National Commission on Recognition of Dental Specialties and Certifying Boards

APPLICATION FOR RECOGNITION OF

Orofacial Pain
Submitted by the American Academy of Orofacial Pain (AAOP)

American Academy of Orofacial Pain

174 S. New York Ave, POB 478, Oceanville, NJ 08231
Tel: (609) 504-1311 Fax: (609) 573-5064

Jennifer Bassiur, DDS. President AAOP

Director of the Center for Oral, Facial, and Head Pain
Associate Professor of Dental Medicine at CUMC
Columbia University College of Dental Medicine

Contact person:
James Fricton, DDS, MS
Professor Emeritus, University of Minnesota School of Dentistry
Minneapolis, Minnesota 55455 Email: [email protected]

April 9th, 2019

____________________________________________________________________________

Material provided in the application for specialty recognition contains statements that represent conclusions of the
sponsoring organization. Recognition of a dental specialty by the National Commission on Recognition of Dental
Specialties and Certifying Boards is based on compliance with established Requirements and does not imply concurrence
1
with all of the statements presented in the sponsoring organization's application.

TABLE OF CONTENTS............................................................................................. 2

APPLICATION
Executive Summary.................................................................................................. 6
Introduction to the Application..................................... ………………………………. 15
I. Requirement 1: sponsoring organization with certifying board............................. 16
II. Requirement 2: knowledge and skills beyond pre-doctoral.................... ............. 33
III. Requirement 3: separate and distinct from any recognized specialty................. 43
IV. Requirement 4: substantial public need and demand that is not met................. 79
V. Requirement 5: benefits of clinical patient care .................................................. 96
VI. Requirement 6: Formal advanced education programs ................................... 100
Sample of curricula currently used ……………...................................................… 106
References.............................................................................................................. 115

APPENDICES
Appendix I
a) The American Academy of Orofacial Pain Constitution and Bylaws…………….. 121
b) The American Academy of Orofacial Pain 2017-2020 Strategic Plan…………… 136
c) The American Board of Orofacial Pain Constitution and Bylaws…………………. 139

Appendix II
a) Standards for Advanced Education Programs in Orofacial Pain ………………… 146
b) Self Study Accreditation Guidelines for Orofacial Pain………………………….… 160

Appendix III
Practice Survey of Orofacial Pain Dentists, Dentists and Dental Specialists in the
Upper Midwest……………………………………………………………………………… 229

Appendix IV
Educational efforts to support specialty status
a) Improving Access to Care for Patients with Orofacial Pain………………………… 243
b) Systematic Review of RCTs for Treatment of Orofacial Pain an
Temporomandibular Disorders including References ……………………………… 247
c) National Academy of Sciences Summary to 2019 Committee on Temporomandibular
Disorders (TMD): From Research Discoveries to Clinical Treatment…………………… 304

Appendix V. Letters from each institution's chief executive officer verifying sponsorship
of the program…………………………………………………………………………………. 321

List of Tables
Table 1. Characteristics and scientific evidence of different
treatments of orofacial pain by ABOP certified Orofacial Pain Dentists……………………… 9

Table 2. Prevalence of Orofacial Pain Disorders….……………………………………………. 9

Table 3. List of Advanced Education Programs in Orofacial Pain…………………………… 10

Table 4. AAOP 10 Year Membership Summary……………………………………………… 18

Table 5. The table lists the disorders that require advanced knowledge and skills
for diagnosis and management and whether they are included in either the

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pre-doctoral curriculum or treated in clinical practice in the community, based on the
clinical practice survey of 311 general dentists……………………………………………….. 34

Table 6. Reference to diagnosis and treatment of orofacial disorders in 2019

CODA Accreditation standards for existing dental specialties. (2) ………………..……..….. 43

Table 7. Treatment and Referral Practice Patterns for Orofacial Pain (OFP) Dentists (n=120),
General Dentists (n=329) and Dental Specialists (n=97) Relative to
12 Orofacial Pain Disorders. (Appendix III)…………………………..………………………..… 44

Table 8. Orofacial Pain skills that are not included in the scope of other recognized
specialties as indicated by the 2019 accreditation standards…………………………………. 65

