Survey of orthodontic residency programs: Teaching about occlusion, temporomandibular joints, and temporomandibular disorders in postgraduate curricula

Introduction

Teaching orthodontic postgraduate students about occlusion and the temporomandibular joint is a fundamental component of their education, but faculty members are confronted with disputes and controversies about these topics. The purpose of this study was to ascertain where the orthodontic teaching community currently stands on the topics of occlusion, temporomandibular joint, and temporomandibular disorder.

Methods

A 46-question survey was sent to every orthodontic program director in the United States and Canada (n = 69). Responses were submitted by 46, and the results were tabulated.

Results

Three interrelated topics (normal or ideal temporomandibular joint, normal or ideal occlusion, and management of temporomandibular disorder) are being taught in diverse ways in these postgraduate orthodontic programs.

Conclusions

The results of this survey will help us to understand and improve how these topics are being taught at accredited orthodontic programs in the United States and Canada. Perhaps a standardized curriculum can be developed.

Teaching orthodontic postgraduate students about occlusion and the temporomandibular joint (TMJ) is a fundamental component of their education. The faculty members responsible for this task, however, are confronted with a serious problem caused by disputes and controversies about these topics; this is true in the orthodontic community as well as in the dental profession at large. To further complicate matters, the issue of temporomandibular disorders (TMDs) is viewed by some orthodontists as another major concern of the orthodontic profession, and many of them advocate orthodontic treatment to either prevent or cure these problems. However, the literature on that topic is generally not supportive of those viewpoints, and, as a result, there is disagreement among orthodontists about their proper role in dealing with patients who are referred for treatment of TMDs. Furthermore, even if orthodontists believe that they should not be primary caregivers for those patients, they still must deal with their own patients who might have pretreatment TMD symptoms, as well as patients who develop such symptoms during treatment.

Therefore, we thought it was important to ascertain where the orthodontic teaching community currently stands on the topics of occlusion, TMJ, and TMDs because their teachings will have a significant effect on the mind-set and skills of future practitioners. There are didactic components for all of these topics, and then there are clinical experiences that follow, so that every orthodontic student can expect to learn something about these matters in the 24 to 36 months of the various programs. To determine the current opinions and practices among orthodontic faculty members, a 46-question survey was developed to obtain that information. It was sent to every orthodontic program in the United States and Canada, and the responses were tabulated by computer.

In this article, we present the results of that survey, and we offer suggestions for improving the current teaching situation based on the juxtaposition of the findings of this survey with the current evidence-based literature on these topics.

Historical review

Curriculum guidelines for teaching the topics of occlusion and orthodontics have been established and reported in the dental education literature. However, the American Association of Orthodontists does not prescribe specific guidelines for either the content or the process of how these topics should be taught, even though it does require that they must be part of the postgraduate orthodontic curriculum. The same is true for the undergraduate dental curriculum, where the educational standards are the administrative responsibility of the Curriculum Change and Intervention section of the American Dental Education Association. The situation is even worse in regard to TMD and orofacial pain (OFP), because no educational guidelines have been established and accepted as components of a standardized curriculum. In most dental schools, this subject matter is meted out to various dental school departments, and it is commonly treated as an “educational orphan” with no specific home for its inclusion in the curriculum.

Before publication of the American Dental Association’s President’s Conference on the Examination, Diagnosis and Management of Temporomandibular Disorders in 1983, little information was available that addressed the subject of TMDs in a dental school curriculum. In a literature search for curriculum-related publications, we found that 2 dental schools in the late 1980s had reported on guidelines established in their curricula for teaching the management of facial pain, but neither suggested how these programs might be adapted for use in other schools. About the same time, a similar article about educational guidelines for dealing with facial pain was published by the Council on Dental Education of the American Dental Association. These “Guidelines for teaching the comprehensive control of pain and anxiety in dentistry” were approved by the council for implementation in dental school curricula, but no mention was made of TMD; instead, the main focus was on anesthesia and postoperative pain-control issues.

In an attempt to fill this void in the dental curriculum, 2 educational conferences were held in 1990 and 1992 to develop curriculum guidelines for TMD and OFP. The group that sponsored these conferences was the Association of University Teachers of Orofacial Pain Programs. The guidelines produced during these conferences were intended for use at the predoctoral, postdoctoral, and continuing education levels, so proposals were made for all 3 levels of teaching. The outcomes generated from these conferences were published as suggested curricular standards, but unfortunately they were never officially adopted by the American Association of Dental Schools for implementation.

