In a previous article, we reported the results of a survey of American and Canadian orthodontic postgraduate programs to determine how the topics of occlusion, temporomandibular joint, and temporomandibular disorders were currently being taught. Based on the finding of considerable diversity among those programs, we decided to write a curriculum proposal for temporomandibular disorders that would be compatible with and satisfy the current curriculum guidelines for postgraduate orthodontic programs. These guidelines arose from a combination of the requirements published by the American Dental Association’s Commission on Dental Accreditation and the written guide (July 2010) of the American Board of Orthodontics for the its clinical examination. The proposed curriculum, based on the latest scientific evidence in the temporomandibular disorder field, gives program directors a template for covering these subjects thoroughly. At the same time, they can focus on related orthodontic issues, so that their future graduates will be prepared to deal with patients who either have or later develop temporomandibular disorder problems.
We previously published the results of our survey of American and Canadian orthodontic graduate programs in which we asked the program directors about their didactic and clinical teaching of topics relating to the temporomandibular joint (TMJ). Their responses indicated that didactic and clinical exposures to the topics of occlusion, the TMJ, and temporomandibular disorders (TMD) were being presented in many different ways. Some programs were devoting much time to these issues, and their teaching generally was consonant with current scientific evidence. However, others were either insufficiently covering these topics or presenting outdated concepts, especially in regard to possible relationships between orthodontic treatment and TMD. At the end of our article, we recommended that every orthodontic graduate program should try to align its teaching in this area with the currently available scientific evidence.
We recognize that each orthodontic postgraduate program is separate and free to control its own curriculum, but all of them must satisfy the requirements established by official accrediting agencies such as the American Dental Association’s Commission on Dental Accreditation. We also know that many aspects of the orthodontic curriculum are based on standards established by the American Association of Orthodontists and the American Board of Orthodontics (ABO). Therefore, we decided to present a proposal for designing a curriculum that covers the topic of TMD and orthodontics in a manner targeted specifically at future practicing orthodontists, in the hope that teaching programs will find it helpful. In addition, we believe that the official orthodontic associations will find it useful when revising or expanding present standards for evaluating and accrediting advanced education programs in orthodontics.
What is currently required?
The American Dental Association’s Commission on Dental Accreditation has published Accreditation Standards for Advanced Specialty Education Programs in Orthodontics and Dentofacial Orthopedics that deal with the topic of occlusion and TMD in 8 words: “Manage patients with functional occlusal and temporomandibular disorders” (Standard 4-3.4 g). This is a required proficiency rather than a familiarity, which means that an orthodontic graduate should become proficient at doing something clinically about these conditions, rather than simply knowing about them or recognizing the symptoms before any orthodontic intervention.
The World Federation of Orthodontists ∗
∗ The World Federation of Orthodontists Guidelines for Postgraduate Orthodontic Education: Occlusion and TMJ. On page 165, occlusion and TMD and the specific areas that need to be addressed in the curriculum are listed in Appendix 2: Educational Topics. One more mention of occlusion and TMD in this document is on page 166, Appendix 2, Educational Topics (Continued), under Special Orthodontic Subjects: TMD and orthodontics.
has published a much more specific list of topics to be covered in dealing with these issues: (1) occlusion and TMD; (2) anatomy and function; (3) general TMJ concepts; (4) normal occlusion and function; (5) differential diagnosis of TMD; (6) TMD in children, adolescents, and adults; and (7) management philosophies.
However, this broad list does not even mention orthodontics or the real-life dilemmas of orthodontic practitioners. We believe that it is possible to narrow the focus of teaching in this area so that the issues are being discussed at a higher (graduate) level, with special emphasis on the needs of a clinical orthodontist in terms of essential diagnostic and management proficiency.
