Orofacial pain as a new dental specialty

Background

The National Commission for Recognition of Dental Specialties and Certifying Boards (NCRDSCB) was created by the American Dental Association for independent assessment and recognition of new dental specialties to expand the profession of Dentistry into new fields of healthcare. In response, the American Academy of Orofacial Pain (AAOP) submitted a proposal to establish Orofacial Pain as a new dental specialty. To best understand this new Orofacial Pain specialty, it is helpful to review the definition and rationale for the dental specialty and how it can both improve care for patients and expand the profession of dentistry.

Definition of the discipline of orofacial pain

Orofacial Pain is the discipline of dentistry that includes the assessment, diagnosis, and treatment of patients with orofacial pain disorders, including temporomandibular disorders, masticatory muscle and joint disorders, oromotor and jaw behavior disorders, neuropathic and neurovascular pain disorders, orofacial sleep disorders, and chronic orofacial, head and neck pain, as well as the pursuit of knowledge of the underlying pathophysiology and mechanisms of these disorders. The prevalence of these conditions is listed in Table 1.

Table 1. The lifetime prevalence and need for treatment of orofacial pain disorders is comparable to the prevalence and need for treatment of most dental disorders, including caries, periodontal disease, and missing teeth. References are listed in the proposal to the NCRDSCB.

Orofacial Pain Disorders	% of Population
Temporomandibular disorders, including masticatory muscle and joint pain disorders	5–7%
Orofacial pain disorders (burning mouth, neuropathic, atypical pain, neurovascular)	2–3%
Headache disorder (tension-type headaches, migraine, mixed, cluster)	20%
Orofacial sleep disorders, e.g., sleep apnea, snoring	3–4%
Neurosensory/chemosensory disorders, e.g., taste, paresthesias, numbness	0.1%
Oromotor disorders, e.g., occlusal dysesthesia, dystonias, dyskinesias, bruxism	4.2%
Total Prevalence of Orofacial Pain Disorders	30–40%

Rationales for supporting specialty status for orofacial pain

Chronic pain is the most significant problem in health care today. It is the leading reason to seek care, the dominant cause of disability and addiction, and the primary driver of healthcare utilization, resulting in greater expenditures than for cancer, heart disease, and diabetes [1–4]. As a result, the nationwide chronic pain and opioid crisis is having a devastating personal effect on individuals, families, and communities and imposing enormous financial costs on federal, state, and local governments. Since 1999, the number of deaths from prescription opioids has more than quadrupled and is now over 40,000 deaths per year, a greater number than from motor vehicle accidents [4]. It is estimated that the costs to our communities and governments is at least $80 billion annually, while the financial impact on individuals and families is even more burdensome [4]. The human personal toll is enormous and lamentable. To reverse the chronic pain and opioid crisis, many respected national institutions, such as the Institute of Medicine, have recommended that all health professionals, including dentists, improve their recognition, training, and care of pain conditions [1–4].

The discipline of orofacial pain expands the profession of dentistry and improves care for patients with these goals

1. Increase access to care for patients with orofacial pain conditions by improving the knowledge base of Orofacial Pain, expanding the number of advanced education programs in Orofacial Pain, training all dentists and other health professionals in Orofacial Pain, and encouraging more dentists to pursue a career in Orofacial Pain.

2. Help Identify Orofacial Pain specialists with knowledge and experience in managing simple to complex orofacial pain problems and to provide a resource for patients and health professionals to refer patients.

3. Help address the chronic pain and opioid crisis by ensuring that the public is served and protected through recognition of an evidence-based standard of care for orofacial pain disorders.

4. Bring dentistry and medicine together in healthcare. Since specialists in Orofacial Pain are primarily reimbursed by medical health plans instead of dental insurance plans, dentistry will be closer to medicine and health care in general.

5. Support and expand the role of dentistry in the rapidly evolving field of pain management and science, broaden the scope of practice, and maintain a high profile in the rapidly evolving field of pain management.

National commission requirements for specialty status

For the past 40 years, the specialty of Orofacial Pain, through the AAOP, Commission on Dental Accreditation’s (CODA)-approved advanced education programs in Orofacial Pain, and the American Board of Orofacial Pain, has consistently met each of the American Dental Associations’ and National Commission Requirements of Specialty Status as documented at https://www.ada.org/en/ncrdscb. Here is a summary of these requirements:

Requirement 1

The American Academy of Orofacial Pain (AAOP) is affiliated with CODA-accredited advanced education programs in Orofacial Pain and a well-validated Certifying Board, the American Board of Orofacial Pain. However, several other organizations have collaborated on previous specialty efforts and contributed to further development of the field, including the American Academy of Craniofacial Pain, the American Equilibration Society, and the International College of Craniomandibular Orthopedics. Even though only one organization is involved with the National Commission, the specialty in Orofacial Pain is inclusive of specialists who limit their practices and are members of these other orofacial pain organizations.

Requirement 2

The specialty of Orofacial Pain is a distinct and well-defined field with unique knowledge and skills beyond those commonly possessed by dental school graduates. Orofacial pain disorders are not included in the CODA 2019 Standards for Pre-doctoral Dental Education Programs. Few dental schools provide a didactic course in orofacial pain disorders, and no dental school requires a pre-doctoral rotation in orofacial pain clinics. Most community dentists would like their patients with orofacial pain disorders to see a specialist. They recognize that these patients are complex, requiring special knowledge, unique skills, and a team approach that can best address chronic pain, physical, behavioral, psychosocial, and addiction issues.

