TMJ Disorders: From Research Discoveries to Clinical Treatment (2020)
As a result of TMJA’s tireless advocacy efforts, in 2019, the prestigious National Academy of Medicine (NAM) undertook its first study of Temporomandibular Disorders. The effort resulted in a landmark report, published in March 2020, entitled Temporomandibular Disorders: From Research Discoveries to Clinical Treatment. It examines the entire continuum of TMJ disorders or TMD– research, education and training, diagnosis and assessment, clinical management and treatment, comorbidities, treatment efficacy, models of care, insurance practices, clinical translation, and other issues.
As the nation’s source of nonpartisan, objective guidance for decision-makers, the NAM is a prestigious voice positioned to make lasting and transformational recommendations to advance areas like TMD, which have been historically plagued with a siloed, non-evidence-based approach.
With implementation of the NAM study recommendations, our vision for the future of TMD health care can actually become a reality – a health care system that is informed by evidence and addresses the complexity of patients with TMD and coexisting medical conditions with an individualized, patient-centered, whole-person approach.
Some of the major findings include:
The temporomandibular joint – which is vitally important to human existence – has been overlooked, underappreciated and understudied:
“Consider the joints of the human body. What might first come to mind are the hips and knees… followed by the wrists, ankles, elbows, fingers, and toes. What can be overlooked … is one of the most used, most necessary, and perhaps most misunderstood set of joints – those of the jaw – which are critical to the vital work of human life.” (Page S-1)
There are a number of conditions that fall under the umbrella term of “Temporomandibular Disorders” – they range in their complexity, symptom presentation and severity, and their relationship to other chronic conditions:
“TMDs are a set of diseases and disorders related to the alterations in the structure, function, or physiology of the masticatory system [i.e., teeth, jaws, TMJ, and the muscles and nerves supplying these tissues] and that may be associated with other systemic and comorbid medical conditions. The term ‘TMDs’ is used as an umbrella term to encompass disorders that can range from muscle or joint pain to joint disorders … to joint diseases. The pain associated with TMDs can range from none to severe high-impact pain. TMDs can range from a single isolated condition to multi-system involvement and can be associated with other comorbid and systemic disorders and overlapping pain conditions.” (Pages S3-4)
Research on the causes and mechanisms of TMDs is still in its infancy, which has contributed to the poor state of clinical care for patients:
Despite investment in research directly and indirectly related to TMDs … researchers have yet to unravel the etiologies [i.e., causes] and pathophysiologies [i.e., disease mechanisms] of TMDs or to translate, in a meaningful way, research findings into improved clinical care practices.”
Limited scientific information exists to inform clinicians and patients about treatment effectiveness:
“The goals are for each patient to know the specific type of disorder that s/he has and to be provided with an appropriate treatment plan specific to that diagnosis. The challenge is that the evidence base for matching a specific treatment (or group of treatments) with a specific diagnosis is not yet fully developed so that in some cases, particularly for chronic conditions, much remains to be learned.” (Page S-3)
“Patients testified to the profound impact of TMD on all aspects of their lives, including:
lack of coordinated care; clinician abandonment; difficulty in identifying qualified and/or knowledgeable health care providers; over and/or harmful treatment; compromised ability to work and to care for their families; profound emotional consequences; lack of insurance coverage for recommended treatments; enormous financial burden; lack of availability of public information that is evidence-based; and challenges with co-existing chronic conditions.” (Pages S2-3)
A new, team-based model of treatment and care is needed to address the range and complexities of TMDs:
“The committee supports a bio-psycho-social model of TMDs that is inter-disciplinary and can be used across medicine and dentistry to focus on the total person’s health and well-being. The biopsychosocial approach is a broad model that can encompass the range of TMD disorders and apply the best science from medicine, dentistry, physical therapy, integrative health, and multiple other fields to the care of individuals with a TMD. This approach acknowledges that TMDs are not a single entity and consequently most often have varying causes … that affect differing parts of the masticatory system and potentially other body systems and require varied, and sometimes multiple, treatment modalities.” (Page S-4)
