National Academies Press: OpenBook

Temporomandibular Disorders: Priorities for Research and Care (2020)

Chapter: 8 Next Steps and Recommendations

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Suggested Citation:"8 Next Steps and Recommendations." 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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8

Next Steps and Recommendations

Living with TMD has been a roller coaster for me…. Forming words can be difficult, as can drinking from a glass without a straw due to lack of muscle control inside of my mouth. Eating can be difficult, which is made worse by a lack of taste that was apparently damaged in my six surgeries.

—Lynne P.

We need to know what causes TMD, why it is more prominent in women, how to treat it, and long-term effects from current treatments out there. We need better treatment options. We need you to listen to the patients. We need your help. This is a very complex condition that needs medical experts from numerous specialties not just dentistry and oral facial pain medicine.

—Heather

Action is urgently needed to improve care for individuals with a temporomandibular disorder (TMD). Too long compartmentalized as a dental issue, both the clinical management of and the research addressing TMDs need to implement a holistic and multidisciplinary approach. Individuals with TMD symptoms often encounter health professionals (across medicine, dentistry, and beyond) that are unfamiliar with TMDs and do not know where best to refer patients for further diagnosis and treatment. The gaps and divides between medical and dental care are currently vast in the United States (IOM, 2011; Mertz, 2016) and, as a result, patients can get lost between the two systems or not receive the multidisciplinary care

Suggested Citation:"8 Next Steps and Recommendations." 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.
×

they need. Evidence-based clinical practice guidelines for TMD care are needed as well as efforts to enhance accessibility to high-quality, patient-centered care.

Because TMDs represent a grouping of varied disorders—with diverse etiologies, symptoms, and treatments—rather than a single disorder, health professionals and researchers need to focus on learning more about individual TMDs (e.g., myalgia, disc disorders, arthralgia) and on the specific treatments for each. Much of TMD research is siloed and simultaneously fragmented across niche areas of dentistry or medicine and needs a coordinated approach focused on patient-centered and clinically meaningful outcomes.

The committee worked to review the scientific literature; to seek information from patients and their family members, researchers, clinicians, policy makers, research funders, and others; to analyze the data; and to develop its conclusions and recommendations. The recommendations in this chapter focus on the actions that many organizations and agencies should take to improve TMD research and care. The committee also emphasizes the critical role that individuals with a TMD and their family members have played—and hopefully will continue to play—in bringing TMD issues to the attention of policy makers and health professionals and moving the research and care agenda forward on multiple levels in the public and private sectors. These efforts are to be commended and are encouraged to continue and expand. It is the committee’s hope that increased opportunities will be available for individuals with a TMD and their family members to engage in these important efforts to improve the state of TMD research and care. Specifically, it is hoped that individuals with a TMD and their families will be able to partner with their health care professionals to find the best options for care, to continue to actively participate in patient support networks, to explore ways to be a participating voice in research efforts (such as serving as a patient representative in research design), and to be active advocates for improvements in care and services for themselves, their family members, and other people with a TMD.

The goals of the following recommendations are to build a strong base of knowledge about TMDs and to facilitate actions needed to improve the overall health and well-being of individuals with a TMD. Some of these recommendations can be accomplished rapidly with actions by key decision makers. Other recommendations are more aspirational and will require the collaboration and commitment of multiple organizations and dedicated resources—including investments of time, funds, and innovative energies—to accomplish these goals. The committee has provided both short-term and longer-term priorities to be used as starting points and long-range planning points. Key to making a difference in improving care for individuals with a TMD will be:

Suggested Citation:"8 Next Steps and Recommendations." 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.
×
  • pioneering pathways that span medicine, dentistry, physical therapy, and other fields of health care to provide holistic, comprehensive approaches to care—interprofessional and interdisciplinary efforts are of critical importance;
  • willingness of health care agencies, organizations, and professionals to commit the resources needed to address this long-neglected and often dismissed area of health care; and
  • openness and commitment to using and strengthening the evidence base on TMD treatment and changing practice as needed.

