational content directed at TMDs, require hiring of faculty with expertise in TMDs, and encourage more faculty research on the topic as a downstream effect.

Post-Graduate Training

Most traditional post-graduate dental fellowships and residencies (such as orthodontics, periodontics, or prosthodontics) also contain little TMD content. While patients with TMDs are often referred to and treated by oral and maxillofacial surgeons, programs in oral and maxillofacial surgery have little focus on TMDs. Surgical residency programs are a mixture of M.D.-integrated and single-degree programs, and there are no fellowship programs specific to TMDs. Experience in TMJ surgery is extremely varied among programs and depends on the faculty at each training program. CODA requirements for the residencies discuss pain only in the context of anesthesia training, and the TMJ is mentioned in only two requirements: fellows must get experience in the management of TMJ pathology and at least three other types of procedures, and experience in reconstructive surgery could include TMJ reconstruction (CODA, 2017).

Post-graduate programs in orofacial pain provide the most focused training on TMDs. Orofacial pain fellowships are 1- or 2-year fellowships following dental school, with around half of the emphasis on the diagnosis and management of TMDs. There is often a focus on multimodal treatment, although the programs are housed in specific departments, such as oral medicine, endodontics, or oral and maxillofacial surgery. There are currently 12 fellowship programs across the country which train about 30 dentists per year (AAOP, 2018). These programs could serve as initial pilot sites for centers of excellence in TMDs and orofacial pain (see below).

The American Board of Orofacial Pain offers board certification for dentists who either have attended one of these programs or have practiced

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
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in orofacial pain dentistry for at least 2 years and have completed 400 hours of continuing education in orofacial pain. Upon completion of oral and written examinations, dentists may be certified as diplomates who have demonstrated competency in orofacial pain. Diplomates must meet continuing education requirements to maintain their certification.

While these programs are beneficial in that they provide advanced training for dentists as well as appropriate care for patients, the programs do not produce a large number of dentists who remain working in the field of TMDs or orofacial pain. The programs have had challenges in attracting dentists due to the lack of adequate and consistent reimbursement for TMD care. Furthermore, there is an absence of a clear career pathway in TMD care because there is not an American Dental Association (ADA)recognized specialty in TMDs and orofacial pain. Currently, nearly all of the graduates are foreign dental students who often have difficulty gaining a license to practice their specialty in the United States. There is a need to address these barriers in order to fully realize the potential of post-graduate programs in TMDs and orofacial pain and to expand fellowship and residency opportunities for dentists who want to study TMDs. The official recognition by ADA of orofacial pain as a specialty of dentistry may spur the expansion of programs and may lead to the resolution of some of the barriers to practice (see discussion below on specialty certification).

Continuing Dental Education

There are no requirements for continuing dental education (CDE) in TMDs. Courses are available from a variety of institutions, both public and private, but it is entirely up to individual dentists how much additional training they wish to receive. As noted in Chapter 5, there are no best practice standards to inform the content of these continuing education offerings. ADA has an evidence-based criterion for CDE that many organizations sponsoring CDE align with, but the interpretation of the standard is inconsistent, resulting in “approved” education that may have no evidential basis.

Continuing dental education in TMDs is available via both online and in-person courses. However, the content of these courses varies widely. Ready perusal of the syllabi of many continuing education courses indicates that an adequate evidence basis is absent; moreover, information from individuals with a TMD suggests that not all diagnosis and treatment recommendations from practitioners conducting these courses are evidence based. Efforts need to be made to ensure that relevant continuing education courses convey the evidence base on TMDs so that a biopsychosocial approach is used that begins with conservative, non-intrusive treatment approaches and engages relevant medical expertise as needed to address pain and comorbid conditions.

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
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Physical Therapy

While many patients visit a physician, nurse practitioner, or dentist first when experiencing symptoms of TMDs, physical therapists are also a point of entry to the health care system for many patients (APTA, 2013). Additionally, dentists and primary care clinicians who see individuals with pain, including those with TMDs, often refer their patients to physical therapists, and physical therapists are routinely part of an interdisciplinary plan of care. Thus, it is critical to improve the TMD education of physical therapists. As discussed below, the field of physical therapy has already taken significant steps at a national level to incorporate improved pain education in both entry-level and post-graduate education.

Curriculum

The management of TMDs is generally integrated within existing coursework in the curriculum of physical therapy schools. A survey of the 224 accredited, entry-level U.S. doctor of physical therapy professional programs found that TMD content is covered in almost all (more than 98 percent) of the responding programs (84 of 224 responded) (Prodoehl et al., 2019). An average of 12 hours of TMD-specific content is provided in the physical therapy education curricula, and the majority of respondents used established evidence-based diagnostic criteria for TMDs (Prodoehl et al., 2019) (see Chapter 2).

A survey of pain education curricula as part of accredited doctorate of physical therapy schools in the United States was published in 2015 (Hoeger Bement and Sluka, 2015). The survey found that only 61 percent of respondents believed that their students received adequate education in pain management. While the majority of schools that responded covered the science of pain assessment and management, there was a large range of content coverage. Less than 50 percent of respondents were aware of the Institute of Medicine report on pain (IOM, 2011) or the International Association for the Study of Pain (IASP) guidelines for physical therapy pain education (IASP, 2018).

After the publication of the interprofessional pain competencies (Fishman et al., 2013), a position paper was written by leading physical therapy educators on how these could be adopted into entry-level curricula (Hoeger Bement et al., 2014). In 2015 the American Council of Academic Physical Therapy endorsed the pain competencies, which led to an improved awareness of the need for pain education. Perhaps most impactful, in 2018 the house of delegates of the American Physical Therapy Association (APTA) adopted and agreed to promote the IASP’s pain curriculum guidelines and the pain competencies. Approval and adoption by

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
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the national organization has led to greater awareness and new ongoing initiatives to provide resources and training over the next several years to promote the adoption of pain science education into entry-level and postgraduate physical therapy curriculum. While these steps are ongoing, there is substantial support by the organization and leading educators to improve pain education within the profession. However, it should be noted that as with medical and dental schools, the curriculum is up to the individual schools and is not mandated by the national organization. Currently the amount of pain or TMD education in physical therapy schools is highly variable, with some schools having only a few hours on pain assessment, others providing integration throughout their curriculum, and a few with stand-alone pain management courses.

The APTA is currently developing and promoting improved pain education nationally that is based on the IASP curriculum and pain competencies. This support has been and will be critical for the continued growth and development of an educated physical therapy profession.

Licensing Exam

All physical therapists must take the National Physical Therapy Examination to be able to practice physical therapy within the United States. It is unclear at present what is covered on this exam with regard to pain management or TMDs or if what is covered reflects current evidence and guidelines. An examination of the current exam and recommendations for additional TMD-related questions could lead to an improved uptake of pain science and TMD education within the curriculum.

Post-Graduate Training

The physical therapy profession has advanced residency, fellowship training, and board certification. Several pain residencies and fellowships in pain management are available for physical therapists. These are not associated with national organizations but rather with private organizations or health systems; as such, none are accredited by the American Board of Physical Therapy Residency and Fellowship Education, which requires the development and approval of practice standards. There are nine areas for board certification. While there is no board certification specifically in pain, the orthopedic board certification has both TMDs and pain competencies embedded within the required knowledge base. The certification exam in orthopedics currently includes questions on craniofacial pain and pain in general.