A third educational conference sponsored by Association of University Teachers of Orofacial Pain Programs was held in 2001, with its principal aim to “enhance the teaching of TMD and OFP to predoctoral dental students and to postdoctoral students in this field.” Several position papers were developed as a result of this conference, and they specifically addressed the need for standardized educational guidelines in TMD. In addition, they stressed the critical need for teaching evidence-based concepts related to this discipline and the integration of structured guidelines into current dental school curricula. Finally, they recommended a clinically based training experience to accompany and augment the proposed didactic changes.

In Europe, proposals for a standardized TMD and OFP curriculum at the undergraduate and postgraduate levels were published a year later. Subsequently, these recommendations were reflected in a proposal from The Netherlands for the development of a new curriculum in oral kinesiology, a discipline devoted to “the diagnosis and treatment of TMD and bruxism” and “the restoration of worn dentitions.” In another Dutch article, the development of a “specialized” curriculum in TMD and OFP was recommended as a means of closing the gap between didactic instruction and clinical application for this discipline in European dental schools. The author called for a more unified adoption of evidence-based information in didactic courses and the eventual implementation of this knowledge in the clinical management of TMD and OFP patients. Within the framework of these European proposals for educational changes, a survey was sent to Swedish dental practitioners to determine whether evidence-based concepts were being used by them in the treatment of TMD and OFP patients. In support of the need for a more standardized TMD and OFP curriculum, the authors noted that the responses to their survey indicated that “TMD specialists still need to reach a consensus which is founded on evidence-based TMD knowledge . . . and that can be used in undergraduate teaching.”

Recently, Klasser and Greene published the results of a survey sent out to US and Canadian dental schools regarding the teaching of topics related to TMDs and OFP at the predoctoral level. They reported that, although some schools were presenting current didactic concepts about these topics, few had any clinical exposure available for undergraduate students. However, a significant number of schools were either presenting outdated and inappropriate information or simply not presenting much information of any kind. Therefore, those authors concluded that there is a significant need regarding “qualitative and quantitative standards” for teaching this subject in dental schools at the predoctoral and postdoctoral levels.

Survey methods and results

To obtain information about how the topics of occlusion, TMJ, and TMD and OFP are taught in advanced education programs in orthodontics, a questionnaire was designed to gather feedback from orthodontic program directors in the United States and Canada. Since no previous studies have used a survey methodology to address these topics specifically, we had to compose and arrange appropriate questions. Initially, each author (all of whom except D.C. are orthodontic educators with expertise in occlusion, TMJ, OFP, and TMDs) independently wrote questions for this survey. The questions were then compiled and reviewed by each investigator. After a series of e-mails and telephone discussions, a final list of questions was selected. At this point, the survey was presented to several orthodontic faculty and practitioner colleagues for their review and input, but these persons were not part of the actual survey. Additionally, a professional market researcher (D.C.) facilitated the design, execution, analysis, and reporting of the research, using state-of-the-art tools and industry practices.

An e-mail invitation from an author (J.S.) was sent to all graduate orthodontic program directors in the United States and Canada (n = 69), requesting participation in an online survey. The program directors were asked to respond on behalf of their institutions or to forward the survey to the faculty member who was most responsible for these educational components. The introductory letter stipulated that this survey was about how the subjects of occlusion, TMJ, and TMD and OFP are taught in their programs. The online survey was posted from September 16 to November 23, 2009.

The survey questionnaire included 46 single-response, multi-response, and open-end questions, which allowed the respondents to write explanatory answers. The survey questions were divided into 5 broad areas: (1) didactic educational component of TMD and OFP; (2) didactic educational component of occlusal relationships and the TMJ; (3) clinical education and case management; (4) clinical TMD screening, diagnosis, and management; and (5) clinical TMD problems arising during and after orthodontic treatment.

Of the 69 orthodontic residency programs in the United States and Canada, 46 programs filled out the online questionnaire, yielding a response rate of 67%. Since it was not specified whether the responses came from program directors or designated faculty members, we will use “respondents” when reporting these results. Because of the small sample size, the results are reported by counts and percentages. Base numbers are included for each question; some questions had smaller base numbers because of previous response and skip patterns. Responses of “don’t know” and “missing responses” were included in the base numbers if appropriate. Salient findings from the survey are listed in the Table .

