The New Specialties of Orofacial Pain and Oral Medicine: Practical Strategies to Improve Access to Care for Orofacial Disorders

ABSTRACT

Orofacial disorders are common and complex disorders with an estimated collective prevalence of over 40% of the general population. To improve access to care, orofacial pain and oral medicine have now been recognized as dental specialties. Thus, it is recommended that all dental schools and other health professional schools increase pre- and post-doctoral education, patient care, clinical training, and research on these conditions. This paper reviews the barriers and solutions to improving access to quality, effective, and affordable care for oral and facial disorders to prevent complications, chronic pain and the negative impact on the lives of those who suffer from them.

KEYWORDS:

• bruxism
• burning mouth
• chronic pain
• headache
• orofacial pain
• oromotor disorders
• oral medicine
• oral lesions
• sleep apnea
• temporomandibular disorders

Introduction

Orofacial disorders such as temporomandibular disorders, headache, burning mouth, oral lesions, xerostomia, dental sleep disorders and others are common and complex disorders with an estimated collective prevalence of over 40% of the general population (Table 1).^1–23 Because oral and facial structures also have close association with functions of eating, communication, sight, and hearing as well as form the basis for appearance, self-esteem and personal expression, pain and disorders in this region can deeply affect an individual.^22–25 Additionally, oral and facial disorders can be a manifestation of systemic disease as well as have an impact upon systemic health.^26–28

Table 1. Estimated prevalence of orofacial disorders that require special diagnostic and treatment needs.^9–23.

Orofacial disorders	Estimated prevalence
Temporomandibular disorders	5–7%
Orofacial pain disorders (burning mouth, neuropathic, atypical pain, neurovascular pain)	2–3%
Headache disorder (tension-type headaches, migraine, mixed, cluster)	20%
Orofacial sleep disorders (e.g. sleep apnea, snoring)	3–4%
Neurosensory and chemosensory disorders (e.g., taste, paresthesias, numbness)	0.1%
Oromotor disorders (e.g., occusal dysethesias, dystonias, dyskinesias, bruxism)	4%
Oral lesions (herpes, apthous, pre-cancer, cancer)	3–5%
Oral mucosal disease (e.g., lichen planus, candida)	1–2%
Salivary disorders and xerostomia	2%
Oral systemic disorders (e.g., oral effects of autoimmune, cancer, AIDS, heart disease)	2–3%
Total estimated prevalence in general population	42% to 50%

To improve access to care for these conditions, orofacial pain and oral medicine are now recognized as dental specialties by the National Commission of Dental Specialties, the American Dental Association, the American Board of Dental Specialties, and the Council on Affordable Quality Healthcare (CAQH).^29–32 Both specialties have advanced specialty training programs in dental schools that integrate dentistry and medicine, national board-certification, and successful clinics to improve evaluation, diagnosis, and management of these conditions using evidence-based care and team management.

Despite the development of these new specialties, access to care for patients with TMD, orofacial pain, oral medicine, and dental sleep disorders is limited due to many barriers to care including;

• A limited number of care providers specialize in orofacial pain and oral medicine.

• Schools of dentistry, medicine, and other health professions often do not include TMD, oral and facial disorders , and dental sleep conditions within their pre-doctoral or post-doctoral curriculums.³³

• Care of patients with orofacial disorders can be complex with multiple symptoms, co-morbid conditions, and concomitant systemic conditions that often confuse health professionals resulting in trial and error treatments.^34–42

• The etiology of orofacial conditions including onset factors, risk factors, and protective factors can be diverse and requires both treatment of the condition and management of etiologic factors that involves a whole-person approach to care with collaboration and team management.^40–49

• Since orofacial care lies between medicine and dentistry, both medical and dental health plans may not cover the cost of care and often exclude it in standard commercial and national health insurance policies or the plans may create barriers to reimbursement with complex policy guidelines.⁵⁰

The purpose of this paper is to review these and other barriers and provide solutions for health professionals to improve the quality, effectiveness, and affordability of care for patients with TMD, orofacial pain, oral medicine, and dental sleep disorders and help our health care system prevent chronic pain and its devastating effects.