BUILD AND SUSTAIN COLLABORATIVE AND MULTIDISCIPLINARY RESEARCH

Engagement by multiple stakeholders will be required to dismantle the siloes keeping research fields isolated and to advance TMD research and care. It will be necessary to apply innovative research models and theory-based research designs to the challenges of TMDs. Patients, dentists, physicians, and other health professionals must be involved in advancing research. The committee recommends that a research consortium be established to bring together relevant National Institutes of Health (NIH) institutes and centers and other stakeholders from the public and private sectors to focus future research efforts on filling key evidence gaps in TMD research and care and to ensure that clinically meaningful, patient-centered outcomes are prioritized. The committee stresses the importance of an organized research approach for TMDs, but the mechanism to carry this out should be flexible (i.e., if not an NIH-led consortium, another trusted leader in the field could organize a research network with the goals outlined in Recommendation 1).

Fresh ideas and multiple disciplines are needed to advance TMD research to improve patient care. NIH provides approximately one-third of all biomedical research funding in the United States (IOM, 2011) and therefore, the interests and priorities of NIH institutes and centers can stimulate research interests and training programs throughout the country. TMDs are not the primary mission of any NIH center or institute. NIH funding for TMD research falls largely within the National Institute of Dental and Craniofacial Research (NIDCR) (which has one of the smallest research budgets of the NIH institutes) with a total budget of approximately $461 million compared to the National Cancer Institute’s $5.99 billion for fiscal year 2019 (NIH, 2020). Given the number of individuals suffering from TMDs, the severity of some of the disorders, and the substantial public health burden of TMDs, there is a significant opportunity for NIH and other biomedical research institutions to drive increased funding to TMDs in order to spark new research interest and discoveries. Efforts are

Suggested Citation:"8 Next Steps and Recommendations." 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.
×

needed to ensure that TMD research is incorporated into NIH-wide initiatives, including the NIH Pain Consortium. Furthermore, as noted in Public Law 116-94, an NIH inter-institute working group is being called on to focus on coordinating TMD research across the multiple NIH institutes and centers relevant to this field (see Recommendation 1 for details).

Recommendation 1: Create and Sustain a National Collaborative Research Consortium for Temporomandibular Disorders (TMDs)

A National Collaborative Research Consortium for TMDs should be established and sustained to coordinate, fund, and translate basic and clinical research (including behavioral, population-based, and implementation research) to address evidence gaps, generate clinically meaningful knowledge, identify safe and effective treatments, and improve the quality of TMD care.

The consortium would:

  • Establish and implement a national research framework for TMDs;
  • Provide infrastructure for the implementation of research projects;
  • Establish milestones and timelines;
  • Facilitate research collaborations;
  • Develop public–private partnerships;
  • Develop and test evidence-based strategies for knowledge transfer;
  • Support the development of a multidisciplinary research workforce for TMDs through existing and new training and center initiatives; and
  • Evaluate progress and disseminate research findings.

Near-term implementation actions:

  • The National Institutes of Health (NIH) Office of the Director and the National Institute of Dental and Craniofacial Research should lead an effort to establish the National Collaborative Research Consortium for TMDs by convening relevant stakeholders and research funders (including but not limited to the Agency for Healthcare Research and Quality [AHRQ], the NIH Pain Consortium, the Patient-Centered Outcomes Research Institute, the Health Resources and Services Administration, the Centers for Medicare & Medicaid Services, the Centers for Disease Control and Prevention, the Department of Defense [DoD], the Department of Veterans Affairs [VA], and relevant NIH institutes including the National Institute of Neurological Disorders and Stroke, the National Institute of Mental Health, the National Institute of Arthritis and Musculoskeletal
Suggested Citation:"8 Next Steps and Recommendations." 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.
×

and Skin Diseases, the National Center for Complementary and Integrative Health, the National Institute of Biomedical Imaging and Bioengineering, the National Institute of Nursing Research, NIH Office of Nutrition Research, NIH Office of Research on Women’s Health, NIH Office of Behavioral and Social Sciences Research, TMJ Patient-Led RoundTable, Chronic Pain Research Alliance, The TMJ Association, academic research centers, research foundations, private-sector research funders, professional health care associations, private and public insurers, and patient advocacy organizations) to:

