Sometimes it is interesting and perhaps insightful to step back and relook at our history, appreciate our present, and develop some thoughts regarding our future. Here is one person's perspective of just that.
Considerations of Our Past
In 1934, an otolaryngologist by the name of James Costen brought dentistry into the field of temporomandibular disorders (TMD) with a very mechanistic view that loss of vertical dimension could create pain
in the masticatory structures. Since dentistry is a very mechanistic profession, the concept made sense to us.
In fact, this relationship was reinforced when dental therapies seemed to have a positive effect on reducing patients’ symptoms. Our mentors taught us the precise nature of occlusion and suggested to us that following these concepts would resolve all of our patients' problems. When the pain problem was not resolving, we were told that we were not doing it correctly, try harder; “It always works for me.” The teaching style was not based on science but instead on mentorship. Many were not satisfied with this approach, and so we began investigate alternative answers to TMD. We started to recognize that occlusion, although sometimes an important part of TMD, does not represent the entire picture. We then began to explore other possible issues such as
psychological stress, trauma, and parafunctional activities. We also became enthralled with dysfunctional mechanics of the temporomandibular joint (TMJ) itself. As we moved in this direction, some felt we had left occlusion behind, and so academic battles began between the occlusally supportive groups and non-occlusal supportive groups.
As we matured in the field, we began to appreciate that pain in the masticatory structures could originate from either arthrogenous or myogenous sources or both. So we developed the term TMD to include all of these. We soon began to appreciate that TMD represented only one group of pain conditions that our patients can experience in the oral and facial structures. The field of orofacial pain became recognized as a very broad and complex area encompassing all pain conditions felt in the face and head. TMD is only one subcategory of orofacial pain. Our profession had moved from a mechanistic model, which was under the control of the clinician, to a massive and complicated field almost impossible to control. Many did not like or did not want to acknowledge what had happened. However with this knowledge came new challenges with the ultimate goal of reducing our patients' suffering.
Considerations of Our Present
Presently, we are beginning to offer care to a population of people who have not been well served in the past. We are establishing the foundation for a new specialty in dentistry. Yet, organized dentistry is resisting this concept. We have on several occasions applied to the American Dental Association for consideration of specialty status, only to be turned down. On one occasion, the only criterion we failed to meet was the public need for this specialty. That is most interesting since epidemiologic studies clearly demonstrate that a significant number of patients in the general population are suffering with orofacial pain problems.
Some dental colleagues have suggested that we do not need an orofacial pain specialty because TMD is already being addressed in the existing specialties of prosthodontics, orthodontics, and oral surgery. How-ever, when one reviews the accreditation standards in these specialties, it is clear that diagnosis and management of TMD is a very minor part and may be only discussed in its relationship to that particular specialty (in fact, in some programs, it is not even discussed). It is worthy to note that the subject of orofacial pain disorders get almost
no attention.
Perhaps some of the resistance in establishing an orofacial pain specialty comes from poor communication with our colleagues about the nature and role of this specialty. Presently, general practitioners, prosthodontists, orthodontists, and oral surgeons all manage TMD problems. With all these professionals treating TMD, why do we need a specialty? I think the answer lies in how we are treating our patients. Certainly acute TMD patients can be managed well with simple education and minimum reversible care. Most knowledgeable practitioners can provide this type of care, and I believe it is their right and privilege to do so. An orofacial pain specialty should not take these patients from these practitioners. Yet, in the past it has been common to find that individual specialists often routinely offer their TMD patients their specialty treatment. All TMD patients do not benefit from prosthodontics or orthodontics or surgical procedures. Therefore, each specialist needs to be knowledgeable regarding when his or her special dental training may be useful for a TMD problem and when it is not. A specialty of orofacial pain would offer clinicians options to help determine when dental changes would be useful for a TMD patient. Also, an orofacial pain specialist would certainly assist the clinician who either does not feel comfortable treating these patients, or who needs help with patients who are not appropriately responding to therapy. Endodontics is a perfect example of this model. All general practitioners can preform endodontic procedures, and many do. However, when a clinician elects not to perform these procedures, or when difficult cases present, referral to the endodontist is an appropriate option.