Certifying residencies, fellowships, and board certification requires conducting a practice analysis as a first step. The pain management special

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
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interest group in the Academy of Orthopaedic Physical Therapy has begun the process of conducting a practice analysis (to be completed by 2020) with the ultimate goal of creating a board certification in pain, as well as petitioning to accredit residency and fellowship programs.

Several potential paths could be taken to improve post-graduate training in pain and TMDs for physical therapists. Because a practice analysis is already performed for pain, this could include an analysis on TMDs, with appropriate content in the area to appear on a specialization exam. There is a need for pain residencies and fellowships in pain management from the American Board of Physical Therapy Residency and Fellowship Education to include the appropriate management of TMDs within the educational and exam process. Because these certifications are currently being developed, the physical therapy profession has a unique opportunity to develop and include appropriate content on TMDs from the beginning.

Continuing Education

Currently a number of pain-focused continuing education courses are available to physical therapists; most are offered by for-profit organizations. Additionally, the APTA has two meetings per year, where content can be provided and suggested by members, in addition to access to an educational portal. The APTA also has academies related to various specialties (e.g., orthopedics, neurology). At present there is no academy devoted to pain; however, there is a pain special interest group within the Academy of Orthopaedic Physical Therapy, which is active in promoting better pain education, management, advocacy, and research. This organization provides online continuing education courses, including one on pain management.

Nursing

Curriculum

The education and training of nurses varies, depending on the type of nursing degree program. Registered nurses (RNs) can have a diploma in nursing, an associate’s degree in nursing, or a bachelor’s degree in nursing. Advanced practice registered nurses (APRNs) have a master of science in nursing, a doctor of nursing practice, or a Ph.D. in nursing science or a related field.

Because pain management is central to nursing practice, the assessment and management of acute and chronic pain are taught at all levels of nursing education (Campbell, 2019). The pathophysiology of pain, assessment techniques, pharmacological and non-pharmacological management, patient- and family-centered care, and effective communication are

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
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included in nursing curricula. The depth of these topics is dependent on the type and level of nursing program. APRNs who specialize in pain are part of an interdisciplinary team in clinics and practices that specialize in pain management (Jones et al., 2019). Another important focus of nursing education is symptom management. Patients with TMDs often report other symptoms including fatigue, musculoskeletal and headache pain, and sleep disturbances. These topics are relevant to the care of a patient with an acute or chronic TMD condition as well as other comorbid conditions.

Several efforts in recent years have promoted pain education in nursing. For example, the American Society for Pain Management Nursing has produced a core curriculum to advance and promote optimal nursing care for people affected by pain, and the National Institute of Nursing Research participated in the funding of the National Institutes of Health’s Centers of Excellence in Pain Education.

Licensing Exam

Once educational requirements are completed, an aspiring nurse must take the appropriate licensing or certification exam. The exam for RNs is administered by the National Council of State Boards of Nursing and is called the NCLEX-RN. APRNs take one of four different certification exams, depending on the specialty track chosen. APRNs take the certification exam that is appropriate to their area of specialization (clinical nurse specialist, nurse practitioner, nurse anesthetist, nurse midwife) and population (pediatrics, adult/gerontology, family, psychiatric/mental health).

Post-Graduate Training

During post-graduate training, some RNs may focus on a specific area that is relevant to TMDs. A certification in pain management is available through the American Society for Pain Management Nursing and the American Nurses Credentialing Center.

However, there are no requirements that they receive training in TMDs or orofacial pain, so they may or may not be exposed to patients with TMDs and TMD-specific clinical training. For example, a certified registered nurse anesthetist might be trained in how to avoid causing or exacerbating TMDs while anesthetizing patients. A nurse practitioner might specialize in acute care and see patients who are suffering from high-impact TMD pain or joint dysfunction or might specialize in adult care or family practice, where he or she could care for patients who are seeking first-line treatment for their TMD issues. Clinical rotations for family nurse practitioners, pediatric nurse practitioners, and adult-geriatric nurse practitioners might include exposure to and participation

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
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in interdisciplinary specialty clinics focused on the care of patients with a TMD.

Continuing Education

Continuing education requirements are determined by the state in which the nurse is licensed. A variety of continuing nursing education programs in pain management are available, but none identified by the committee are specific to TMDs.

Other Types of Health Care Professionals

In addition to the professions discussed above, other types of health care professionals may be involved in the treatment of patients with TMDs, such as chiropractors, acupuncturists, dieticians, and naturopaths. This committee has not found evidence that there is specific education or training in TMDs or orofacial pain for any of these professions. While there is a modest body of literature on the use of chiropractic and acupuncture in the management of TMDs (see Chapter 5), there appear to be no specific curriculum or training requirements regarding proficiency in TMDs for becoming licensed in either of these disciplines. Similarly, in naturopathy there are no specific standards regarding education in TMD (CNME, 2017).

Conclusions on Education and Training

The committee reached the conclusions below regarding the gaps and opportunities for education and training. Chapter 8 provides the committee’s recommendations for next steps in improving education and training on TMDs both within and across health care professional schools. The need to ensure that the disorders related to the TMJ are studied in parallel fashion with other joints of the body is critical and would be greatly enhanced through opportunities for interprofessional training opportunities across medicine, health, and dentistry.

Conclusion 6-2: Health care professionals—including physicians, dentists, nurses, physician’s assistants, and physical therapists—need better education and training in the assessment, treatment, management, and referral of patients with pain, orofacial pain, and temporomandibular disorders with attention to interprofessional education opportunities where possible. The extent of training will vary depending on the specialty and the nature of the practice.

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
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Conclusion 6-3: Some dentists continue to use harmful or costly treatment approaches that are known to be ineffective for temporomandibular disorders (TMDs). As discussed in Chapters 2 and 5, editorials and letters to the editor in dental journals suggest resistance to the less invasive but more evidence-based treatment approaches for TMDs. The reliance on aggressive or invasive treatment methods as the first step rather than starting with behavioral or rehabilitative treatments follows the decades-long adherence to structural models that have been shown to be non-intrusive conservative treatments. Education efforts, particularly basic dental education and continuing education classes for practicing dentists, need to focus on ensuring that dentists are fully informed about the complexity of pain and movement as identified for other musculoskeletal disorders and current evidence-based treatments for chronic pain in general and TMDs in particular.

Conclusion 6-4: Most general dentists and many specialists receive inadequate education and training in temporomandibular disorders (TMDs) and orofacial pain and this leads to inconsistent and sometimes harmful and unnecessary treatments provided to individuals with a TMD. A transformation in dental education is urgently needed to ensure that dentists receive updated, evidence-based information about the management of patients with TMDs during predoctoral education, post-graduate training, and continuing education. This transformation can only be accomplished if systematic and ongoing efforts by relevant stakeholders work to ensure that improved education standards, metrics, and monitoring are developed and implemented. Commission on Dental Accreditation standards for the accreditation of predoctoral dental schools do not currently address education regarding TMDs.

IMPROVING ACCESS TO SPECIALTY CARE

A consistent theme expressed by many patients with a chronic TMD has been the difficulty in finding practitioners with particular expertise in TMDs. For the individual with a chronic TMD or with high-impact chronic pain,2 resources for escalation of care are needed. Given that reimbursement issues will play a role in any effort to improve access to specialty care, one approach to improving TMD care would be to increase access to health care professionals with specialized training in TMDs and orofacial pain.

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2 High-impact chronic pain is associated with a substantial restriction of participation in work, social, and self-care activities for 6 months or more (HHS, 2016).

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
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This could be accomplished through several avenues, including creating an ADA-recognized specialty, establishing centers of excellence in TMDs and orofacial pain, and improving access for rural and underserved populations.