  • Determine the governing structure (including the vision and mission statement) and strategic plan;
  • Design and implement a national research framework for TMDs that would establish short- and long-term research priorities and cultivate multidisciplinary research focused on the needs of the patient; and
  • Conduct an annual symposium to explore promising research directions, methods, and tools for TMD research and to foster multidisciplinary, and possibly international, collaborations.

Medium- to long-term implementation actions:

  • Once established, the National Collaborative Research Consortium for TMDs should implement the research framework by synchronizing and guiding research efforts across stakeholders and research areas;
  • Encourage and incentivize multidisciplinary collaborations;
  • Leverage funding resources to address research priorities that may overlap with and be part of larger research initiatives (e.g., HEAL initiative);
  • Develop public–private partnerships across relevant disciplines, especially medicine and dentistry, to support research on TMDs;
  • Disseminate research findings and implement evidence-based strategies for knowledge translation from research to clinical and public health practice and policy; and
  • Set priorities and direct funds to support multidisciplinary research training and workforce development in the TMD field using existing NIH and other funding mechanisms.

Recommendation 2: Strengthen Basic Research and Translational Efforts

The National Collaborative Research Consortium for temporomandibular disorders (TMDs) along with other funders should fund

Suggested Citation:"8 Next Steps and Recommendations." 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.
×

basic research efforts and ensure its translation as part of a patient-focused, multidisciplinary research agenda on TMDs to address evidence gaps, generate clinically meaningful knowledge, identify effective treatments, and improve quality of care. Research priorities should include:

  • Biopsychosocial mechanisms related to the development of tissue dysfunction and pain generation, maintenance, and suppression across TMDs and patient groups;
  • Basic and translational behavioral and social sciences;
  • Factors that promote risk for symptom induction;
  • Sex differences related to tissue dysfunction and pain generation, maintenance, and suppression across TMDs and patient groups;
  • Biomarkers and predictive factors for diagnosis, prognosis, response to treatment, and resilience;
  • Neuroimmune mechanisms in etiology, progression, and treatment;
  • Neuroendocrine system interactions and stress-induced mechanisms in the progression of a specific TMD;
  • Shared biopsychosocial mechanisms of TMDs and comorbid conditions;
  • Integrative research to understand how risk factors interact and how clinical, psychological, and genetic factors confer different levels of TMD risk in different groups of individuals;
  • Biomechanics research, including the development of new tools to measure intra-articular space;
  • Regenerative medicine research, including research involving the use of stem cells;
  • Artificial intelligence and novel data approaches, including identifying patterns in genomic and proteomics data;
  • Prevention of transitions from acute to chronic pain; and
  • Clinically relevant and mechanistically anchored patient subgroups and framing of future research to improve treatments that match to identified subgroups.

Recommendation 3: Strengthen Population-Based Research on the Public Health Burden of Temporomandibular Disorders (TMDs)

The National Collaborative Research Consortium for TMDs along with other funders should expand and strengthen the collection, assessment, and dissemination of population-based data on the burden and costs of TMDs and the effects of TMDs on patient outcomes in order to improve the prevention (primary, secondary, and tertiary) and management of TMDs.

Suggested Citation:"8 Next Steps and Recommendations." 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.
×

Near-term implementation actions:

  • The National Collaborative Research Consortium for TMDs and other relevant organizations and agencies should convene key stakeholders to:
    • Review questions related to TMDs in current national population surveys and make recommendations regarding the standardization, addition, or refinement of questions and use of case definitions; and
    • Develop guidelines encouraging future research proposals to use standardized case definitions and diagnostic criteria.