Table
Salient findings from a 46-question survey of orthodontic graduate programs in the United States and Canada (46 of 69 orthodontic residency programs responded)
  • 1.

    Didactic educational component of TMD and OFP

    • Formal teaching about TMD and OFP is included in most programs (40 or 87%).

    • Written examinations are most often used to evaluate the competency of residents in TMD and OFP.

    • Faculty from the orthodontic department or other faculty in the same institution teach most subjects related to these topics.

  • 2.

    Didactic educational component of occlusal relationships

    • Static and functional occlusion concepts are taught separately from TMD and OFP in about half of the programs; the others teach them simultaneously.

    • Occlusal relationship concepts are taught in the first year.

    • Guidelines for functional occlusion most often mentioned were “working-side guidance must be either canine rise or group function” and “cases must have anterior disclusion.”

    • Most programs (28 or 61%) believe it “very important” to finish cases to ABO phase III standards.

  • 3.

    Clinical education and case management of occlusal relationships

    • Centric relation is defined as an “antero-superior” position in half of the programs (24 or 52%).

    • Slightly more programs (28 or 61%) treat patients “most often” to a defined centric relation position.

    • Most programs (31 or 67%) do not “often” routinely mount study casts on articulators.

    • Nearly half (22 or 48%) recommend “canine guidance” when finishing cases.

  • 4.

    TMD screening, diagnosis, and management

    • Most programs (37 or 80%) have screening examinations that “always” look for sign or symptoms related to the TMJ and related musculature.

    • Most programs (35 or 76%) assess joint sounds with “digital palpation.”

    • Many programs (20 or 43%) use “panoramic radiographs” for imaging followed by “cone-beam CT” if TMD sounds are detected with no other symptoms.

  • 5.

    TMD problems arising during or after treatment

    • When TMD signs or symptoms arise during orthodontic treatment, the most common protocol is to “modify the orthodontic treatment plan to minimize forces on the TMJs.”

    • When a patient in retention has TMD symptoms, slightly more than half of the programs (25 or 54%) “request the patient to come in for an evaluation and refer them for treatment.”

Survey methods and results

To obtain information about how the topics of occlusion, TMJ, and TMD and OFP are taught in advanced education programs in orthodontics, a questionnaire was designed to gather feedback from orthodontic program directors in the United States and Canada. Since no previous studies have used a survey methodology to address these topics specifically, we had to compose and arrange appropriate questions. Initially, each author (all of whom except D.C. are orthodontic educators with expertise in occlusion, TMJ, OFP, and TMDs) independently wrote questions for this survey. The questions were then compiled and reviewed by each investigator. After a series of e-mails and telephone discussions, a final list of questions was selected. At this point, the survey was presented to several orthodontic faculty and practitioner colleagues for their review and input, but these persons were not part of the actual survey. Additionally, a professional market researcher (D.C.) facilitated the design, execution, analysis, and reporting of the research, using state-of-the-art tools and industry practices.

An e-mail invitation from an author (J.S.) was sent to all graduate orthodontic program directors in the United States and Canada (n = 69), requesting participation in an online survey. The program directors were asked to respond on behalf of their institutions or to forward the survey to the faculty member who was most responsible for these educational components. The introductory letter stipulated that this survey was about how the subjects of occlusion, TMJ, and TMD and OFP are taught in their programs. The online survey was posted from September 16 to November 23, 2009.

The survey questionnaire included 46 single-response, multi-response, and open-end questions, which allowed the respondents to write explanatory answers. The survey questions were divided into 5 broad areas: (1) didactic educational component of TMD and OFP; (2) didactic educational component of occlusal relationships and the TMJ; (3) clinical education and case management; (4) clinical TMD screening, diagnosis, and management; and (5) clinical TMD problems arising during and after orthodontic treatment.

Of the 69 orthodontic residency programs in the United States and Canada, 46 programs filled out the online questionnaire, yielding a response rate of 67%. Since it was not specified whether the responses came from program directors or designated faculty members, we will use “respondents” when reporting these results. Because of the small sample size, the results are reported by counts and percentages. Base numbers are included for each question; some questions had smaller base numbers because of previous response and skip patterns. Responses of “don’t know” and “missing responses” were included in the base numbers if appropriate. Salient findings from the survey are listed in the Table .

Apr 13, 2017 | Posted by in Orthodontics | Comments Off on Survey of orthodontic residency programs: Teaching about occlusion, temporomandibular joints, and temporomandibular disorders in postgraduate curricula
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