Currently, many clinicians who advertise that they are “specialists” in the care of people with TMDs may not actually have any advanced training in TMDs or orofacial pain and may not be aware of or follow the current approach to TMDs. A recent study to determine the accuracy of information provided on 255 websites of dental professionals who advertise themselves as “specialists” in treating individuals with a TMD found that (1) more than two-thirds of the dental professionals who advertised specialty services in TMDs were general dentists; (2) 66.7 percent of the websites attributed TMDs to problems with occlusion; (3) 38.8 percent of the websites labeled TMDs as a single disorder rather than a group of disorders; and (4) 54.5 percent of the websites recommended occlusal approaches to alleviate TMDs (Desai et al., 2016). The study authors expressed concern for individuals with a TMD seeking care, given that many general dentists are advertising expertise in TMDs but are displaying significant inaccuracies in the diagnosis and management of TMDs on their websites and do not seem to be following current concepts about TMDs. Creating an ADA-recognized official specialty in TMDs and orofacial pain could help alleviate this problem by giving patients and other health care professionals the ability to quickly ascertain whether a dentist is a certified specialist.

Creating an ADA-Recognized Specialty

Unlike physicians, the majority of dentists practice general dentistry, with only 21 percent of dentists practicing in a recognized specialty (ADA, 2019). After completing 4 years of dental school or, in some states, 4 years of dental school followed by 1 year of general dentistry residency, dentists are eligible to be licensed by the state. While all states require dentists to pass the NBDE (introduced above), other state requirements vary. After licensure, dentists can choose to focus on a specialty through additional years of education or residency, or both. The dentist then takes the board certification examination from the relevant specialty board. Specialization or certification is not required for licensure or insurance reimbursement. Depending on state dental practice acts, dental board rules, and dental board policies, dentists who advertise as specialists and meet the state-determined requirements for specialty may or may not be able to practice general dentistry.

Ten dental specialties are recognized by ADA’s National Commission on Recognition of Dental Specialties and Certifying Boards (NCRDSCB): dental public health, endodontics, oral and maxillofacial pathology, oral and

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
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maxillofacial radiology, oral and maxillofacial surgery, orthodontics, pediatric dentistry, periodontology, prosthodontics, and dental anesthesiology.

In addition to these NCRDSCB-recognized dental specialties, dentists can also become board certified in general dentistry through the American Board of General Dentistry or in four additional specialties offered by the American Board of Dental Specialties (ABDS). The ABDS was founded by several professional organizations that were frustrated with ADA’s continued refusal to recognize dental anesthesiology as a specialty. ABDS recognizes specialties based on diplomate boards without requiring ADA acceptance. ABDS recognizes specialties in the areas of anesthesiology, oral implantology/implant dentistry, orofacial pain, and oral medicine.

ADA, in response to the creation of ABDS, passed two new resolutions. First, it is no longer considered unethical for a dentist to advertise as a specialist for a specialty that is not recognized by ADA (Resolution 65H-2016). Second, ADA created the NCRDSCB and removed the ADA House of Delegates from the recognition process (Resolution 30H-2017). State boards are also addressing these issues.

In April 2019 the American Academy of Orofacial Pain (AAOP) submitted an application to the NCRDSCB for recognition of the specialty of orofacial pain (AAOP, 2019). According to the AAOP application, the recognition of an orofacial pain specialty by the NCRDSCB could have a number of potential benefits for both patients and health care professionals, including:

  • encouraging more dentists to enter advanced education programs in TMDs and orofacial pain;
  • improving the public’s access to the care of these conditions;
  • encouraging more dental schools to train specialists in TMDs and orofacial pain;
  • increasing the confidence of dentists and physicians in referring their patients to qualified specialists;
  • ensuring that specialists use evidence-based therapies and adhere to a standard of care;
  • enabling patients, health care professionals, and insurers to identify practitioners with knowledge and experience in managing chronic pain conditions; and
  • providing a resource for general practitioners and specialists to refer patients who are not responding to initial management (AAOP, 2019).

An additional important benefit of creating an ADA-recognized specialization in TMDs and orofacial pain could be a realignment of incentives so that patients are receiving the best care, rather than the care that is most

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
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readily available or best reimbursed. Currently, if a patient is seeking a TMD “specialist,” he or she might be referred to a variety of health care professionals, including oral and maxillofacial surgeons, orthodontists, or individuals who advertise as “focusing on TMDs” as a result of some type of training, such as a weekend CDE course. These health care professionals, based on their training and experience, may be likely to recommend the treatments that are in line with their practice and that are covered by insurance (i.e., interventions). Creating a specialty would allow patients to see clinicians who are trained in a wide variety of approaches for managing and treating TMDs, and it could open the door to improved insurance coverage for these treatments. However, if insurance reimbursement is not addressed, the lack of potential for a viable and sustainable dental practice may prevent dentists from pursuing this specialty.

Importantly, creating a specialty would allow patients to identify clinicians who are experts in TMDs and in orofacial pain disorders and could greatly enhance the effectiveness and efficiency of referrals to the specialists needed by some TMD patients. Currently, patients, primary care and internal medicine clinicians, and general dentists often do not know where to turn for specialty care. Patients have reported that they are often shuttled between various types of health care providers with no specialty area focused on their concerns.

Ideally, a specialty on TMDs and orofacial pain would span medicine and dentistry and other health professions. However, given the current divides in the educational structures, provision of care, and insurance systems in the United States between dentistry and health care, the committee could not identify a cross-professional path forward for a TMD and orofacial pain specialty that crosses dentistry and medicine. As detailed in Chapter 8, the committee recommends an ADA-approved specialty in orofacial pain and TMDs. This is a starting point for specialization in this area, and the committee hopes that this specialty would emphasize a strong interprofessional focus. Barriers need to come down between health care and dental care and a strong step forward with an interprofessional approach for TMD care would be a solid step in the right direction on breaking down some of the current barriers.

Establishing Centers of Excellence

Centers of excellence, which are multidisciplinary centers for the evaluation and management of specific acute and chronic disorders, have existed for decades for various disorders. These centers use a model of coordinated care across multiple disciplines, and proponents of centers of excellence posit that this model yields better outcomes than usual care, which is typically uncoordinated across clinicians and settings (Elrod and Fortenberry,

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
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2017). Centers of excellence are patient focused; that is, they are “assembled to supply an exceptionally high concentration of expertise and related resources centered on a particular area of medicine, delivering associated care in a comprehensive, interdisciplinary fashion to afford the best patient outcomes possible” (Elrod and Fortenberry, 2017, p. 16). Centers of excellence may encompass the full disease course of a disorder from the time of diagnosis forward, such as with treatment centers for amyotrophic lateral sclerosis (ALS Association, 2019), or else be designed to accept referrals at a stage at which a disease is not responsive to initial management provided by frontline clinicians and generalists, such as with the National Association of Epilepsy Centers (NAEC, 2019). Other disorders for which centers of excellence are designated include stroke, muscular dystrophy, and cystic fibrosis. There is some evidence that the quality of care is higher in these types of contexts for some of these conditions, with the evidence for this conclusion typically obtained through quasi-experimental program evaluation designs (Anderson et al., 2002; Mogayzel et al., 2014). Most of the disease-specific centers are established and certified by foundations for those diseases, with funding provided for systems or groups that meet the particular program’s criteria.