Table 9. The lifetime prevalence and need for treatment of orofacial pain disorders
compared to caries and periodontal disease…………………………………………………….. 79

Table 10. Referral sources for patients of Orofacial Pain dentists (Survey of AAOP members)… 85

Table 11. The estimated need for Orofacial Pain dentists nationally over the next 5
years based on health services rates of treatment need, current numbers of orofacial
pain dentists, and patient load.……………………………………………………………. 88

Table 12. Information on advanced Orofacial Pain programs that are a minimum of
2 years for 1997-98............................................................................... ........................ 96

Table 13. Data regarding the training of Orofacial Pain dentists from
the survey of AAOP membership...............………………….............................……........... 98

Table 14. A summary of information on enrollment in advanced educational Orofacial

Pain programs…………………………......................................................................... 98

Table 15. Comparison of the numbers of additional Orofacial Pain dentists that
are needed in the field in selected regions and nationally to the number of specialists
that will complete a graduate program in the next year and 5 years..................................... 99

List of Figures
Figure 1. Limited access to care for patients with orofacial pain………………………..…… 10

Figure 2. The percentage of patients with orofacial pain disorders presenting to a

general dentist(n=311) or dental specialist office(n=96) who are treated versus
those who rather refer to another specialist……………………………………………………….. 42

Figure 3. The percentage of general dentist(n=311) or dental specialist office(n=96)

who either currently do or would prefer to refer these patients to an orofacial pain dentist…. 42

Figure 4. The reasons that general dentists(n=311) and dental specialists(n=96)

state for referring these patients instead of treating them……………………………………… 42

Figure 5. The figure illustrates that many of the patients have a high number of
previous clinicians, previous treatment, and many years with pain prior to being
referred to an Orofacial Pain dentist……………………..………………………………............ 83

Figure 6. The percent of dentists currently devoting full-time to the practice

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of Orofacial Pain. ………………………………………..…………………………………………. 86

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 NATIONAL COMMISSION ON RECOGNITION OF DENTAL SPECIALTIES AND CERTIFYING BOARDS

PERMISSION TO PUBLISH
APPLICATION FOR RECOGNITION AS A DENTAL SPECIALTY
The National Commission on Recognition of Dental Specialties and Certifying Boards has sole responsibility
related to the recognition of special areas of dental practice and, in that capacity, obtains applications for
specialty recognition, including exhibits and supplemental material (the “Specialty Application”). The
undersigned hereby grants its full permission and authorization to the National Commission to republish, post
and otherwise use or make available the Specialty Application in various ADA publications, including but not
limited to the National Commission’s website. Furthermore, the undersigned consents to the reproduction,
display, transmission and use of the Specialty Application by the National Commission on a perpetual basis,
worldwide, without charge, in any media now existing or hereafter created, including, without limitation:
brochures, periodicals, Internet, Intranet, websites and CD-ROMs, and to receive or otherwise use the
Specialty Application in electronic format as well as print or any other media.

The undersigned, for itself and all its agents, assigns and successors, hereby waives all rights to any
consideration, whether by payment of money or otherwise, for time and expenses, and for the reproduction,
display, transmission and use of the Specialty Application. Further, the undersigned, for itself and all its
agents, assigns and successors, hereby releases and forever discharges the National Commission and its
permittees, their respective subsidiaries, affiliates, officers, trustees, directors, employees, agents, insurance
carriers, predecessors, successors, heirs and assigns, and any others acting with their permission or under
their authority from: (1) any and all claims arising out of the foregoing, including but not limited to any claims for
blurring or distortion or for failure to exercise such right to use the Specialty Application; and (2) any and all
past and present claims, demands and causes of action of any nature whatsoever that we had, have or may
hereafter claim to have, whether directly or indirectly, whether based on statute, tort, contract or otherwise,
whether known or unknown, suspected or unsuspected, foreseen or unforeseen, liquidated or unliquidated,
asserted or unasserted, arising in connection with the activities described above.