Action is needed NOW to advance research, bridge the medical-dental divide and implement a “whole person” approach to TMD treatment and health care:
“Action is urgently needed to improve care for individuals with a TMD. Too long compartmentalized as a dental issue, both the clinical management of and research addressing TMDs need to implement a holistic and multidisciplinary approach… The divide between medical and dental care is currently vast … and profoundly affects care systems, payment mechanisms, and professional education and training.” (Page S-1)
Patients and family members have played – and continue to play – a key role in advocating for change:
“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.” (Page S-4)
The NAM Report contains a set of 11 transformative recommendations, the goals of which “are to build a strong base of knowledge about TMDs and to facilitate actions needs to improve the overall health and well-being of individuals with a TMD. Some … 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.” (Page S-4)
The 11 recommendations fall underneath a few broad goals, which include:
Goal #1: Build and Sustain Collaborative and Multidisciplinary TMD Research
- Rec 1: Create and Sustain a National Collaborative Research Consortium (NCRC) for TMD to: coordinate, fund, and translate basic and clinical research to address evidence gaps, generate clinically meaningful knowledge, identify safe and effective treatments, and improve the quality of TMD care.
- Recs 2-4: Coordinate and Expand TMD Research – The NCRC for TMDs, led by the National Institutes of Health, along with other funders should fund and strengthen: basic research efforts and the translation of that research as part of a patient-focused, multidisciplinary research agenda on TMDs; 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 and management of TMDs; and clinical and implementation research to clearly define effective treatments and continuously improve the quality of care.
Goal #2: Improve Access and Quality for TMD Health Care
- Rec 5: Improve the Assessment and Risk Stratification of TMDs to Advance Patient Care – Multiple stakeholder groups should collaborate to develop diagnostic, screening, and risk stratification tools for TMDs, including a list of high-risk/red-flag symptoms for health care professionals (primary care providers and dentists). These tools 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.
- Rec 6: Develop and Disseminate Evidence-Based Clinical Practice Guidelines and Quality Metrics for Care of TMDs – Multiple stakeholder groups should collaborate to develop evidence-based consensus clinical practice guidelines for dentists and primary care clinicians to guide diagnosis, initial treatment, and referral strategies for TMDs. Once developed, clinical performance measures should be deployed in quality improvement initiatives.
- Rec 7: Improve Reimbursement and Access to High-Quality Assessment, Treatment, and Management of TMDs – Multiple stakeholder groups should collaborate to develop mechanisms for providing access to consistent, fair, equitable, and appropriate insurance coverage for safe and effective TMD treatments. The Center for Medicare & Medicaid Innovation should conduct demonstration projects that would explore new delivery and payment models to improve access, quality, and coverage for TMD care.
- Rec 8: Develop Centers of Excellence (CoEs) for TMDs and Orofacial Pain – Multiple stakeholder groups should develop CoEs to provide comprehensive evaluations and treatments of people with TMDs to: serve as a resource for clinicians; contribute to the research base; and provide onsite and virtual education and training for a range of health care professionals. CoEs should include a range of specialists across medicine, dentistry and other areas of health care and should include patients in planning and implementation.
Goal #3: Improve Health Care Professional Education about TMDs
- Rec 9: Improve Education and Training on TMDs for Health Care Professionals – Health professional schools and professional associations and organizations across medicine, dentistry, nursing, physical therapy and all other relevant areas of health care should strengthen educational curricula for all levels of health care professionals and work to ensure interprofessional and interdisciplinary training opportunities.
- Rec 10: Establish and Strengthen Advanced/Specialized Training in Care of Orofacial Pain and 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.
Goal #4: Raise Awareness, Improve Education, and Reduce Stigma
- Rec 11: Raise Awareness, Improve Education, and Reduce Stigma – Multiple stakeholder groups should collaborate to develop, update and widely disseminate evidence-based communications and patient-focused tools on TMDs.