Creating centers of excellence for TMDs and orofacial pain would have multiple benefits for both clinicians and patients. Centers of excellence could:

  • provide multidisciplinary coordinated care teams, involving specialists across various areas including medicine, dentistry, physical therapy, psychology, neurology, nursing, and complementary and alternative medicine;
  • focus on patients with a TMD who do not have successful outcomes from initial interventions and management;
  • serve as a resource for health care professionals by, for example, creating a clear referral pathway or by collaborating with distant clinicians by offering consultation via phone, video, or other telehealth opportunities;
  • work with other professionals to develop and disseminate clinical practice guidelines and standards of care for TMD patients;
  • conduct research on TMDs;
  • publicly report on a standard set of quality, outcome, and health services data; and
  • provide onsite and virtual education and training, particularly continuing education, for a range of health and human services professionals.

There are currently 12 post-graduate fellowship programs in orofacial pain housed at academic institutions across the United States (see discussion

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
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above in the section on dental post-graduate training). These programs already carry out some of the functions of centers of excellence, such as providing evidence-based patient care and serving as training grounds for health professionals. Using one or more of these programs as a pilot site for the development of a center of excellence in TMDs and orofacial pain would be a way to leverage existing resources to expand care, research, and resources for patients with TMDs. Additionally, existing medical pain management and research programs could add a focus on TMDs and orofacial pain. Efforts to break through the medical and dental silos are needed.

One significant barrier for TMD care is the lack of overlap between medical and dental coverage for most Americans; the multidisciplinary care model of centers of excellence must by necessity span health care professionals across these fields and be able to link them through electronic medical records and incentivize the coordination of services. A center of excellence must be able to recoup the costs of providing comprehensive services, which might include self-management education from a health educator, nurse, or community health worker; access to community services with a social worker; mental health services; and support from primary clinicians in the location where the patient and family reside. Some recent incremental changes in health care financing (e.g., new Current Procedural Terminology codes that pay for physician-to-physician advisory consults, virtual visits, and virtual check-ins) can help support centers of excellence but fall short of providing the necessary financial resources to fully support such models. The introduction of value-based payments, in which health systems are incentivized to maximize care quality and outcomes and given the flexibility to design the most cost-effective model, would be an ideal first step in improving TMD care and outcomes. The involvement of persons with expertise in health economics, qualitative research, and health-related quality of life and outcomes assessment should be integral to the centers.

Centers of excellence should not be created for severe TMDs without a broader strategy for treatment of all TMD patients. Given that many patients’ symptoms resolve with minimal intervention or with the use of initial, low-risk therapies, centers of excellence would need to be part of a broader strategy that includes broadly disseminated, professional society–endorsed clinical practice guidelines for frontline health care professionals and patients (see Chapter 5), with staged management and stepped care referrals as needed to appropriate centers for those patients whose symptoms are not responsive.

Reaching Rural and Underserved Populations

Given the currently limited number of programs in orofacial pain and other specialties related to TMDs, patients from rural areas and in

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
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underserved populations may have difficulty accessing specialty care. Improved telehealth options may be one solution for reaching patients who do not have easy access to specialists. Evidence regarding the effectiveness of telehealth programs, including for behavioral health consultations, is growing (Shigekawa et al., 2018). Telehealth offers opportunities to improve TMD care by improving access to care for patients in rural areas or for those who have trouble with transportation, by providing expanded opportunities for patient education and coaching in self-management, and by providing opportunities for dentists and other health care professionals to consult with specialists.

Creating centers of excellence for TMDs would be one way to help reduce barriers to care for TMD patients in rural and underserved populations. Although these patients would be unlikely to be able to visit a center in person, the centers of excellence network could improve care through:

  • Offering telehealth consultations to clinicians who do not have the specialized expertise to treat their TMD patients,
  • Offering telehealth consultations directly to patients,
  • Helping to develop clinical practice guidelines and standards of care that can be disseminated to health care professionals across the country, and
  • Offering distance continuing education opportunities so that health care professionals can bring TMD expertise back into their communities.

An additional way in which centers of excellence could improve the care of rural and underserved populations could be by implementing a program such as Project ECHO, which was initially created to improve treatment of patients with hepatitis C in New Mexico. Project ECHO uses technology to connect groups of community health care professionals with specialists at different centers in real-time collaborative sessions. Rather than using the traditional model of telemedicine, in which a specialist assumes the care of a distant patient, Project ECHO helps local health care professionals gain the skills and knowledge necessary to provide care to local patients (Project ECHO, 2019). Centers of excellence in TMDs and orofacial pain could implement this type of program to reach and educate health care professionals around the country to reach patients who may have difficulty accessing care.

Conclusions on Specialty Care

Conclusion 6-5: Even many dental specialists (e.g., oral and maxillofacial surgeons) do not receive broad, comprehensive

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
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education and training in diagnosing, treating, and managing temporomandibular disorders (TMDs). Improved post-graduate training opportunities are needed, including specializations specific to TMDs and orofacial pain.

Conclusion 6-6: Central resources are needed to provide interdisciplinary care to patients with temporomandibular disorders (TMDs), to gather and disseminate information about best practices for TMDs, and to coordinate research priorities. Centers of excellence have proven to be successful for other diseases and disorders in improving care, and a similar model could be effective for improving TMD care.

IMPROVING PAYMENT AND COVERAGE

Paying for care for TMDs can be difficult and complex. Patients may see a variety of clinicians in the pursuit of treatment, including dentists, physicians, physical therapists, and more, and each of these health care professionals may or may not be covered under the patient’s insurance plan. Furthermore, different treatments for TMDs—from massage to intraoral appliances to surgery—may or may not be covered. Some of the patients who talked with the committee reported extensive bills for TMD care that they had to pay out of pocket with no reimbursement, into the thousands of dollars. When the patient’s TMD condition is caused or exacerbated by an accident or by medical malpractice, navigating the legal system in order to receive compensation can be challenging and may result in less than ideal care. As an illustration of this problem faced by many patients, one prominent national dental plan considers intraoral appliances for the treatment of TMDs to be medical care and therefore not covered, but the Centers for Medicare & Medicaid Services considers intraoral appliances for TMDs to be dental care and therefore not covered (UHC, 2019).

Insurance Coverage

Unlike the case with most medical conditions, coverages for TMD care vary widely by state and by insurance provider. The principal reason for this is the position that TMDs occupy on the medical–dental divide. The TMJ and its disorders are considered by many health insurers to be part of the structures supporting teeth and therefore excluded from medical coverage; in contrast, treatments for TMDs such as physiotherapy, cognitive-behavioral therapies, or injections are performed by non-dentists and therefore considered outside of the scope of coverage for most dental insurance plans. In addition, there is little professional consensus on which

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
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treatments are useful for TMDs, and some common treatments may even be harmful (see Chapter 5). Ideally, insurance would not cover treatments that are ineffective or harmful and would incentivize patients and clinicians to choose effective treatments. However, the lack of consensus on the appropriate clinical care for TMDs hinders the ability of insurers to make consistent, evidence-based decisions.

One particular challenge is insurance reimbursement for low-risk, early interventions. As discussed in Chapter 5, self-management can be a successful, low-cost, early intervention that patients use to manage and improve their TMD symptoms. Self-management includes techniques such as education, cognitive-behavioral therapy, exercise, and skill building. While these are ultimately carried out by the patient, there is a need for clinician education and guidance on using this approach. However, the time that a clinician spends discussing these tools with a patient is often not considered reimbursable by insurance. Another low-risk, effective strategy for TMDs is physical therapy, but, again, payment issues can prevent patients from fully using this resource. The model for physical therapy often involves weekly visits over the course of weeks or even months. Co-pays for these visits vary, depending on insurance plan, but can range from $20 to $100 per visit, which can become a substantial barrier over repeated visits. There is a need to realign financial incentives so that patients have better access to these types of treatments.