IN WITNESS WHEREOF, the undersigned, through its duly authorized representative, has executed this
Agreement on this 10thday of April, 2019

American Academy of Orofacial Pain

Name of Applicant Organization

Jennifer Bassiur, DDS, President of the American Academy of Orofacial Pain

Title

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EXECUTIVE SUMMARY
Chronic pain is, perhaps, the most significant issue 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 (1-2). As a result, the nationwide chronic
pain and opioid crisis is having a devastating 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 are now over 40,000 deaths per year, a greater number
than from motor vehicle accidents. (3) 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. (1-4)
The human toll is enormous and lamentable.

To reverse the chronic pain and opioid crisis, respected institutions such as the Institute of Medicine, the
National Pain Strategy, the Institute for Health Care Improvement, and the U.S. Department of Health and
Human Services Pain Management Best Practices Inter-Agency Task Force have recommended that health
professionals including dentists improve their recognition, training, and care of pain conditions.(1-5)

This recommendation has been the goal of the American Academy of Orofacial Pain (AAOP) for the past 40
years. The AAOP has represented the field of Orofacial Pain during this time and is the sponsoring body for
submission of this application for recognition of Orofacial Pain as a dental specialty to the National
Commission on Recognition of Dental Specialties and Certifying Boards. The purpose of this application is to
provide clear objective evidenced-based documentation that the field of Orofacial Pain and the AAOP have
met all requirements for approval of a dental specialty by this Commission and to demonstrate this specialty is
much needed by our patient population.

Additionally, the more important point of this proposal is to ensure that we, as a profession, provide the public
access to high quality evidence-based orofacial pain care for patients. Consider the following case as a typical
example. A female patient presents with a 5-year history of jaw pain, pain in multiple teeth, ear pain, and
headaches with additional symptoms of neck and shoulder pain, limited jaw function, and TM joint noise. Her
pain began with a dental visit and progressed to having endodontic treatment, restorative dentistry, TMJ
surgery, and opioid analgesics from her pain physician that resulted in opioid dependency. Her diagnoses
included masticatory and cervical myofascial pain, TMJ disc disorder, TMJ arthralgia, migraine headaches, and
atypical tooth pain. She also reports clenching and grinding of her dentition, depression, work loss, financial
stress and a dysfunctional family among other stressors.

In a case such as this, health professionals should refer to an orofacial pain specialist who could work with a
team including a physical therapist to improve the musculoskeletal function, a pain psychologist to provide
counseling for depression and other psychosocial factors, and assistance from other health professionals
including the patient’s primary care dentist and physician and a physician pain specialist as needed. An
orofacial pain dentist would bring together a patient-centered pain management program to both treat the
conditions and address the many contributing factors that drive chronic pain, addiction, disability, and ongoing
dependency on the healthcare system.

As members of the National Commission on Recognition of Dental Specialties and Certifying Boards, we
believe it is time to expand Dentistry into the field of Orofacial Pain, and encourage more dentists to enter
advanced education programs, which will provide comprehensive evidence-based care for these patients. This
will improve the public’s access to care of orofacial pain conditions, and will also encourage more dental
schools to train orofacial pain specialists, similar to what has occurred with other areas of dentistry, i.e., oral
and maxillofacial radiology.

Thus, the goal of this proposal is to clearly demonstrate that the field of Orofacial Pain has developed
sufficiently in the past 40 years to meet all Commission requirements for a dental specialty, and also improves
access to quality evidence-based care for millions of patients who suffer from these conditions. No less
important will be the confidence of dentists and physicians in referring to qualified Orofacial Pain dentists.

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Definition of the Discipline of Orofacial Pain
Orofacial Pain is the discipline of Dentistry which includes the assessment, diagnosis and treatment of patients
with orofacial pain disorders, including temporomandibular disorders, oromotor and jaw behavior disorders,
neuropathic and neurovascular pain disorders, related 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.