The Impact of Limited Access to Care

Access to care is defined as the timely use of needed health care services for health conditions to achieve the best long-term health outcomes for a population. High-quality access to care involves many factors including:

• Availability of health care providers with expertise and qualifications to provide culturally competent evidence-based care for the presenting condition.

• Ability and timeliness to receive care when the need is recognized.

• Affordability of care that facilitates entry into the health care system.

• Acceptability of the care to achieve optimal long-term health outcomes.

Lack of Education

Access to care for orofacial conditions is limited by the lack of sufficient numbers of pre-doctoral and post-doctoral training programs that focus on these conditions and the lack of recognition of these specialties by health care entities including health systems, health plans, and health care organizations. A survey of medical and dental health professionals found that 95% choose to refer these patients to an orofacial pain dental specialist due to insufficient training and the complexity of care required.⁵⁰ Most dentists and dental students surveyed stated that they feel poorly prepared for the diagnosis or treatment of orofacial pain.^50–52 These statistics are similar for oral medicine as well. Thus, patients with these conditions often see an array of medical and dental specialists with trial-and-error treatments such as long-term opioid analgesics, polypharmacy, implantable devices, injections, occlusal reconstruction, irreversible jaw repositioning, or surgeries. Many of these treatments have higher risk, lack research on their long-term efficacy, and increase health care costs. Yet, clinical trials have shown that comprehensive patient-centered rehabilitation approaches for TMD and orofacial pain conditions such as splints, exercise, physical therapy, cognitive-behavioral training, and non-opioid pharmaceuticals have the best long-term outcomes.¹³ The utilization of trained specialists in oral medicine and orofacial pain can better ensure that accurate diagnoses will be made and appropriate, proven therapies are applied, resulting in better health outcomes.

Personal Impact

Patients with orofacial disorders often suffer for many years before finding care with a specialist. For example, in one study, the average number of clinicians seen by orofacial pain patients prior to seeing an orofacial pain dentist was 4.5 and the mean number of previous clinicians was 5.3 prior to seeing an orofacial pain dentists.¹³ These numbers are similar for oral medicine referrals as well. If recognition and treatment of the problem by clinicians is inadequate or inappropriate, the personal impact can be tragic and the costs great. The pain becomes entrenched in the patient’s life with the development of dependencies, functional limitations, disabilities, and consequential behavioral, emotional, and psychosocial problems. They present a frustrating medical and dental picture with patients undergoing costly surgeries, diagnostic tests, long-term medications, and an ongoing dependency on the health care system.^17–19 In addition, some conditions such as bacterial or viral oral infections, candidiasis, and pre-malignant erosive oral lesions may progress to cancer or systemic disorders with significant health consequences. A study of the impact of pain on the workplace found that 156.9 million work days are lost due to head pain and over 50% of this head pain is related to orofacial pain disorders.^5–7 These studies collectively provide convincing support that there is a significant unmet need for care in the general population and that the demand for quality successful care for oral and facial disorders is not being met by general dentists, physicians, and existing specialists. The negative personal and lifestyle consequences of inadequately treated orofacial conditions warrants referring care to experienced clinicians instead of trial-and-error treatments.

High Cost

Poor recognition and understanding of these conditions by health professionals can result in an annual total cost of care for these patients that is substantially higher than those without the conditions.^50–55 A study published in Pain Practice found that pain conditions, including head, neck, and orofacial pain, cost patients $31,692 per patient, per year. This cost increased by 29% in the second year of the study.⁵¹ The researchers examined medical records and claims from 12,165 patients at the Henry Ford Health Care System to assess the overall cost and demand for resources triggered by 24 different chronic pain conditions during calendar year 2010.⁵¹ Except for pharmacy visits, the most common resource was an outpatient visit, at a mean 18.8 visits per patient. Of these visits, 59% represented specialty consultations. Chronic pain complaints resulted in a mean of 5.2 discrete imaging tests per patient. Almost 39% of patients were prescribed opioid medication for their condition. Pain conditions such as arthritis, head, neck, and orofacial pain were associated with the highest overall costs. Another study of the Trillium health plan in Oregon evaluated the cost of health care for members with and without a pain condition. For members without a pain condition, the cost was $245 per member per month (PMPM) or $2,940 per year, while the cost for members with a pain condition was more than four times higher at $1,023 PMPM or $12,276 per year.⁵² This research supports the need for comprehensive integrated care programs that include evidence-based conservative treatment with self-management training to improve long-term patient outcomes and lower long-term costs. Orofacial care dentists are trained in this model of transformative team care.