Medium- to long-term implementation actions:

  • The National Collaborative Research Consortium for TMDs in collaboration with other relevant stakeholders (e.g., large integrated health care systems such as Kaiser Permanente and the Department of Veterans Affairs) should fund and evaluate:
    • Projects to explore the linkage and use of electronic health and dental records with payer claims databases and other electronic repositories to gain insights into the prevalence of individual TMDs and the burden and impact of TMDs;
    • Work that builds on the Orofacial Pain Prospective Evaluation and Risk Assessment study and further explores the directionality of the relationship between TMDs and comorbidities. Future studies should seek to identify prognostic biomarkers of TMDs in order to understand how risk factors interact and how clinical, psychological, and genetic factors confer different levels of TMD risk in different groups of individuals;
    • Research that focuses on longitudinal studies in diverse populations to better understand the natural history of common and uncommon TMDs and the interactions of risk factors to inform whether, when, and how to manage TMDs; and
    • The impact of TMDs, treatment of TMDs, and trajectories of these disorders on health, function, economic productivity, and quality of life.

Recommendation 4: Bolster Clinical Research Efforts to Build the Evidence Base for Patient-Centered Care and Public Health Interventions for Temporomandibular Disorders (TMDs)

The National Collaborative Research Consortium for TMDs along with other funders should fund clinical and implementation research to clearly define effective treatments and continuously improve the quality of care for patients with a TMD. These near-term efforts should:

Suggested Citation:"8 Next Steps and Recommendations." 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.
×
  • Explore and develop pilot projects on TMD treatment effectiveness and implementation through the National Institutes of Health Collaboratory on Pragmatic Trials; the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks public–private network; the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials; the National Patient-Centered Clinical Research Network; and other relevant clinical research networks;
  • Develop a set of common data elements for use in clinical research on TMDs, which could include validating existing relevant measures (such as the Patient-Reported Outcomes Measurement Information System or the TMJ Patient-Led RoundTable patient outcomes) and the development of new measures for consistent use in all studies on the TMD population and determining which components are most relevant for patients;
  • Prioritize funding for innovative TMD clinical research projects that focus on meaningful outcomes that are important to patients and patient care, including pragmatic trials and other comparative effectiveness research;
  • Expand the scope of research on TMDs conducted via the Dental Practice Based Research Network to enhance evidence regarding treatment outcomes for TMDs in routine practice;
  • Test novel self-management interventions (using intervention development theoretical frameworks) that foster the translation of theory and basic science to improve TMD care; and
  • Explore and support the development and implementation of a national TMD patient registry:
    • National Institute of Dental and Craniofacial Research, The TMJ Association, TMJ Patient-Led RoundTable, and Medical Device Epidemiology Network Initiative (MDEpiNet), in collaboration with professional associations and TMD centers of excellence (see Recommendation 8), should convene a workshop to:
      • Explore various options for a TMD patient registry;
      • Obtain input on best practices and lessons learned from other and ongoing patient registry efforts on TMDs and other diseases and disorders (including, but not limited to, MDEpiNet’s work on a TMD registry and the Platform for Engaging Everyone Responsibly, operated by the Genetic Alliance); and
      • Outline next steps for the development of a national patient registry.
Suggested Citation:"8 Next Steps and Recommendations." 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.
×

IMPROVE ACCESS TO AND QUALITY OF TMD HEALTH CARE

Throughout this report, the committee emphasizes a number of important elements of TMD care, including:

  • Patient centeredness, recognizing that individuals with a TMD are more than their medical condition and that quality-of-life factors are important;
  • Coordinated and multidisciplinary care as needed that may involve a team of professionals across disciplines; and
  • A focus on education, in order to improve clinicians’ knowledge and skills, the general public’s awareness and understanding of TMDs, and the self-management skills of individuals with a TMD.