Patients with TMDs shoulder the burden of navigating this complex system, and there are few resources available to assist them. Prior to receiving care, patients may need to communicate with their insurance providers (both dental and medical) to determine what initial visitation and testing services will be covered and what evidence needs to be collected in advance of future treatment. For patients with persistent symptoms, this process of wrangling multiple parties (medical doctors, dentists, insurers, billing departments, etc.) to prove medical necessity and pushing their claims through appeals processes can have a significant emotional and financial toll.

Medicaid

Coverage determinations for Medicaid are made on a state-by-state basis. While all states provide dental services for children under Medicaid, currently only 27 states plus the District of Columbia offer non-emergency dental care for adults (Singhal et al., 2017). Medicaid reimbursement for services is poor for both dental and medical providers, and it may be especially challenging for patients to locate a dental professional who will accept Medicaid reimbursement even in states where dental benefits are included; thus, an expansion of dental benefits to more patients in more states is not likely to solve all access problems (Singhal et al., 2017).

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
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Medicare

Medicare’s original charter includes a statutory dental exclusion that precludes payment for services involving “teeth or structures directly supporting teeth” (CMS, 2013). Medicare does, however, provide coverage for the manipulation of the occipitocervical or temporomandibular regions of the head for conditions affecting these locations.

Medicare dental coverage pays for dental services that are an integral part of a covered procedure (e.g., reconstruction of the jaw following accidental injury) (CMS, 2013). Primary and secondary services related to the teeth or the structures supporting the teeth are excluded from coverage, unless part of a covered service (such as a tumor removal) is performed at the same time and by the same dentist or physician.

Private Insurance

The coverage for TMD care offered by private insurers varies widely, although state insurance commissions can mandate that private health insurance providers that issue policies within the state cover certain procedures.3 Prior to the passage of the Patient Protection and Affordable Care Act (ACA), 20 states mandated coverage of TMDs (ADA, 2004). Under the ACA, states develop their own benchmark plans that set the bar for health plans in the state. As of 2015, 34 states have included TMDs in these plans or have determined TMDs to be an essential health benefit that must be covered (Nierman, 2015). However, the actual treatments covered by these plans vary widely.

Some states have mandates that require coverage for medically necessary procedures for the TMJ for certain types of plans, such as group health benefit plans, or for other specified situations. In contrast to Medicare, many private insurers do provide coverage for both procedural and non-procedural treatments for TMDs, including intraoral appliances, muscle relaxants, physical therapy, and, in some instances, biofeedback and cognitive-behavioral therapies (see Box 6-1).

When a health insurance company denies care for TMDs, this denial of coverage is most frequently challenged on the grounds that while TMDs are frequently treated by dentists, it should not be excluded from coverage by medical insurance because the TMJ is similar to the other joints in the body. When a person is covered by private insurance through his or her employer, this insurance is governed by the Employee Retirement Income Security Act, and the denial of coverage may be challenged in federal court.

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3 A list of state statutes related to TMD coverage can be found at http://www.tmjoints.org/policy/TMJState.htm (accessed November 13, 2019).

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
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Employees may face coverage challenges because their plans may variously define TMD treatments as medical or dental so that coverage may fall between the cracks, may impose restrictive coverage caps, or, where permitted by state law, may exclude the TMJ and TMDs entirely. In lawsuits challenging denials of coverage under employer-sponsored plans, courts have variously held treatment for TMDs to be excludable as uniquely dental,4 to raise a question of fact as to whether it is medical or dental,5 to be medi-

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4Kraut v. Wisconsin Laborers Health Fund, 992 F.2d 113 (7th Cir. 1993).

5Erker v. American Community Mut. Ins. Co., 663 F.Supp.2d 799 (D. Ne. 2009).

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
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cal or dental depending on the treatment,6 to be subject to strict coverage limitations,7 or to be entirely excludable under the authority of the plan administrators to limit covered conditions.8 The opinion of this committee is that TMDs should not be considered exclusively dental disorders.

Veterans Health Administration

The Veterans Health Administration provides health care to more than 9 million Americans, either through TRICARE for active and retired service members or CHAMPVA for certain civilians. TRICARE covers some TMD treatment but only if it is a medical issue that involves immediate relief of pain. Both CHAMPVA and TRICARE cover X-rays, up to four office visits, and construction of an intraoral appliance (VA, 2013; TRICARE, 2019).

Other Coverage and Payment Mechanisms

Federal Disability Insurance

Individuals who are disabled and unable to work because of a TMD may be eligible to receive support under either of two federal programs, Social Security Disability Insurance (SSDI; available to individuals with a certain number of work credits) or Supplemental Security Income (SSI; available to individuals with limited or no work history). Yet, claimants with a TMD may face challenges within the disability system, some of which are unique to their disorder and others that are shared with other chronic pain conditions. Under SSDI and SSI, a claimant may be eligible for benefits if he or she has a disabling condition that meets specific criteria (SSA, 2020). Individuals may apply based on one or more medical conditions listed in the Social Security Blue Book, which is the federal compendium of covered conditions and their eligibility criteria, or may apply based on non-listed conditions that are medically equivalent to listed conditions and that cause the individual to have a residual functional capacity precluding employment (SSA, 2012).

However, claimants and disability examiners alike have little guidance in how to set forth or to evaluate a disability claim grounded in a TMD

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6Boyd v. Peoria Journal Star, Inc., 679 N.E.2d 788 (Ill. App. 3d 1997) (holding that the plan could not deny coverage for surgery to remove a failed TMJ implant, as the procedure was to correct a failed device, not treat TMD itself).

7Midwest Sec. Life Ins. Co. v. Stroup, 730 N.E.2d 163 (In. 2000) (enforcing a $1,000 annual cap on TMD treatment under employer plan). See also, e.g., Solger v. Wal-Mart Stores, Inc. Associates Health and Welfare Plan, 144 F.3d 567 (8th Cir. 1998) (enforcing $5,000 coverage cap under plan for employee who required jaw surgery to remove failed TMJ implant).

8Stratton v. E.I. DuPont De Nemours & Co., 363 F.3d 250 (3d Cir. 2004).

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
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and in TMD-related chronic pain, as the same anatomical findings may be associated with very different degrees of pain across individuals. The difficulty of evaluating cases with TMDs under the present framework—and their high costs to individuals and to the administrative and federal court systems—is in part shown by federal courts’ not-infrequent reversals of TMD disability denials9 (see Box 6-2).