There are likely other reasons for the resistance to an orofacial pain specialty. Presently, the clinicians who primarily manage TMD and orofacial pain disorders offer a wide variety of treatments for their patients. This diversity is quite different than in other existing specialties. Some of our therapies are derived from sound evidence-based science and others are not. This leads to a professional community of significant diversity, exposing our patients to a great variety of treatments from simple to very complex; from conservative to aggressive; and from inexpensive to very expensive. How can we explain this to our colleagues, our patients and the public? Perhaps one reason for this diversity lies in the fact that the field of TMD and orofacial pain is very complex consisting of multiple disorders and etiologies. The days of calling this TMJ must end, so we can advance to a higher level of helping our patients. Labeling these problems as TMJ suggests this to be one single problem which implies a single solution. This thought process greatly limits our ability to help our patients. TMD is a group of musculoskeletal disorders of the masticatory system. In fact most of the disorders have little to do with the actual function of the temporomandibular joints. A review the data collected from more than 4500 consecutive orofacial pain patients at the University of Kentucky Orofacial Pain Center reveals that 46.5% of the patients had a muscle pain disorder as their primary diagnosis. Only 25.4% of the patients had a primary diagnosis of a joint pain disorder. Muscle pain is nearly twice as common as joint pain, and yet, many continue to call these disorders TMJ problems when in fact the TMJs are not the source of the problem. The astute clinician realizes that the etiology, pathology, and management of muscle pain is quite different than that of joint pain, and therefore, we must be able to separate these disorders to select appropriate treatment. This process is referred to as differential diagnosis and is the most critical task needed to achieve success. I am always very troubled to learn that in some offices the same treatment is offered to all of their TMJ patients, since this denotes to me a very naïve approach to a multifactorial pain problem and one that will often lead to treatment failure. The key to helping our patients is for us to gain a better understanding of the many different types of orofacial pain problems, so that we can differentially diagnose the patient's precise disorder. Once this has been accomplished, we can then select the proper treatment that will predictably help the patient. I do not believe at this time we need additional treatments, although that seems to be where much attention is focused. I think we need a better way to diagnose the problem, so we can apply the correct treatment to the correct patient at the correct time.
Considerations of Our Future
I believe the greatest challenge the orofacial pain community faces in the future is education. We need to better educate ourselves to the nature of the problems we are attempting to manage. We need to center our education on evidence-based research, so that we do not over or under manage our patients. We need to educate our dental colleagues to the role of an orofacial pain speciality in the profession. We also need to educate our medical colleagues to this field since many orofacial pain conditions span into the medical arena. And, we also need to better educate our patients regarding the nature of their conditions.
Our broadest and most significant educational task needs to begin with better educating the general dentist in diagnosing and management of TMD. I think this must begin in the dental schools. A recent publication1 reports that there has been significant progress in dental education over the last 30 years with a greater number of dental schools more formally teaching TMD. Dental schools now need to continue to improve the quality of their TMD educational programs. The Commission on Change and Innovation for the American Dental Education Association is presently recommending a new competency for TMD which emphasizes the need to teach basic TMD in our educational systems. This certainly will help. In the future, the well-trained general dentist should be able to diagnose and manage uncomplicated TMD. If the practitioner determines the condition is not best managed in his or her office or if the patient's diagnosis is unclear, the patient should be referred to the appropriate orofacial pain specialist. This is precisely what is done in the practice of medicine and in several areas of dentistry.
In the future, we also need to educate competent practitioners not only in the field of TMD but also in the broader area of orofacial pain. There are many conditions that produce pain in the orofacial structures that are not TMD. These conditions must be identified so that treatment can be appropriately selected. In fact, 28.1% of the patients who present to the University of Kentucky Orofacial Pain Center have an orofacial pain disorder that is not TMD. Conditions such as neuropathic pain, including nonodontogenic toothache and neurovascular pain are the most common. It is very important that we recognize these disorders, so they are not mismanaged as TMD.
Unfortunately, orofacial pain disorders are not presently taught well in dental schools, current specialty programs, or within the practicing dental profession. This training needs to occur at the graduate training level similar to the other established dental specialties. The profession is moving in that direction now with 11 Universities in the United States and Canada offering formal fulltime graduate training programs in orofacial pain.1 These programs are training individuals to understand the complex nature of pain and how to manage chronic, nonresponding TMD and other orofacial pain disorders. These specially trained individuals are not only needed in the dental profession, but they will help link our profession with the other health professionals who manage pain. In the future, I would like to think that each dental community would have access to trained orofacial pain practitioners to assist in the diagnosis and management of complex pain disorders.
Establishing an orofacial pain specialty does not take the management of routine TMD out of the hands of the general dentist nor the dental specialist. Instead, it opens an option for all practitioners to better care for their patients. We must constantly remind ourselves that we are health care professionals. We have been given the privilege of providing care for our patients' in need of our expertise. We are ethically and morally obligated to provide the best possible care for our patients. Providing the best care begins with acquiring the knowledge needed to make the correct decisions for our patients. Patients depend on us for this, for they do not have the data needed to select their best treatment. We always need to remember to treat our patients as we would want to be treated. Follow the Golden Rule. Select the most appropriate treatment for the patient's condition. When several options are available, choose the least aggressive, most conservative with the best cost/risk benefit. That is how you would want to be treated. If you are unsure of the condition, refer the patient to the appropriate health care professional. Do not extend treatment just because that is all you know to do. When new therapies are brought to you, ask for the supporting data. Do not just accept what a lecturer presents, because it is easy or because it is profitable. Understand the scientific merit of your therapy. And always remember, do what is best for your patient, not what is best for your practice. If you do this, your practice will flourish.
Jeffrey P. Okeson, D.M.D.
Chair, Department of Oral Health Science
Director, Orofacial Pain Program
University of Kentucky College of Dentistry
Lexington, Kentucky
References
1. Klasser GD, Greene CS: Predoctoral teaching of temporomandibular disorders: a survey of U.S. and Canadian dental schools. J Am Dent Assoc 2007; 138:231-237.
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