Proposed curriculum for a TMD course
A list of suggested topics to be covered in a 1-semester TMD course is presented in the Table , along with a brief list of issues to be discussed under each topic. This proposed course outline is based on our collective experiences because we have taught generations of orthodontic residents about TMJ issues for several decades. Although it would be nice to be able to cite empirical data supporting the efficacy of our proposed curriculum, such data simply do not exist. Specific concepts and detailed content proposals are not presented here, because we believe that program directors and faculty should have the freedom to make those choices in the overall context of their programs. However, we do recommend that an evidence-based and problem-based approach to this contentious field is the best strategy to follow. As part of that approach, we believe that the following points should be made clear throughout the didactic course and during the clinical exposure in every program.
- 1.
Orthodontic treatment will not prevent children or adult patients from developing a TMD problem later in life.
- 2.
Orthodontic treatment will not generally cause children or adults to develop TMD problems later in life. However, if TMD symptoms arise during orthodontic treatment, they might be due to various forces or appliances that exceed the patient’s adaptive capacity, and appropriate responses will be required.
- 3.
Orthodontic treatment is neither a first-line nor a second-line therapy for symptomatic TMD patients, regardless of how their occlusion appears at presentation.
The literature supporting these 3 statements is abundant in the orthodontic field and in the wider TMD field. Therefore, these statements should be regarded as fundamental knowledge in 21st century orthodontics, and they should be discussed with graduate students by contrasting them to older belief systems in the orthodontic specialty. Readers of this article and all graduate orthodontic students should especially look at the most recent review of this literature by Michelotti and Iodice, which includes an outstanding table summarizing 24 articles on “studies published between 1989 and November 2009 that examined the relationship between orthodontic treatment and TMD.”
In addition, it is important to stress throughout the TMD course that, in the modern orofacial pain community, these disorders are currently being studied and managed in a medical orthopedic framework; this represents a significant departure from a traditional dental model. In addition, TMD patients today are being managed in a biopsychosocial paradigm, and some (especially chronic patients) have significant psychosocial issues that must also be dealt with. Finally, many chronic TMD patients suffer from various comorbid pain conditions (fibromyalgia, irritable bowel syndrome, interstitial cystitis, and so on), and these conditions impact both the diagnosis and the management of chronic TMD problems.
Proposed curriculum for a TMD course
A list of suggested topics to be covered in a 1-semester TMD course is presented in the Table , along with a brief list of issues to be discussed under each topic. This proposed course outline is based on our collective experiences because we have taught generations of orthodontic residents about TMJ issues for several decades. Although it would be nice to be able to cite empirical data supporting the efficacy of our proposed curriculum, such data simply do not exist. Specific concepts and detailed content proposals are not presented here, because we believe that program directors and faculty should have the freedom to make those choices in the overall context of their programs. However, we do recommend that an evidence-based and problem-based approach to this contentious field is the best strategy to follow. As part of that approach, we believe that the following points should be made clear throughout the didactic course and during the clinical exposure in every program.
- 1.
Orthodontic treatment will not prevent children or adult patients from developing a TMD problem later in life.
- 2.
Orthodontic treatment will not generally cause children or adults to develop TMD problems later in life. However, if TMD symptoms arise during orthodontic treatment, they might be due to various forces or appliances that exceed the patient’s adaptive capacity, and appropriate responses will be required.
- 3.
Orthodontic treatment is neither a first-line nor a second-line therapy for symptomatic TMD patients, regardless of how their occlusion appears at presentation.
The literature supporting these 3 statements is abundant in the orthodontic field and in the wider TMD field. Therefore, these statements should be regarded as fundamental knowledge in 21st century orthodontics, and they should be discussed with graduate students by contrasting them to older belief systems in the orthodontic specialty. Readers of this article and all graduate orthodontic students should especially look at the most recent review of this literature by Michelotti and Iodice, which includes an outstanding table summarizing 24 articles on “studies published between 1989 and November 2009 that examined the relationship between orthodontic treatment and TMD.”
In addition, it is important to stress throughout the TMD course that, in the modern orofacial pain community, these disorders are currently being studied and managed in a medical orthopedic framework; this represents a significant departure from a traditional dental model. In addition, TMD patients today are being managed in a biopsychosocial paradigm, and some (especially chronic patients) have significant psychosocial issues that must also be dealt with. Finally, many chronic TMD patients suffer from various comorbid pain conditions (fibromyalgia, irritable bowel syndrome, interstitial cystitis, and so on), and these conditions impact both the diagnosis and the management of chronic TMD problems.