Lack of Health Plan Reimbursement

The plight of the patient with oral and facial disorders in seeking health care can also be challenging due to the limited reimbursement of care for these problems. Lack of reimbursement has led to delayed recovery, patient frustration, neglect of the problem, overuse of medications, and progression of the pain and illness. As a result, many states and the Centers for Medicare and Medicaid have determined that orofacial disorders are medical in nature and should be covered by medical health plans regardless of whether a dental or medical professional provides care.⁵⁶ Even with these regulations, many health plans have added language to their health care policies to create barriers to exclude or limit coverage of orofacial disorders and specific treatments such as protective intraoral splints. They have also created challenging clinical guidelines and strict prior authorization requirements and frequently deny care or cover only high-risk, high-cost surgical treatment. Most patients do not require surgery and are successfully treated with rehabilitation modalities such as self-management strategies, intra-oral splints, physical therapy, cognitive-behavioral therapy, or non-opioid medications. Patients often select surgical care over rehabilitation because of insurance coverage, not necessarily because the care is appropriate.

Some states have responded to these discriminatory policies of insurance companies by issuing regulations that prohibit discrimination against patients with these conditions. For example, the Minnesota Legislature passed policy 62A.043 stating that any policy or certificates of health, medical, hospitalization or accident and sickness insurance regulated by the state must specifically provide the same coverage for surgical and non-surgical treatment of temporomandibular disorders and orofacial conditions as coverage for treatment to any other joint in the body administered or prescribed by a physician or dentist.⁵⁶ As a result, discriminatory practices by health plans to deny coverage for these conditions are determined by state commerce departments and insurance regulators as both unethical or illegal. However, insurance plans including Medicare and Medicaid still deny coverage for essential services for patients with oral and facial disorders including therapeutic intraoral TMD splints. In addition, many health plans create barriers to care such as complex, confusing or hidden policy requirements that limit or deny access to care.⁵⁷ Some patients with denials have worked diligently to educate health plans to change policies and bring orofacial and oral medicine specialists into the network. To improve reimbursement, patients can file complaints to the state’s commerce department, the National Government Services (NGS), or their state government representatives to report that a health plan policy is discriminatory.

Progression of TMD and Orofacial Pain

Oral and facial pain conditions often begin with mild pain and dysfunction. However, if not treated successfully at the early stage, they can progress to severe chronic pain in the jaw, face, head and neck. Successful management of these disorders can usually be accomplished with rehabilitation treatment such as physical therapy, splints, cognitive-behavioral therapy, self-care and, if needed, medications, injections or surgery. If successful treatment is not available or is denied by health plans, the personal consequences can be tragic and the costs great. The pain may become entrenched in the patient’s life with the development of functional limitation, missed work, disability, emotional stress, and behavioral and psychosocial problems. A Harris Poll estimates that 156.9 million work days are lost due to head pain.⁵³ A frustrating medical and dental picture can result involving multiple surgeries, diagnostic tests, long-term medications, emergency room visits, and on-going dependency on the health care system.

Research has found that more than half of the persons seeking care for orofacial pain conditions at one month still have chronic pain five years later due to lack of appropriate care and up to 20% develop long-term disability.^58–62 These problems exist because of patient-centered risk factors that cause delayed recovery and chronic pain. This delayed recovery is primarily due to many patient-centered risk factors not addressed in routine care, including poor ergonomics, repetitive strain, prolonged sitting, persistent stressors, sleep difficulty, anxiety, depression, and many others that increase peripheral and central pain sensitization.^58–62 If usual care fails, clinicians and patients often escalate care to passive higher-risk interventions such as opioids, polypharmacy, surgery, or extensive medical and dental treatment instead of training patients to reduce the risk factors that drive chronic pain.^32,33,63,64 Yet, clinical trials have shown that the long-term outcomes of passive interventions are no better and are in many cases, worse than patient-centered approaches that activate and empower patients with self-management strategies such as cognitive behavioral therapy (CBT), therapeutic exercise, and mindfulness-based stress reduction.^65–70

