Jaw Disorders Are Common, But Care Is Fragmented and Evidence-Based Approaches Are Needed, Says New Report

WASHINGTON – Although less invasive and more evidence-based approaches are available for temporomandibular disorders (TMDs) some dentists continue to rely on aggressive or costly procedures as a first-line treatment, says a new report from the National Academies of Sciences, Engineering, and Medicine. To avoid harmful and unnecessary treatments and improve patient care, professional societies, including the American Dental Association (ADA), should develop TMD clinical practice guidelines to inform diagnosis, treatment, and referral strategies for patients.

An individual may have more than one TMD and may also have overlapping conditions, such as migraines, fibromyalgia, and other forms of widespread pain. Because TMDs have varying causes (injury, genetics, and environmental factors), affect different body systems, and pose different health and quality of life issues, care can involve multiple disciplines. These include primary care, dentistry, physical therapy, chiropractic care, behavioral health, and clinical psychology.

In addition to the development of clinical practice guidelines, the report recommends creating an ADA-recognized dental specialty in TMDs and orofacial pain; improving reimbursement for TMD care; establishing a TMD patient registry; and coordinating TMD research efforts through a new National Collaborative Research Consortium for TMDs led by NIH. The report also offers strategies to overcome the lack of coordination between dentistry and medicine in TMD care, noting that every year, 108 million Americans visit a physician but not a dentist – which represents an opportunity to ask patients about oral health concerns.

 Creating a Dental Specialty in TMDs

The ADA should recognize TMDs and orofacial pain as a dental specialty, the report recommends. This would help increase access to qualified professionals and ensure patients receive the most appropriate care, rather than resorting to what is most readily available or easily reimbursed.

Currently, there is no certified specialty for TMDs in either dentistry or medicine. Patients report they are often “shuttled” between multiple professionals, and even abandoned with no referral options when their treatment did not work.

 Improving Reimbursement

The reimbursement mechanisms for dental and medical care are generally separate in the United States, which makes coordinated care difficult. One potential solution is to integrate dental and medical practices within the same health care system or cover them under a single insurance program instead of separate ones, says the report.

In addition, the report recommends that the Centers for Medicare & Medicaid Services’ Innovation Center explore new TMD care delivery and payment models for Medicare, Medicaid, and the Children’s Health Insurance Program, and the Social Security Administration should explore ways to support access to disability benefits for people with TMDs, in parity with other similar conditions.

Strengthening Education and Training

Dentists and physicians are likely to focus on the body systems and symptoms of TMDs that relate to their specialty, rather than viewing the TMD condition and the patient in a holistic, integrated manner.

Schools of health professions (medicine, dentistry, nursing, physical therapy, and other areas) should include the assessment, management, and referral of TMDs in their curriculum. Health professional licensing organizations should also increase the number and quality of questions about TMDs on exams, the report says. In addition, professional associations should expand clinical rotation and fellowship opportunities in orofacial pain and TMD care.

Establishing Centers of Excellence

Currently, there are 12 post-graduate fellowship programs in orofacial pain in the U.S., the report says. One of these programs could serve as a pilot site for a “Center of Excellence for TMDs and Orofacial Pain,” by providing continuing education and training for health professionals and disseminating best practices. Centers of Excellence could also reduce barriers to care for TMD patients in rural areas by offering, for example, telehealth consultations to clinicians who do not have specialized expertise in TMDs, or telehealth visits directly to patients.

Advancing Research on TMDs

In FY 2018, NIH reported funding approximately $605 million within the category of “pain research” and $474 million within the category of “chronic pain” — compared with just over $14 million for TMDs. NIH should incorporate TMD research into NIH-wide initiatives, including the NIH Pain Consortium, and coordinate TMD research across the multiple NIH institutes and centers relevant to this field.

The report also calls for the establishment of a National Collaborative Research Consortium for TMDs, led by the NIH Office of the Director and the National Institute of Dental and Craniofacial Research, to coordinate, fund, and translate basic and clinical research. It identified a number of research priorities, including:

 Basic research focused on improving clinical outcomes

• Sex differences in TMDs and orofacial pain
• Population-based research to further understand the burden and costs of TMDs
• Comparative effectiveness research on TMD treatments

Artificial intelligence and novel data approaches

The study — undertaken by the Committee on Temporomandibular Disorders (TMDs): From Research Discoveries to Clinical Treatment — was sponsored by the Office of the Director of the National Institutes of Health and by the National Institute of Dental and Craniofacial Research.