An important challenge in ensuring the availability of high-quality care for TMDs, particularly for those who have a TMD that is not easily resolved, is making sure that patients have access to coordinated care across medicine, dentistry, and other health professions. Innovative approaches and interprofessional efforts will be needed. Specialized TMD centers, especially for individuals that need multiple types of care, would be vital and could contribute significantly to telehealth options for improving access to specialty care as well as to innovative approaches to health professional education, clinical research, and data collection and analysis. Much remains to be learned about how to individualize patient care to the extent possible in order to provide the most effective management and treatment options for that individual.

Recommendation 5: Improve the Assessment and Risk Stratification of Temporomandibular Disorders (TMDs) to Advance Patient Care

Diagnostic tools and resources for TMDs should be improved for the initial assessment by primary care clinicians and dentists and for referrals to specialists as needed. These efforts should include the development of decision criteria for risk stratification to aid in identifying patients who are likely to escalate from self-limiting and localized symptoms to a systemic pain condition and then to high-impact pain. Initial instruments will be based on the current understanding of TMD science, though limited, and should be informed by the science as it evolves.

Near-term implementation actions:

  • The International Network for Orofacial Pain and Related Disorders Methodology (INfORM), the American Dental Association
Suggested Citation:"8 Next Steps and Recommendations." 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.
×

(ADA), the American Academy of Orofacial Pain, and The TMJ Association, in collaboration with the American Academy of Family Physicians, Society of General Internal Medicine, American College of Rheumatology, and other relevant professional organizations and stakeholders should:

  • Develop diagnostic and screening tools, including a list of high-risk/red-flag symptoms for health care professionals (primary care and dentists) for TMDs with attention to:
    • Strategies to identify common and concerning alternative diagnoses that can mimic TMDs (i.e., neoplasm, rheumatic disease) so that these can be ruled out prior to initiating TMD treatment and
    • Criteria for referrals from primary care professionals to specialists.
  • Determine next steps for developing diagnostic criteria for the subtypes of TMDs that are less common and validating those criteria for reliability and validity.

Medium- to long-term implementation actions:

  • Dentists, primary care clinicians, and other relevant health care professionals should:
    • Implement assessment tools in clinical practice and evaluate changes to practice and patient outcomes and
    • Combine evolving science regarding biology and mechanisms of TMDs with clinical findings to improve diagnosis and risk stratification.

Recommendation 6: Develop and Disseminate Evidence-Based Clinical Practice Guidelines and Quality Metrics for Care of Temporomandibular Disorders (TMDs)

Clinical practice guidelines should be developed and widely disseminated that provide evidence-based pathways for the initial recognition and stepped care management of TMDs and for specialty care for patients with TMDs. Once clinical practice guidelines are developed, clinical performance measures should be deployed in quality improvement initiatives.

Near-term implementation actions:

  • The International Association for the Study of Pain, American Academy of Pain Medicine, American Academy of Orofacial Pain, International Network for Orofacial Pain and Related Disorders Methodology, and the American Chronic Pain Association should
Suggested Citation:"8 Next Steps and Recommendations." 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.
×

convene stakeholders (including the American Dental Association [ADA], American Academy of Family Physicians, Society of General Internal Medicine, American Association of Nurse Practitioners, and The TMJ Association) to develop evidence-based consensus clinical practice guidelines for dentists and primary care clinicians to guide diagnosis, initial treatment, and referral strategies for patients with TMD symptoms.

Medium- to long-term implementation actions:

  • ADA, in conjunction with the American Association for Dental Research and the International Association for Dental Research, the American Academy of Family Physicians, Society of General Internal Medicine, the Agency for Healthcare Research and Quality, the National Committee for Quality Assurance, The TMJ Association, and other professional organizations involved in quality metrics and in the care of TMDs should:
    • Develop a national quality measurement and improvement strategy for TMD care. These efforts would include ongoing efforts to disseminate and refine the clinical practice guidelines as well as the development and establishment of performance metrics for quality TMD care. This work should be done in collaboration with independent organizations with expertise in quality measurement and improvement.
    • Develop, implement, and evaluate clinical decision tools for TMDs for use in electronic health records (both medical and dental) that are based on the clinical practice guidelines.
  • Health systems that provide integrated medical and dental care (e.g., the Department of Defense, Kaiser Permanente, and Marshfield Clinic) should use TMD care as a pilot case study for their innovative and continuing efforts to coordinate medical and dental care. These institutions are also well poised to study the effectiveness of building clinical practice guidelines for TMDs into clinical decision support tools for staff physicians and dentists.