Medical Malpractice

Some TMDs arise due to medical malpractice—for example, improper intubation or oral surgery that results in new or exacerbated TMD symptoms or from inappropriate occlusal therapies. Court cases involving medical malpractice related to a TMD demonstrate a degree of confusion over the nature of TMDs as a medical or dental condition and even as to the existence of a standard of care for TMDs against which a malpractice claim could be evaluated. For general medicine and dentistry, courts look to the standard of care in the community where treatment was sought or provided. For medical and dental specialties, courts look to a national standard of care. In several cases, courts have held either that TMD treatment is not a specialty and thus must be evaluated based on a community standard of care or else that a triable factual dispute exists as to the appropriate standard of care.10 In at least one recent case, a state court of appeals held that there is no national standard of care for TMDs below which a treatment could fall.11

Coverage Due to Injuries and Accidents

While the majority of TMDs are not directly attributable to a traumatic incident, studies indicate that for some individuals, trauma—particularly collisions and motor vehicle accidents—is strongly associated with the subsequent development of TMDs (Sharma et al., 2019). For injuries that

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9 See, e.g., Sorber v. Commissioner of Social Security Administration, 362 F. Supp. 3d 712 (D. Az. 2019); Cindy F. v. Berryhill, 367 F. Supp. 3d 1195 (D. Or. 2019); Tilton v. Colvin, 184 F. Supp. 3d (M.D. Pa. 2016); Cumella v. Colvin, 936 F.Supp.2d 1120 (D.S.D. 2013); Lorence v. Astrue, 691 F.Supp.2d 1008 (D. Mn. 2010); Walterich v. Astrue, 578 F.Supp.2d 482 (W.D.N.Y. 2008); Bragg v. Commissioner of Social Security Admin., 567 F.Supp.2d 893 (N.D. Tx 2008).

10 See, e.g., Spivey v. James, 1 S.W.3d 380 (Ct. App. Tx. 1999) (issue of fact over who can be qualified as an expert in TMD); Burlingham v. Mintz, 891 P.2d 527 (Mo. 1995) (standard of care for TMD not established); Herpin v. Witherspoon, 664 So.2d 515 (Ct. App. La. 3d 1995) (holding that locality rule applies; TMD treatment is not a “specialty”).

11Saucier v. Hawkins, 2013 113 So.3d 1277 (Ct. App. Ms. 2013) (affirming trial court’s directed verdict for defendant on the ground that the plaintiff had not established the existence of a national standard of care for TMD, where the plaintiff’s expert outlined the existence of guidance on TMD treatment from professional organizations but testified that treatment practices vary widely).

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

are work related, workers compensation insurance provides full coverage with no deductibles in all states, as long as the causation standard is met for that jurisdiction (Melhorn et al., 2013). The relationship between whiplash resulting from motor vehicle accidents and the subsequent development of TMDs has been debated for years, with widely varying estimates of prevalence. While treatments related to motor vehicle accidents will likely be covered, most individual auto insurance policies have limits on medical payments, typically $10,000 to $20,000. Where coverage is insufficient, particularly for lost past and future earnings, individuals with a TMD may resort to the court system. In cases involving negligence, including road accidents or other traumatic injuries, plaintiffs may recover substantial damages, particularly if a TMD co-occurs with other serious injuries.12 However, judgments in numerous cases reveal confusion about TMDs and, in particular, the relationship of chronic pain to psychological disorders, with courts at times attributing the former to the latter.13

Conclusions on Insurance Coverage

Conclusion 6-7: Comprehensive insurance coverage for care of temporomandibular disorders (TMDs) is lacking. Patients must navigate coverage decisions between health and dental insurance and may be left to assume all costs. For patients with persistent TMD symptoms, this process of working with multiple parties (medical doctors, dentists, insurers, billing departments, etc.) to prove medical necessity and pushing their claims through appeals processes can have a significant emotional and financial toll. While anecdotal, the committee heard numerous communications from patients whose out-of-pocket costs for treatment of TMDs were an extreme financial burden.

Conclusion 6-8: Insurance coverage for care of temporomandibular disorders is not consistent and may not provide coverage for low-risk effective treatments (such as self-management and physical therapy), while higher-risk treatments (such as medications and surgery) are covered. Misalignment may result in patients receiving the care that is best reimbursed, rather than the care that is best.

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12 See, e.g., Desselle v. LaFleur, Court of Appeal of Louisiana, Third Circuit. February 4, 2004, 865 So.2d 954 2004 WL 205728 (affirming award of $350,000 to plaintiff who suffered back and neck injuries, and TMD, incident to automobile accident).

13 See, e.g., Torno v. Hayek, Court of Appeals of Washington, Division 3. May 25, 2006, 133 Wash.App. 244 135 P.3d 536; Commonwealth Department of Corrections v. Workers Compensation Appeals Board (Wagner-Stover), Commonwealth Court of Pennsylvania. 2010 6 A.3d 603 2010 WL 3811308.

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

CONCLUSIONS AND RESEARCH PRIORITIES

TMD care is generally fragmented between dentistry and medicine, often leaving patients to navigate among clinicians with little guidance or efforts at coordinated care. Furthermore, insurance coverage is often lacking for TMD care, leaving patients to bear significant out-of-pocket financial burdens. Efforts are needed at multiple levels to improve the training and education of health professionals on TMD care, to provide specialist certification for professionals in TMD with independent accreditation, to coordinate centers of excellence in TMD care, and to improve insurance coverage. Research to inform those efforts is also needed (see Box 6-3). The committee’s recommendations for future actions in these areas are detailed in Chapter 8.

Conclusion 6-1: Due to education, training, and financing mechanisms, there is often a lack of collaboration between clinicians, particularly dentists and physicians, and this divide can make it challenging for patients with temporomandibular disorders to access and coordinate care.

Conclusion 6-2: Health care professionals—including physicians, dentists, nurses, physician’s assistants, and physical therapists—need better education and training in the assessment, treatment, management, and referral of patients with pain, orofacial pain, and temporomandibular disorders with attention to interprofessional education opportunities where possible. The extent of training will vary depending on the specialty and the nature of the practice.

Conclusion 6-3: Some dentists continue to use harmful or costly treatment approaches that are known to be ineffective for temporomandibular disorders (TMDs). As discussed in Chapters 2 and 5, editorials and letters to the editor in dental journals suggest resistance to the less invasive but more evidence-based treatment approaches for TMDs. The reliance on aggressive or invasive treatment methods as the first step rather than starting with behavioral or rehabilitative treatments follows the decades-long adherence to structural models that have been shown to be non-intrusive conservative treatments. Education efforts, particularly basic dental education and continuing education classes for practicing dentists, need to focus on ensuring that dentists are fully informed about the complexity of pain and movement as identified for other musculoskeletal disorders and current evidence-based treatments for chronic pain in general and TMDs in particular.

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

Conclusion 6-4: Most general dentists and many specialists receive inadequate education and training in temporomandibular disorders (TMDs) and orofacial pain and this leads to inconsistent and sometimes harmful and unnecessary treatments provided to individuals with a TMD. A transformation in dental education is urgently needed to ensure that dentists receive updated, evidence-based information about the management of patients with TMD during predoctoral education, post-graduate training, and continuing education. This transformation can only be accomplished if systematic and ongoing efforts by relevant stakeholders work to ensure that improved education standards, metrics, and monitoring are developed and implemented. Commission on Dental Accreditation standards for the accreditation of predoctoral dental schools do not currently address education regarding TMDs.

Conclusion 6-5: Even many dental specialists (e.g., oral and maxillofacial surgeons) do not receive broad, comprehensive

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

education and training in diagnosing, treating, and managing temporomandibular disorders (TMDs). Improved post-graduate training opportunities are needed, including specializations specific to TMDs and orofacial pain.

Conclusion 6-6: Central resources are needed to provide interdisciplinary care to patients with temporomandibular disorders (TMDs), to gather and disseminate information about best practices for TMDs, and to coordinate research priorities. Centers of excellence have proven to be successful for other diseases and disorders in improving care, and a similar model could be effective for improving TMD care.