Progression of Oral Lesions

Clinicians also encounter various oral lesions in everyday practice. Oral lesions can arise from a range of different etiologies including infective, idiopathic, inflammatory, reactive and neoplastic changes.^71–74 A clinician should obtain a thorough clinical history and have adequate knowledge of the signs and symptoms to establish the correct diagnosis and treatment. Factors such as the location and size of the oral mucosal lesion, its color and morphology and selective biopsies are required to make a proper diagnosis and treatment. Biopsies, pathological analysis and tracking changes in the lesion are required to ensure it resolves or to determine if it needs to be removed to prevent increasing pathology or progression to cancer. In one study of oral lesions, malignant transformation (MT) of oral leukoplakia, including classic and differentiated epithelial dysplasia, progressed to malignancy in 23% of the patients with an annual MT rate of 4.9% (95% CI: 3.5–6.6), remained consistent. High-risk subsites such as the tongue and floor of the mouth were clinical predictors for MT.⁷⁴

Need for Evidence-Based Care

The lack of access to care for orofacial disorders has led to a proliferation of expensive non-evidence-based treatment strategies marketed directly to the patient by providers.^56,57 For example, repositioning dental splints used 24 hours per day, occlusal expanders, and partial coverage splints can change the occlusion permanently, create malocclusions and, in some cases, cause loss of teeth. These occlusal changes will often require orthodontics, prosthodontics care, dental implants, or orthognathic jaw surgery to allow stable occlusions and normal function.^1,64 The use of electronic surface EMG, jaw tracking and other diagnostic tests that do not have sufficient evidence of reliability and validity for TMD, orofacial, and dental sleep conditions have also been promoted, as well as the use of some long-term medical treatments that have questionable long-term efficacy including opioid analgesics, repeated high-risk surgeries or pain implant interventions.^32,33,63 Clinical trials and systematic reviews have found that patient-centered rehabilitation approaches such as intra-oral splints, physical therapy, cognitive-behavioral training, mindfulness, and self-management techniques such as exercise and relaxation are effective and able to prevent long-term chronic pain, addiction, and disability.^65–70 The specialty of orofacial pain through the American Academy of Orofacial Pain and the specialty of oral medicine through the American Academy of Oral Medicine have provided evidence-based guidelines that promote safe evidence-based treatments that can be integrated into patient self-management training to prevent chronic pain, persistent oral lesions, and their consequences.^{34–36,75,76}

Solutions to Improve Access to Care

While dental care utilization is at its highest level ever among children, utilization among adults is in a decline with only 35.4% of working-age adults visiting the dentist.⁷⁷ Furthermore, caries, periodontal disease, and loss of teeth have declined in the past 30 years in adolescents and adults. Overall, one of the top reasons for not seeking care include having a healthy mouth (i.e., not needing dental care) and not having time to get to a dentist. With the high prevalence of orofacial disorders, dentists are recognizing the need to expand their scope of practice to these disorders.^77–82 Thus, there is an opportunity for the profession of dentistry to expand care into orofacial pain and oral medicine by improving education, patient care, and research in these new fields. Efforts by the American Academy of Orofacial Pain and the American Academy of Oral Medicine have provided a framework for improving access to care in clinical practices, dental and health professionals schools, professional associations, and state boards of dentistry, which are needed to ensure quality, affordable, and effective care for patients. Here is a summary of these recommendations:

Expand Clinical Practice for Patients With Orofacial Disorders

An expansion of successful clinical practices that are inclusive of TMD, orofacial pain, oral medicine, and sleep disorders is needed to improve access to care. These practices include:

• Screen dental patients for orofacial disorders in general dentistry and specialty dentistry practices. Because dental care can cause or aggravate orofacial disorders, each patient should be screened prior to and after dental treatment with brief questions to help identify TMD, orofacial pain, oral medicine, and sleep disorders. If they need immediate care for these conditions, initial care can be provided and a referral made to a specialty practice in orofacial disorders. Table 2 lists a sample of a screening survey for patients with orofacial conditions.

  Table 2. Dental screening survey to identify TMD, orofacial pain, oral medicine, and dental sleep disorders.