Recommendation 7: Improve Reimbursement and Access to High-Quality Assessment, Treatment, and Management of Temporomandibular Disorders (TMDs)

Insurers and health care systems across dentistry and medicine should provide consistent, fair, equitable, and appropriate insurance coverage for safe and effective treatments for TMDs.

Suggested Citation:"8 Next Steps and Recommendations." 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.
×

Near-term implementation actions:

  • The American Dental Association, in collaboration with The TMJ Association and private and public health insurers (including Medicare and Medicaid) and health professional associations, should convene a working group across public and private health and dental insurers and health care systems to:
    • Realign financial incentives to improve reimbursement and reduce patient out-of-pocket costs to ensure that patients can access appropriate and evidence-based care;
    • Develop recommendations for overcoming discrepancies and gaps in medical and dental billing practices for health care professionals who provide TMD care; and
    • Explore novel reimbursement structures for the provision of patient education and self-management training relevant to TMD care.
  • The Center for Medicare & Medicaid Innovation should:
    • Conduct demonstration projects that would explore new delivery and payment models for Medicare, Medicaid, and the Children’s Health Insurance Program to improve access, quality, and coverage for TMD care; and
    • Explore next steps for the development of value-based reimbursement models for TMD care coverage.
  • The Social Security Administration should explore ways to support the parity of TMDs with other similar conditions in access to disability benefits.

Medium- to long-term implementation actions:

  • Implement lessons learned in demonstration projects and conduct cost–benefit analyses and other health services research to determine the impact of reimbursement changes.

Recommendation 8: Develop Centers of Excellence for Temporomandibular Disorders (TMDs) and Orofacial Pain

Centers of Excellence for TMDs and Orofacial Pain should be established to provide comprehensive evaluations and treatment of individuals with TMDs; to serve as a resource for clinicians (including interprofessional consultations and telehealth opportunities); to contribute to the research base for TMDs; and to provide onsite and virtual education and training, particularly continuing education, for a range of health care professionals. Centers should involve a range of specialists across medicine, dentistry, and other areas of health care and should include patient representatives in the planning and implementation.

Suggested Citation:"8 Next Steps and Recommendations." 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.
×

Near-term implementation actions:

  • The American Academy of Orofacial Pain and the existing orofacial pain programs in academic health centers, working with other relevant medical and dental professional associations and with patient advocacy organizations, should:
    • Develop a strategic plan for the implementation of these centers, including funding and sustainability mechanisms;
    • Develop an accreditation process for the centers involving an independent accrediting organization;
    • Identify sites for pilot centers of excellence and initiate the work of the centers; and
    • Integrate best practices from centers of excellence for other diseases and disorders and their accreditation programs.
  • National Institutes of Health institutes and centers and other research funders should support center-related research through the use of P50 center grants and other relevant funding mechanisms.

Medium- to long-term implementation actions:

  • The network of Centers of Excellence for TMDs and Orofacial Pain should:
    • Develop the metrics and processes to publicly report on a standard set of quality, outcome, and health services data;
    • Serve as a pilot site for novel insurance approaches;
    • Be actively involved in basic, translational, and clinical research;
    • Expand and continually improve the quality of care offered in-house and via online resources;
    • Expand and continually improve the interprofessional education and training offered on TMD care to a range of health and human services professionals; and
    • Be actively engaged in the dissemination of information about TMDs to the public.