Conclusion 6-7: Comprehensive insurance coverage for care of temporomandibular disorders (TMDs) is lacking. Patients must navigate coverage decisions between health and dental insurance and may be left to assume all costs. For patients with persistent TMD symptoms, this process of working with multiple parties (medical doctors, dentists, insurers, billing departments, etc.) to prove medical necessity and pushing their claims through appeals processes can have a significant emotional and financial toll. While anecdotal, the committee heard numerous communications from patients whose out-of-pocket costs for treatment of TMDs were an extreme financial burden.

Conclusion 6-8: Insurance coverage for care of temporomandibular disorders is not consistent and may not provide coverage for low-risk effective treatments (such as self-management and physical therapy), while higher-risk treatments (such as medications and surgery) are covered. Misalignment may result in patients receiving the care that is best reimbursed, rather than the care that is best.

REFERENCES

AACOM (American Association of Colleges of Osteopathic Medicine). 2019. AACOM reports on curriculum. https://www.aacom.org/reports-programs-initiatives/aacom-reports/curriculum (accessed November 19, 2019).

AAMC (Association of American Medical Colleges). 2018. Interprofessional education requirements at US medical schools. https://www.aamc.org/initiatives/cir/403572/02.html (accessed November 19, 2019).

AAMC. 2019. Content documentation in required courses and elective courses. https://www.aamc.org/initiatives/cir/406462/06a.html (accessed November 19, 2019).

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
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AAOP (American Academy of Orofacial Pain). 2018. Orofacial pain programs. https://aaop.clubexpress.com/content.aspx?page_id=22&club_id=508439&module_id=107337 (accessed September 5, 2019).

AAOP. 2019. Application for recognition of orofacial pain. Submitted by the American Academy of Orofacial Pain, April 2019. https://www.ada.org/~/media/NCRDSCB/Files/Orofacial_Pain_Speciality_Application.pdf?la=en (accessed November 18, 2019).

ACGME (Accreditation Council for Graduate Medical Education). 2019. ACGME program requirements for graduate medical education in pain medicine (Subspecialty of Anesthesiology, Child Neurology, Neurology, or Physical Medicine and Rehabilitation). https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/530_Pain%20Medicine_2019.pdf?ver=2019-06-26-115917-800 (accessed November 13, 2019).

ADA (American Dental Association). 2004. TM treatment and third party insurance coverage. https://www.ada.org/~/media/ADA/Advocacy/Files/thirdparty_TMD_coverage.pdf?la=en (accessed October 10, 2019).

ADA. 2019. Workforce. https://www.ada.org/en/science-research/health-policy-institute/dental-statistics/workforce (accessed October 10, 2019).

ADEA (American Dental Education Association). 2008. Competencies for the new general dentist. https://www.adea.org/about_adea/governance/Pages/Competencies-for-the-NewGeneral-Dentist.aspx (accessed October 10, 2019).

Aetna. 2019. Temporomandibular disorders. http://www.aetna.com/cpb/medical/data/1_99/0028.html (accessed November 19, 2019).

ALS Association. 2019. ALS Association centers and clinics. http://www.alsa.org/community/centers-clinics/centers-and-clinics-descriptions.html (accessed November 18, 2019).

Anderson, R. T., C. S. Weisman, S. Hudson Scholle, J. T. Henderson, R. Oldendick, and F. Camacho. 2002. Evaluation of the quality of care in the clinical care centers of the National Centers of Excellence in Women’s Health. Women’s Health Issues 12(6):309–326.

APTA (American Physical Therapy Association). 2013. Vision statement for the physical therapy profession and guiding principles to achieve the vision. https://www.apta.org/Vision (accessed November 19, 2019).

Atchison, K. A., R. G. Rozier, and J. A. Weintraub. 2018. Integration of oral health and primary care: Communication, coordination, and referral. NAM Perspectives. Washington, DC: National Academy of Medicine.

Breckons, M., S. M. Bissett, C. Exley, V. Araujo-Soares, and J. Durham. 2017. Care pathways in persistent orofacial pain: Qualitative evidence from the DEEP study. Journal of Dental Research: Clinical and Translational Research 2(1):48–57.

Campbell, E. 2019. Faculty perspectives of teaching pain management to nursing students. Pain Management Nursing PMID:31492600.

CMS (Centers for Medicare & Medicaid Services). 2013. Medicare dental coverage. https://www.cms.gov/Medicare/Coverage/MedicareDentalCoverage/index.html (accessed October 3, 2019).

CNME (Council on Naturopathic Medical Education). 2017. Handbook of accreditation for naturopathic medicine. https://cnme.org/wp-content/uploads/2017/09/2017_cnme_handbook_of_accreditation.pdf (accessed November 18, 2019).

COCA (Commission on Osteopathic College Accreditation). 2019. Accreditation of colleges of osteopathic medicine: COM continuing accreditation standards. https://osteopathic.org/wp-content/uploads/2018/02/com-continuing-accreditation-standards.pdf (accessed October 23, 2019).

CODA (Commission on Dental Accreditation). 2017. Accreditation standards for advanced specialty education programs in oral and maxillofacial surgery. https://www.ada.org/~/media/CODA/Files/2018_oms.pdf?la=en (accessed November 19, 2019).

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

CODA. 2019. Accreditation standards for dental education programs. https://www.ada.org/~/media/CODA/Files/pde.pdf?la=en (accessed October 23, 2019).

Desai, B., N. Alkandari, and D. M. Laskin. 2016. How accurate is information about diagnosis and management of temporomandibular disorders on dentist websites? Oral Surgery, Oral Medicine, Oral Pathology, and Oral Radiology 122(3):306–309.

Elrod, J. K. and J. L. Fortenberry, Jr. 2017. Centers of excellence in healthcare institutions: What they are and how to assemble them. BMC Health Services Research 17(Suppl 1):425.

Fishman, S. M., H. M. Young, E. L. Arwood, R. Chou, K. Herr, B. B. Murinson, J. Watt-Watson, D. B. Carr, D. B. Gordon, B. J. Stevens, D. Bakerjian, J. C. Ballantyne, M. Courtenay, M. Djukic, I. J. Koebner, J. M. Mongoven, J. A. Paice, R. Prasad, N. Singh, K. A. Sluka, B. St. Marie, and S. A. Strassels. 2013. Core competencies for pain management: Results of an interprofessional consensus summit. Pain Medicine 14:971–981.

Fishman, S. M., D. B. Carr, B. Hogans, M. Cheatle, R. M. Gallagher, J. Katzman, S. Mackey, R. Polomano, A. Popescu, J. P. Rathmell, R. W. Rosenquist, D. Tauben, L. Beckett, Y. Li, J. M. Mongoven, and H. M. Young. 2018. Scope and nature of pain- and analgesia-related content of the United States Medical Licensing Examination (USMLE). Pain Medicine 19:449–459.

Greene, C. S., and A. E. Bertagna. 2019. Seeking treatment for temporomandibular disorders: What patients can expect from non-dental health care providers. Oral Surgery, Oral Medicine, Oral Pathology, and Oral Radiology 127(5):399–407.

HealthPartners. 2019. Temporomandibular disorder (TMD) treatments. https://www.healthpartners.com/public/coverage-criteria/policy.html?contentid=AENTRY_046169 (accessed November 19, 2019).

HHS (Department of Health and Human Services). 2016. National pain strategy: A comprehensive population health-level strategy for pain. https://www.iprcc.nih.gov/sites/default/files/HHSNational_Pain_Strategy_508C.pdf (accessed October 3, 2019).

Hoeger Bement, M. K., and K. A. Sluka. 2015. The current state of physical therapy pain curricula in the United States: A faculty survey. Journal of Pain 16(2):144–152.