  Please complete this brief assessment of signs and symptoms so we can ensure safe dental care and prevent progression of these disorders.
  Do you have any of the following signs or symptoms regularly (more than 1 per week)?
  Headache in the temple, forehead, or back of head			O Yes	O No
  Jaw and facial pain			O Yes	O No
  Clicking or locking when moving the jaw			O Yes	O No
  Difficulty or pain in the jaw on opening or chewing			O Yes	O No
  Earache, ear ringing, fullness or plugged ears			O Yes	O No
  Pain in one or multiple teeth			O Yes	O No
  Mouth, cheek, or tongue pain			O Yes	O No
  Neck or shoulder pain			O Yes	O No
  Poor sleep and waking up frequently			O Yes	O No
  Snoring or breathing noises during sleep			O Yes	O No
  Sores or lumps in the mouth, tongue, or throat			O Yes	O No
  Dry or burning mouth or tongue			O Yes	O No

  If you have any of these symptoms, please tell your dentist or physician. In addition, you can schedule a visit with an orofacial pain or oral medicine specialist to evaluate and help you manage and prevent the pain, dysfunction, or orofacial condition. You can find a specialist through the American Academy of Orofacial Pain at www.aaop.com or the American Academy of Oral Medicine at www.aaom.com.

• Expand interdisciplinary specialty clinical practices in orofacial pain and oral medicine using current models. Specialty clinics can be found at the websites for the American Academy of Orofacial Pain (AAOP.org) and the American Academy of Oral Medicine (AAOM.com). Within these practices, the orofacial pain and oral medicine specialists collaborate with health professionals in medicine, physical therapy, health psychology and health coaching to support successful interdisciplinary clinics. These organizations provide guidelines and support for successful implementation of clinical practices using evidence-based national best practices.

• Implement a full range of evidence-based care for orofacial disorders consistent with clinical guidelines. Clinical guidelines developed by AAOP and AAOM are available to provide guidance to care for patients with orofacial disorders.^34–37,76 Evaluation involves standardized diagnostic histories, examinations, and risk stratification tools in clinical practice including screening for high-risk/red-flag signs, symptoms, and risk factors to identify complex patients. These efforts include the decision-support tools with 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 or eventually to high-impact chronic pain. Once identified, a full range of evidence-based treatments including patient-centered rehabilitation approaches such as intra-oral splints, physical therapy, cognitive-behavioral training, self-management techniques such as exercise, mindfulness, and relaxation, medications, and, as needed, injections and surgery.

• Participate in a network of clinics that provide care for patients with orofacial disorders. Management support organizations have been developed to support clinical practices in orofacial disorders and improve access to care for these patients to help achieve the Institutes for Health Care Improvements triple aims.^83,84 These organizations can provide detailed clinical protocols, electronic health records, billing, and clinical support to help new clinics implement an evidence-based transformative care solution for patients with orofacial disorders. Information on how to collaborate with a team, governance and management, strategic planning, human resource management, employee handbook, third-party payers, managed care credentialing, revenue cycle, coding and billing, and other key elements is available to improve successful clinical practices.

Expand University-Based Education, Patient Care, and Research

To improve access to care, the American Academy of Orofacial Pain, the American Academy of Oral Medicine, he Commission on Dental Accreditation (CODA), the National Academy of Science, Engineering and Medicine (NASEM) report on TMD (2020), and the NASEM Report on Relieving Pain in America (2011) recommends that all dental schools and other health professional schools increase pre- and post-doctoral education, patient care, clinical training, and research on TMD, orofacial pain, oral medicine, and dental sleep conditions. Dental schools are now required by the Commission for Dental Accreditation to teach TMD, orofacial pain and oral medicine at the pre-doctoral dental student level.^1,85–87 However, dental schools should consider many additional activities to further expand the profession into these fields and improve access to care. These include:

Study the Prevalence, Impact and Understanding of Orofacial Disorders in Students and Faculty

To increase awareness of these conditions, each dental school should conduct a survey of the students and faculty to determine the prevalence of TMD, orofacial pain, oral medicine and sleep disorders, the impact on their daily lives, and their understanding of the evaluation, diagnosis, and management of these conditions. Based on other recent studies,^88,89 study materials can be provided to any dental school to integrate the data and become part of a national study.⁸⁹