Requirement 3

The specialty of Orofacial Pain also requires advanced knowledge and skills that are separate and distinct from and not included in any of the currently-recognized dental specialties. Although several specialties provide knowledge and skills in some orofacial pain areas, such as oral surgeons performing TMJ surgery and endodontists treating dental (usually acute) pain, this knowledge and these skills are limited to a defined skill set that are not included in Orofacial Pain Standards. This is reinforced by the recent survey of community dentists, which found nearly all general dentists desire to refer their patients with orofacial pain disorders to an Orofacial Pain specialist.

Requirement 4

The specialty of Orofacial Pain and orofacial pain specialists have actively contributed to new knowledge with scientific studies and publications in its international journal, the Journal of Oral & Facial Pain and Headache (the official Journal of the American, European, Asian, Australian, and New Zealand Academies of Orofacial Pain), as well as many other scientific journals in both dentistry and medicine. The journal publications have resulted from extensive orofacial pain research over the past 40 years, with funding from the National Institute of Dental and Craniofacial Research and other granting agencies. Clinical and research advances have helped define underlying mechanisms, diagnostic criteria, etiology, treatment efficacy, surgical and non-surgical outcomes, and other areas of essential knowledge to improving care. Yet, there is still a strong need for more research in Orofacial Pain, as determined by the recent National Academy of Science Committee on TMD (2019).

Requirement 5

The specialty of Orofacial Pain and orofacial pain specialists have increased access to evidence-based care for patients with these disorders. Specialists in the field of Orofacial Pain have developed and published consensus and evidence-based diagnosis and treatment guidelines that have been widely accepted nationally and internationally by most dental organizations, insurance providers, and government agencies. American Board of Orofacial Pain (ABOP) certified dentists follow these guidelines closely. Table 2 includes a list of evidence-based treatments used by Orofacial Pain dentists that have clinical trials and systematic reviews to support the use of these treatments.

Table 2. The scientific evidence of treatments for orofacial pain disorders reviewed 591 published clinical trials. The references are listed in the proposal to the NCRDSCB.

Intervention	Scientific Basis	Evidence-based treatments covered by health plans
Self-management training	Systematic reviews of clinical trials for exercise and cognitive-behavioral therapies	Exercise Habit-reversal Mindfulness-based stress reduction Biofeedback, relaxation, meditation Cognitive-behavioral therapy
Intra-oral splints	Systematic reviews of clinical trials for intra-oral splints	Full coverage stabilization at night Repositioning splints at night Immediate splints short-term Anterior bite plane short-term
Medications	Systematic reviews of clinical trials for analgesics, muscle relaxants, and sleep medications. Opioids have not been studied with clinical trials for orofacial pain	NSAIDs Acetaminophen Tricyclic medications Muscle relaxants Sleep medications Migraine medication Neuropathic medication
Physical therapy	Systematic reviews of clinical trials for therapeutic exercises, mobilization, and modalities	Therapeutic exercises Mobilization Ultrasound EGS, TENS and micro-current Iontophoresis
Injection and needle therapy	Systematic reviews of clinical trials for muscle injections, Botox®, acupuncture, and dry needling	Dry needling Trigger point injections Botox injections Steroid joint injections Arthrocentesis
Dental occlusal care	Some clinical trials but no systematic reviews	Occlusal equilibration Occlusal treatments for unstable malocclusions
TMJ and orofacial surgery	Some clinical trials but no systematic reviews	Need to meet criteria for surgery for disc repair, arthroscopic surgery, and discectomy, total joint prosthesis as performed by oral and maxillofacial surgeons

Requirement 6

There are currently 12 formal advanced education programs of at least 2 years in the specialty of Orofacial Pain that are accredited by CODA. These formal advanced education programs in Orofacial Pain have been established in accredited dental schools to train future specialists in Orofacial Pain. The total first-year enrollment of residents in all 12 advanced education programs in Orofacial Pain is 35. With at least 10 million people with orofacial pain disorders that require care, there are over 9.7 million people left untreated. With this prevalence, it is estimated that 10,000 more Orofacial Pain dentists are needed, comparable to the number of oral and maxillofacial surgeons and endodontists in practice currently. Support for a specialty in orofacial pain will increase the number of specialists and also highlight the importance of training all dentists to care for those patients with less complex orofacial pain disorders.

Summary

In summary, recognition of Orofacial Pain has been a high priority for the profession of dentistry for the past 30 years because of the lack of access to care for these patients. The specialty has worked to improve access to quality care and address the chronic pain and opioid crisis, as dentists collaborate with colleagues in medicine and other healthcare professions to ensure these patients have successful care. The specialty is expanding the profession of dentistry to help the millions of patients who are currently suffering from orofacial pain disorders. This is possible without jeopardizing the scope of practice of either general dentistry or any existing dental specialty. Support of the specialty of Orofacial Pain will ensure that dentists who limit their practice in this field will be properly trained, knowledgeable, experienced, and Board-certified. In turn, graduate programs will attract the highest-quality candidates to training beyond the undergraduate dental curriculum. These candidates will also gain the knowledge, experience, and credentialing to provide high quality care to these patients. A specialty in Orofacial Pain sets the standard for reliability and accountability of evidence-based care in the field of Orofacial Pain and maintains consistency with current standards practiced in pain medicine, physician clinics, medical centers, and hospital practices. In addition, a specialty in Orofacial Pain will increase public confidence, reimbursement of care by health insurers, and recognition of Orofacial Pain dentistry by medical colleagues, thereby increasing access to care. Thus, it is time for the profession of dentistry to recognize and support this new dental specialty of Orofacial Pain.