TMD and orthodontics—special-interest topics for orthodontists
In addition to the TMD course topics presented in the Table , it would be desirable to follow that course with a series of focused discussions about TMD issues that arise in orthodontic practices. These discussions should be conducted in a problem-based learning format, so that the residents could search for relevant materials and be prepared for an open dialog with their instructors. A number of TMD and occlusion issues frequently arise in most orthodontic programs as well as in outside practice, and the residents should be prepared to deal with them when they do occur. To develop critical thinking skills, a debate format could be used to address many of the issues related to orthodontics, functional occlusion, condyle position, and TMD. A list of suggested topics is presented below.
Specific orthodontic concerns and issues
- 1.
How has the orthodontic literature changed over the years in regard to TMD and orthodontic relationships? The evolution of thinking about the relationship between these topics parallels what has happened in other disciplines within the dental profession. A review of these historical concepts in orthodontics will help new graduates to appreciate the spectrum of professional opinions they will encounter as they enter practice.
- 2.
The topic of occlusal hyper-awareness (also known as phantom bite) has generally been neglected in orthodontic training programs. A recent article reported the results of a survey of practicing orthodontists in the United States about their experiences with patients complaining of occlusal awareness and discomfort. The responses to that survey indicated that most orthodontists were either unaware of this condition or uncertain about how to deal with these patients. Many of these patients either have already had orthodontic treatment or are requesting it as a solution for their problem. Appropriate responses to these situations can be complicated, and dealing with such problems might produce significant amounts of anxiety in both patients and dentists.
- 3.
The TMD course described in the Table includes the topic of screening prospective orthodontic patients for TMD signs and symptoms. However, some additional time is required to have in-depth discussions about how to react to positive findings from those screenings. This should include the following topics: What constitutes a minor finding vs a major TMD sign or symptom? Who should manage the TMD problem if it requires treatment? What cautions are suggested for the orthodontic management of such patients?
- 4.
How should orthodontists react to and deal with TMD problems that arise during their treatments? Who is responsible for managing these situations? When is it appropriate to resume orthodontic treatment? What if the TMD situation cannot be resolved completely?
- 5.
How should orthodontists react to posttreatment TMD complaints from their completed patients? Does it matter whether these complaints arise during the immediate posttreatment period or several years later? What is the orthodontist’s responsibility for providing or seeking appropriate care for these patients?
Interactions between orthodontists and general dentists—TMD and occlusion issues
- 1.
How should an orthodontist respond to a patient referred by a familiar referring dentist, specifically for treatment of a TMD problem? Assume that the linkage between the patient’s occlusion and the symptoms has already been proclaimed by the dentist.
- 2.
Same as number 1, but assume that the referring dentist is new to the practice.
- 3.
A finished orthodontic patient is sent back to the original referring dentist. However, this dentist does not like the occlusal result produced and makes negative comments to the patient (and parents, if a child) about this outcome. The possibilities include: (a) the critique was based only on personal opinion, but no specific occlusal philosophy was cited by the dentist; (b) a more specific critique was offered, based on a specific occlusal theory; (c) the criticism is based on the dentist’s recent involvement with a major occlusion “institute,” which has convinced him that only certain specific occlusal outcomes are acceptable, and that only special occlusally aware orthodontists can render a successful outcome; (d) the patient is told that future TMJ and occlusal problems will occur if this situation is not corrected; and (e) the patient is advised to seek a second opinion from a different orthodontist, rather than returning to you.
- 4.
Same as number 3, except that the patient is seeing a new dentist who did not make the initial orthodontic referral.
All of the above negative scenarios could be discussed under 3 different assumptions: (1) the general dentist is the one who makes the negative phone call to the orthodontist; (2) the patient (or parents) makes the negative phone call to the dentist; or (3) the “special occlusally aware orthodontist” makes the phone call to the treating or original orthodontist to discuss the “inappropriately finished” patient.
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