IMPROVE HEALTH CARE PROFESSIONAL EDUCATION ABOUT TMDs

A critically important component of improving care for TMD patients is ensuring that health care professionals (across medicine and dentistry) have the professional education and training they need on TMDs—that they have the basic knowledge about the set of TMDs and that they are up to date on current research findings and best practices for TMD care. Primary care clinicians—including family physicians, pediatricians, general dentists, nurse practitioners, and physician assistants—need to be well aware that a wide array of disorders are grouped as TMDs and that there

Suggested Citation:"8 Next Steps and Recommendations." 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 initial care practices (including self-management) that can be useful to many patients. Furthermore, they need to know when to refer patients for specialty care and to which specialists to refer patients.

Additionally, relatively few orofacial pain and TMD specialists are credentialed by independent organizations to provide TMD care. The recommendations below point to actions needed to increase the number of qualified specialists and to provide those specialists with the interprofessional training and expertise needed to equip them to help patients bridge the gaps across medicine and dentistry and obtain full and complete care.

Recommendation 9: Improve Education and Training on Temporomandibular Disorders (TMDs) for Health Care Professionals

Health professional schools and relevant professional associations and organizations across medicine, dentistry, nursing, physical therapy, and all other relevant areas of health care should strengthen undergraduate, graduate, pre- and postdoctoral, residency, and continuing education curricula in pain management, orofacial pain, and TMD care for health professionals and work to ensure interprofessional and interdisciplinary training opportunities.

Near-term implementation actions:

  • Deans of health professional schools (across medicine, dentistry, nursing, physical therapy, and all relevant areas of health) should ensure that their schools’ curricula include attention to TMDs and cover the physiology, pathophysiology, and assessment, referral, and management of related conditions. Efforts to improve curricula and education should:
    • Assess the curricula on TMDs for their quality and strength of evidence;
    • Ensure the availability of faculty members who have specialized knowledge and experience in pain management, orofacial pain, and TMDs;
    • Ensure that education materials and programs for health professionals reflect current research, clinical guidelines, and best practices;
    • Explore and promote opportunities to expand interprofessional education and collaborations, particularly across dentistry and medicine education and training; and
    • Ensure that the curricula have training on patient–clinician communications and patient-centered care.
  • Health professional licensing organizations (including the organizations administering the National Board Dental Examinations,
Suggested Citation:"8 Next Steps and Recommendations." 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.
×
  • National Council Licensure Examination, United States Medical Licensing Examination, and National Physical Therapy Exam) should expand and improve exam questions about pain management and TMDs, moving beyond physiology and diagnosis and toward treatment and management.

  • The Commission on Dental Accreditation should amend the accreditation standards for predoctoral dental programs to include screening, risk assessment, and appropriate evidence-based interventions for TMDs.
  • Health professional associations should ensure that all continuing education courses on TMDs for health care professionals are evidence-based and reflect and promote current research, clinical guidelines, and best practices.

Medium- to long-term implementation actions:

  • The American Dental Association, in conjunction with relevant professional associations and patient advocacy groups, should develop innovative approaches to interprofessional continuing education on TMDs that convey evidence-based information on the treatment and management of TMDs, disseminate guidelines for appropriate referral to other health care professionals, and encourage and facilitate interprofessional collaboration for patient care.

Recommendation 10: Establish and Strengthen Advanced/Specialized Training in Care of Orofacial Pain and Temporomandibular Disorders (TMDs)

The number and quality of health care professionals with specialized training in pain management, orofacial pain, and TMDs should be increased, recognizing the existence of such barriers as reimbursement and recognition of the practice of orofacial pain.

Near-term implementation actions:

  • The American Dental Association’s National Commission on Recognition of Dental Specialties and Certifying Boards should recognize orofacial pain as a dental specialty.
  • The American Board of Medical Specialties, Accreditation Council for Graduate Medical Education, and American Society for Pain Management Nursing/American Nurses Credentialing Center’s certification in pain management should ensure that TMDs and TMD care are sufficiently covered in its requirements and certification examination.
  • The Commission on Dental Accreditation should work with oral and maxillofacial surgery programs to ensure that participants receive
Suggested Citation:"8 Next Steps and Recommendations." 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.
×
  • comprehensive training on the surgical and non-surgical management of TMDs, including referral to other health care professionals when appropriate.
  • Relevant professional associations should expand and improve opportunities for all health professionals to pursue clinical rotations and fellowships in pain management, orofacial pain, and TMD care that emphasize interprofessional care.