Hoeger Bement, M. K., B. J. St. Marie, T. M. Nordstrom, N. Christensen, J. M. Mongoven, I. J. Koebner, S. M. Fishman, and K. A. Sluka. 2014. An interprofessional consensus of core competencies for prelicensure education in pain management: Curriculum application for physical therapy. Physical Therapy 94(4):451–465.

IASP (International Association for the Study of Pain). 2018. IASP curriculum outline on pain for physical therapy. https://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1580 (accessed November 19, 2019).

IOM (Institute of Medicine). 2011. Relieving pain in America: A blueprint for transforming prevention, care, education, and research. Washington, DC: The National Academies Press.

Jones, L. K., M. E. Lussier, J. Brar, M. C. Byrne, M. Durham, F. Kiokemeister, K. Kjaer, H. Le, C. Magee, E. McKnight, N. Mehta, J. Papp, E. Pastwa, P. Radovich, K. Ravin, M. Ruther, G. Woodie, S. Wrona, G. Yousefvand, and G. Greskovic. 2019. Current interventions to promote safe and appropriate pain management. American Journal of Health-System Pharmacy 76(11):829–834.

Kaiser Permanente Dental. 2019. About us. https://kaiserpermanentedentalnw.org/about-us (accessed November 19, 2019).

Klasser, G. D., and C. S. Greene. 2007. Predoctoral teaching of temporomandibular disorders: A survey of U.S. and Canadian dental schools. Journal of the American Dental Association 138(2):231–237.

Klasser, G. D., and H. A. Gremillion. 2013. Past, present, and future of predoctoral dental education in orofacial pain and TMDs: A call for interprofessional education. Journal of Dental Education 77(4):395–400.

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
×

LCME (Liaison Committee on Medical Education). 2019. Functions and structure of a medical school. https://lcme.org/wp-content/uploads/filebase/standards/2020-21_Functions-and-Structure_2019-10-04.docx (accessed November 19, 2019).

MedBullets. 2019. Temporomandibular disorders. https://step2.medbullets.com/ear-nosethroat/121832/temporomandibular-joint-disease-tmd (accessed November 19, 2019).

Melhorn, J. M., W. E. Ackerman III, L. S. Glass, D. C. Deitz, and S. Babitsky. 2013. Understanding work-relatedness. In J. M. Melhorn and J. B. Talmage, eds. AMA guides to the evaluation of disease and injury causation, 2nd ed. Chicago, IL: American Medical Association.

Mogayzel, P. J., J. Dunitz, L. C. Marrow, and L. A. Hazle. 2014. Improving chronic care delivery and outcomes: The impact of the Cystic Fibrosis Care Center Network. BMJ Quality and Safety 23(Suppl 1):i3–i8.

NAEC (National Association of Epilepsy Centers). 2019. National Association of Epilepsy Centers. https://www.naec-epilepsy.org (accessed November 18, 2019).

Nierman, R. 2015. Does new legislation mandate TMJ treatments in your state? https://dentalsleeppractice.com/practice-management/roses-reimbursement-rules (accessed November 18, 2019).

Powers, B., R. B. Donoff, and S. H. Jain. 2017. Bridging the dental divide: Overcoming barriers to integrating oral health and primary care. https://www.healthaffairs.org/do/10.1377/hblog20170119.058211/full (accessed November 19, 2019).

Prodoehl, J., S. Kraus, G. D. Klasser, and K. D. Hall. 2019. Temporomandibular disorder content in the curricula of physical therapist professional programs in the United States. Cranio January 4:1–13.

Project ECHO. 2019. How it works. https://echo.unm.edu (accessed November 18, 2019).

Sharma, S., J. Wactawski-Wende, M. LaMonte, J. Zhao, G. D. Slade, E. Bair, J. D. Greenspan, R. B. Fillingim, W. Maixner, and R. Ohrbach. 2019. Incident injury is strongly associated with subsequent incident temporomandibular disorder: Results from the OPPERA study. Pain 160(7):1551–1561.

Shigekawa, E., M. Fix, G. Corbett, D. H. Roby, and J. Coffman. 2018. The current state of telehealth evidence: A rapid review. Health Affairs 37(12):1975–1982.

Singhal, A., P. Damiano, and L. Sabik. 2017. Medicaid adult dental benefits increase use of dental care, but expansion of dental services use was mixed. Health Affairs 36(4):723–732.

SSA (Social Security Administration). 2012. Residual functional capacity. https://www.ssa.gov/OP_Home/cfr20/416/416-0945.htm (accessed November 19, 2019).

SSA. 2020. Disability evaluation under Social Security. https://www.ssa.gov/disability/professionals/bluebook/general-info.htm (accessed January 29, 2020).

TRICARE. 2019. Temporomandibular joint syndrome treatment. https://tricare.mil/CoveredServices/IsItCovered/TempMandJoint?p= (accessed October 14, 2019).

UHC (UnitedHealthcare). 2019. Occlusal guards. https://www.uhcprovider.com/content/provider/en/viewer.html?file=%2Fcontent%2Fdam%2Fprovider%2Fdocs%2Fpublic%2Fpolicies%2Fdental%2Focclusal-guards.pdf (accessed November 19, 2019).

UHC. 2020. Temporomandibular joint disorders. https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/temporomandibular-joint-disorders.pdf (accessed January 27, 2020).

University of Washington School of Dentistry. 2019. Clinical competencies. https://dental.washington.edu/policies/clinic-policy-manual/clinical-competencies (accessed October 14, 2019).

VA (Department of Veterans Affairs). 2013. Temporomandibular joint disorder. https://www.vha.cc.va.gov/system/templates/selfservice/va_ssnew/help/customer/locale/en-US/portal/554400000001036/content/554400000009176/020502-TEMPOROMANDIBULARJOINT-DISORDER-TMD (accessed November 19, 2019).

Suggested Citation:"6 Improving TMD Health Care: Practice, Education, Access, and Coverage." National Academies of Sciences, Engineering, and Medicine. 2020. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. doi: 10.17226/25652.
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Temporomandibular disorders (TMDs), are a set of more than 30 health disorders associated with both the temporomandibular joints and the muscles and tissues of the jaw. TMDs have a range of causes and often co-occur with a number of overlapping medical conditions, including headaches, fibromyalgia, back pain and irritable bowel syndrome. TMDs can be transient or long-lasting and may be associated with problems that range from an occasional click of the jaw to severe chronic pain involving the entire orofacial region. Everyday activities, including eating and talking, are often difficult for people with TMDs, and many of them suffer with severe chronic pain due to this condition. Common social activities that most people take for granted, such as smiling, laughing, and kissing, can become unbearable. This dysfunction and pain, and its associated suffering, take a terrible toll on affected individuals, their families, and their friends. Individuals with TMDs often feel stigmatized and invalidated in their experiences by their family, friends, and, often, the health care community. Misjudgments and a failure to understand the nature and depths of TMDs can have severe consequences - more pain and more suffering - for individuals, their families and our society.

Temporomandibular Disorders: Priorities for Research and Care calls on a number of stakeholders - across medicine, dentistry, and other fields - to improve the health and well-being of individuals with a TMD. This report addresses the current state of knowledge regarding TMD research, education and training, safety and efficacy of clinical treatments of TMDs, and burden and costs associated with TMDs. The recommendations of Temporomandibular Disorders focus on the actions that many organizations and agencies should take to improve TMD research and care and improve the overall health and well-being of individuals with a TMD.

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