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6 Improving TMD Health Care: Practice, Education, Access, and Coverage
Pages 255-296

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From page 255...
... -­ elated r 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.
From page 256...
... 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.
From page 257...
... Psychiatrist Ophthalmologist (cauterizing tear ducts Nutritionist due to nerve damage to eyes, which Physical therapist resulted from temporomandibular joint Naturopath surgery) Acupuncturist Pharmacist Osteopathic physician Alternative medicine specialist Patient C Orthopedic surgeon Primary care physician Chiropractor Orthodontist Massage therapist Oral and maxillofacial surgeon Immunologist Patient G Pain management physician Oral and maxillofacial surgeon Oral and maxillofacial surgeon Medical device company Oral and maxillofacial surgeon Patient D Orthodontist Primary care physician Primary care physician Oral and maxillofacial surgeon Orthopedic surgeon Patient H Various specialists Dentist Physiotherapist Oral and maxillofacial surgeon Primary care physician Patient E Emergency medical technician Dentist Allergist Primary care physician Myofascial and precision neuromuscular Neurologist massage therapist Ear, nose, and throat specialist Chiropractor SOURCE: Public comments to the committee.
From page 258...
... 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.
From page 259...
... Some patients with a TMD e 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.
From page 260...
... . Beginning collaboration early, with interprofessional education during professional school, is essential in foster­ ing understandings between the professions and respect for the roles of other health care professionals (Klasser and Gremillion, 2013)
From page 261...
... , 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.
From page 262...
... 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.
From page 263...
... 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.
From page 264...
... . However, an evaluation of the scope and nature of pain-related questions on the USMLE, which may be similar to TMDrelated 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)
From page 265...
... 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.
From page 266...
... 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.
From page 267...
... competencies for the new general dentist, which state that dental school graduates must be competent to "prevent, diagnose, and manage temporomandibular disorders" (ADEA, 2008)
From page 268...
... 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.
From page 269...
... 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.
From page 270...
... 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.
From page 271...
... 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.
From page 272...
... 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.
From page 273...
... 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.
From page 274...
... 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.
From page 275...
... 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.
From page 276...
... 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)
From page 277...
... . 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 ­ rofessionals, p 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)
From page 278...
... 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.
From page 279...
... 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 spe cialists 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 cli nicians 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 continu ing education, for a range of health and human services professionals.
From page 280...
... 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.
From page 281...
... 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.
From page 282...
... 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.
From page 283...
... 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.
From page 284...
... 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 nonprocedural treatments for TMDs, including intraoral appliances, muscle relaxants, physical therapy, and, in some instances, biofeedback and cognitive-behavioral therapies (see Box 6-1)
From page 285...
... , oral appliances used to directly treat temporomandibular disorders (TMDs) , behavior modification/stress management, diagnostic imaging, and injections.
From page 286...
... . 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)
From page 287...
... 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)
From page 288...
... may either attempt to demonstrate that their TMD symp toms meet the criteria of listed conditions or, alternatively, that their pain and other impairments are medically equivalent to a listed condition and that they lack the residual functional capacity to be employed. Where the primary disabling symp tom is severe chronic pain, a claimant with a TMD must pursue the second path, as chronic pain is specifically excluded from listed conditions.
From page 289...
... 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.
From page 290...
... Conclusion 6-1: Due to education, training, and financing mecha nisms, 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 a ­ ccess 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.
From page 291...
... Conclusion 6-4: Most general dentists and many specialists re ceive 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.
From page 292...
... 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)
From page 293...
... 2013. Vision statement for the physical therapy profession and guiding principles to achieve the vision.
From page 294...
... 2014. An interprofessional consensus of core competencies for prelicensure education in pain management: Curriculum applica tion for physical therapy.
From page 295...
... 2019. Temporomandibular disorders.


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