RAISE AWARENESS, IMPROVE EDUCATION, AND REDUCE STIGMA

Individuals with a TMD and their families have contributed significantly to the progress that has been made in TMD research and care. They are among the most persuasive advocates and educators as they have a firsthand picture of the disorder and its impact. There is a need for patients and their families to have consumer-friendly tools and educational resources to enable them to become more informed for their own well-being and, if they so decide, to inform others and advocate for change.

Recommendation 11: Raise Awareness, Improve Education, and Reduce Stigma

Evidence-based communications and patient-focused tools related to temporomandibular disorders (TMDs) should be strengthened, promoted, and widely disseminated through multiple avenues for adults and youth of all health literacy levels and in multiple languages to raise public awareness about TMDs, improve the resources available to patients and families, and reduce the stigma related to TMDs. Specific implementation steps should include:

Near-term implementation actions:

  • The TMJ Association, American Dental Education Association, TMJ Patient-Led RoundTable, American Chronic Pain Association, and American Academy of Orofacial Pain should lead efforts in collaboration with other relevant stakeholders to:
    • Develop, update, and widely disseminate evidence-based information and resources to patients and family members (in multiple languages and health literacy levels) by:
      • Reviewing and evaluating existing patient- and family-focused materials and resources relevant to TMDs, including community programs in self-management and cognitive behavioral therapy;
      • Updating materials as needed and then widely disseminating patient-focused tools and toolkits across various media; and
Suggested Citation:"8 Next Steps and Recommendations." 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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    • Developing a consumer roadmap for accessing TMD-related care that provides access to evidence-based clinical practice guidelines (see Recommendation 6).
  • Conduct a baseline survey of health care professionals to assess their biases, attitudes, beliefs, knowledge, and behavior regarding people with TMDs.
  • Explore the feasibility of a public awareness campaign on TMDs, and, as appropriate, plan next steps for formative research toward that long-term goal.
  • Explore and implement additional mechanisms and best practices for raising public awareness of TMDs and destigmatizing the condition. Efforts should be made to:
    • Incorporate TMD awareness into Pain Awareness Month,
    • Bolster social media and other communications efforts to raise awareness about TMDs, and
    • Raise employer awareness of TMDs through organizations such as the National Business Group on Health and the Chamber of Commerce.

Medium- to long-term implementation actions:

  • Stakeholders should develop (with formative studies) and evaluate (with outcome studies) new TMD self-management materials and workshop and training protocols.
  • Implement a public awareness program if deemed appropriate.
  • Track and evaluate longitudinal outcomes from educational programs and materials.

OPPORTUNITIES FOR ACTION

Through commitment, dedicated efforts, and interdisciplinary collaborations, the bold goals outlined in this report (and briefly outlined in Box 8-1) can be accomplished to improve the lives of individuals with a TMD.

Suggested Citation:"8 Next Steps and Recommendations." 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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Suggested Citation:"8 Next Steps and Recommendations." 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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Suggested Citation:"8 Next Steps and Recommendations." 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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REFERENCES

IOM (Institute of Medicine). 2011. Advancing oral health in America. Washington, DC: The National Academies Press.

Mertz, E. A. 2016. The dental-medical divide. Health Affairs 35(12):2168–2175.

NIH (National Institutes of Health). 2020. Actual total obligations by institute and center, FY 2001—FY 2019. https://officeofbudget.od.nih.gov/pdfs/FY21/spending-hist/Actual%20Obligations%20By%20IC%20FY%202000%20-%20FY%202019%20(V).pdf (accessed March 4, 2020).

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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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