Offer Pre-Doctoral and Continuing Education Courses in Dental Schools on Orofacial Disorders

To meet both the CODA requirement and the American Academy of Orofacial Pain (AAOP) TMD curriculum guidelines for pre-doctoral education in TMD, dental schools are recommended to provide education on TMD to dental students, dentists and other health professionals.^85–87 A dental school can either hire a, orofacial pain and oral medicine specialist or offer an on-line course that is available for either pre-doctoral students or continuing dental education. A 16-hour on-line TMD course based o AAOP pre-doctoral guidelines is available for dental schools at www.tmd-education.com. These courses will support further education, patient care, clinical training, and research in the specialty of orofacial pain.

Implement TMD, Orofacial Pain, Oral Medicine, and Sleep Clinic Education in Dental Schools

This will improve access to care for patients with these conditions at the university and in surrounding communities. Specialists in orofacial pain and oral medicine need to be added to the school faculty, and a management support organization can support the business side of a clinic.⁸³ Once a clinic is established, an advanced education program in orofacial pain and oral medicine can also be established.

Offer Advanced Education Programs in Orofacial Disorders

Specialty training in orofacial disorders will improve access to care for patients suffering these conditions in the state where the dental school resides. This includes professional residency in clinical practices in the community and practice management services to support successful clinical care. CODA Advanced Education Guidelines and orofacial disorders faculty are available through AAOP to support schools of dentistry interested in hiring a faculty in orofacial pain.^90,91 The orofacial disorders curriculum must also include courses on practice management, differential diagnosis, interdisciplinary team management and prevention of chronic pain and opioid misuse. All evidence-based care should be included in the curriculum including Botox and trigger point injections, dental splints, self-care with personalized assessments and coach-based training in self-care, medication management, opioid use and misuse, and others.

Provide Interdisciplinary Education to all Health Professional Training Program

The National Academy of Science, Engineering and Medicine (NASEM) report on TMD (2020) and the NASEM Report on Relieving Pain in America (2011) recommend that all health care professionals including physicians, physical therapists, health psychologists, occupational therapist, and nurses receive training in the evaluation, diagnosis, and management of TMD and other orofacial disorders, including the criteria for referral between health professionals when appropriate.^1–3 Relevant dental, medical and nursing credentialing boards should also include orofacial disorders knowledge to ensure these conditions are sufficiently covered in its requirements and certification examinations.

Expand Centers of Excellence (COE) in Orofacial Disorders

The NASME Report on TMD supported the development of Centers of Excellence (CoE) in TMD and Orofacial Disorders to improve research, education, and access to care. Support is available from the National Institutes of Dental and Craniofacial Research for schools to participate in funded research to conduct studies on prevalence, impact, and basic neuroscience mechanisms to broaden our understanding of these conditions.¹

Expand State Dental Boards and Professional Organizations’ Efforts To Improve Access to Care for Orofacial Disorders

State boards of dentistry and professional organizations can play a significant role in improving access to care for patients who suffer from these disorders. These include:

1. State dental boards can grant specialty licenses for orofacial pain and oral medicine specialists. To encourage specialists to establish clinical practices in a state, a state dental board can approve specialty licenses for trained and board-certified specialists in orofacial pain and oral medicine even if they have foreign-trained dental degrees. Boards need to support professional announcements and increasing awareness of these specialists consistent with the state board regulations. The board can also recognize the full scope of care for these conditions including utilization of “evidence-based” assessment, diagnosis, management, care coordination, and prevention of orofacial disorders and related addiction, impairment, disability and other negative sequelae.

2. Collaborate with health plans in each state to reimburse all services for orofacial disorders. As noted earlier, many health plans create barriers to care such as complex, confusing, or hidden policy requirements that limit or deny access to care.⁵⁷ Although patients with denials can file complaints to the state commerce department to indicate if a health plan policy and denials are discriminatory, state and national associations need to develop clinical guidelines for these conditions to collaborate with health plan to ensure reimbursement of care. Care should include all procedures related to the assessment, diagnosis, management, and prevention of orofacial disorders including intraoral orthopedic TMJ splints. Health plans should reimburse care on an equal basis regardless of whether the covered services and procedures are provided by a licensed dental specialist or physician. Providers could also then be credentialed as an in-network provider for consistent reimbursement and referrals for care for patients with orofacial disorders.

3. Promote use of evidence-based clinical practice guidelines. Clinical and practice guidelines provide both orofacial pain specialists and other dental and health professionals with evidence-based clinical information to guide prevention, evaluation, diagnosis, initial treatment and, if needed, referral to orofacial pain and oral medicine specialists.^34–36,76 Clinical practice guidelines have been developed and are publicly available and widely disseminated to both consumers and health professionals and provide evidence-based pathways for the initial recognition and stepped-care management of TMDs and for specialty care for patients with TMDs. With clinical practice guidelines developed, clinical performance measures should be deployed in quality improvement initiatives.

4. State dental board should require continuing education (C.E.) on orofacial disorders and use of opioids in dentistry. All dentists and physicians licensed in a state should be required to take a C.E. course that summarizes best practices for prevention of chronic pain and addiction and initial management of orofacial disorders as well as prescribing opioids and controlled substances. State and national boards and associations can also promote C.E. education of evidence-based consensus clinical guidelines, best clinical practices and long-term outcomes, current research evidence, and collaboration between groups.

5. Websites using search engine optimization (SEO) can provide information for consumers, patients, and other health professionals. Professional association websites can provide content-based information to increase SEO for consumers and other health professionals. This will provide a better understanding of orofacial disorders, optimal evidence-based care and how to find an orofacial pain or oral medicine specialist when needed. When people search for medical information, they use Google and other search engines. In 2021, over 1 billion health‐related Google searches occurred each day.⁹² Health care associations need to expand their SEO to engage the public. SEO schema markup implementation is a newer code language for websites that can boost finding accurate and appropriate web pages.

6. Collaboration between health care organizations. Communication between health care organizations, such as the American Dental Association, the American Dental Education Association, the American Academy of Pain Medicine, the International Association for the Study of Pain, and other state and national dental and medical organizations, is also essential to improve access to care for patients with orofacial disorders

Conclusion

Orofacial disorders including TMD, orofacial pain, oral medicine, and dental sleep disorders are among the most common and complex pain disorders that present to health professionals. They often present with a confusing array of signs and symptoms that can deeply affect an individual physically and psychosocially, often leading to chronic pain and other negative consequences. If recognition and treatment of the problem by clinicians is inadequate or inappropriate or if health plans deny coverage and limit access to care, the personal impact can be tragic and the costs great. The pain and illness can progress and become entrenched in the patient’s life with the development of functional limitation, missed work, disability, emotional stress, and behavioral and psychosocial problems. Efforts by the American Academy of Orofacial Pain, the American Academy of Oral Medicine, the American Board of Orofacial Pain, the National Academy of Science, Engineering and Medicine (NASEM) report on TMD (2020), the National Commission of Dental Specialties, and other groups have begun the process to improve access to care. However, there is still much work to do to develop these specialties, including building clinical practices, improving health plan reimbursement, training dentists and other health professionals about these conditions, and ensuring that all state boards of dentistry recognize the need to train existing health professionals and encourage licensure for specialists in the field. Each of these will improve access to successful care for these patients.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

James Fricton

James Fricton, DDS, MS has devoted his career to patient care and research in temporomandibular and orofacial pain disorders and preventing chronic pain and addiction. He is a Professor Emeritus in the Schools of Dentistry, Medicine, and Public Health at the University of Minnesota and is the co-author of several books including TMJ and Orofacial Pain: Diagnosis and Orofacial Disorders: Current Therapies in Orofacial Pain and Oral Medicine. He takes great joy in helping patients with TMJ and orofacial, head and neck pain conditions and obstructive sleep disorders at the Minnesota Head and Neck Pain Clinic and He also has an on-line course on Preventing Chronic Pain: A Human Systems Approach at https://www.coursera.org/learn/chronic-pain

Nelson L. Rhodus

Nelson L. Rhodus, DMD, MPH, FICD, FRCSEd, FAAOM, Diplomate American Board of Oral Medicine, is a Morse Distinguished Professor and Director of the Division of Oral Medicine, Oral Diagnosis and Radiology in the Department of Diagnostic and Biological Sciences in the University of Minnesota School of Dentistry.