Principal rationales for seeking specialty status for Orofacial Pain

1. To improve access to care for patient with orofacial pain disorders by providing a respected and traditional
mechanism to ensure that Orofacial Pain dentists treat with evidence-based therapies and adhere to a
standard of care;
2. To recognize a credentialing board with the highest standards as the certifying board for Orofacial Pain
dentists, and which complies with CODA specialty accreditation standards.
3. To ensure that graduates of Orofacial Pain programs meet CODA standards.
4. To support and expand the historical and current role of Dentistry in the rapidly evolving field of pain
science while addressing concern from the public that Dentistry is not providing leadership in this field.
5. To enable patients, health care providers, and insurers to identify practitioners with knowledge and
experience in managing chronic pain problems and to provide a resource for general practitioners and
specialists to refer patients not responding to basic therapy.
6. To help address the societal crisis of chronic pain and opioid addiction.

For the past 40 years, the specialty of Orofacial Pain, through the American Academy of Orofacial Pain and the
American Board of Orofacial Pain, has consistently met each of the ADA Commission Requirements of
Specialty Status for Orofacial Pain as summarized here and documented in the more detailed proposal that
follows. Here is a summary of the requirements:

Requirement 1: In order for an area to become and/or remain recognized as a dental specialty, it must
be represented by a sponsoring organization: (a) whose membership is reflective of that proposed or
recognized dental specialty; (b) in which the privileges to hold office and to vote on any issue related
to the specialty are reserved for dentists who either have completed an advanced education program
accredited by the Commission on Dental Accreditation in that proposed or recognized specialty or
have sufficient experience in that specialty as deemed appropriate by the sponsoring organization and
its certifying board; and(c) that demonstrates the ability to establish a certifying board.

The field is represented by the American Academy of Orofacial Pain which is the only orofacial pain
organization that is affiliated with CODA-accredited advanced education programs in orofacial pain. Members
of the AAOP who hold office and vote on issues related to the specialty are dentists and other health
professionals who either have completed an advanced education program accredited by the Commission on
Dental Accreditation of Orofacial Pain or have sufficient experience in that specialty as deemed appropriate by
the sponsoring organization and its certifying board. Specialists in Orofacial Pain are credentialed by the
American Board of Orofacial Pain, the only validated Certifying Board in the field of Orofacial Pain. There are
325 ABOP-certified specialists in the United States.

Requirement 2: A proposed specialty must be a distinct and well-defined field which requires unique
knowledge and skills beyond those commonly possessed by dental school graduates as defined by
the Commission on Dental Accreditation’s Accreditation Standards for Dental Education Programs.

Orofacial pain disorders are not included in the Commission on Dental Accreditation’s (CODA) 2019
Standards for Pre-doctoral Dental Education Programs. The most recent standards included in the 2019
Revision of Standards 2-8 and 3-1 were reviewed. Few dental schools provide a didactic course in orofacial
pain disorders and no dental school requires a pre-doctoral rotation in orofacial pain clinics. A study of
community dentists found nearly all general dentists desire their patients with orofacial pain disorders to see

7
orofacial pain specialists, if available. They recognize that these patients are complex requiring special
knowledge, unique skills, and a team approach that can best address each of the chronic pain, behavioral,
psychosocial, and addiction issues. Most states have no access to care to Orofacial Pain specialists.

Requirement 3: The scope of the proposed specialty requires advanced knowledge and skills that: (a)
in their entirety are separate and distinct from the knowledge and skills required to practice in any
recognized dental specialty and (b) cannot be accommodated through minimal modification of a
recognized dental specialty.

In reviewing 2019 curriculum standards of all ADA recognized dental specialties including Dental
Anesthesiology, it is clear that the scope of practice for the specialty of Orofacial Pain is separate and distinct
from all other dental specialties. The knowledge and skills are included in the 2019 CODA requirements and
curriculum standards of any other dental specialty are separate and distinct and cannot be accommodated
through minimal modification of a recognized dental specialty. 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 that found
nearly all general dentists desire to refer their patients with orofacial pain disorders to an orofacial pain
specialist, if available. They recognize that these patients are complex requiring special knowledge, skills, a
team approach and understanding of chronic pain, psychosocial, and addiction issues. Most states have no
such specialists, primarily due to an historical lack of support from organized dentistry and the ADA, thus,
contributing to the lack of access to care for patients who suffer from these conditions.

Requirement 4: The specialty applicant must document scientifically, by valid and reliable statistical
evidence/studies, that it: (a) actively contributes to new knowledge in the field; (b) actively contributes
to professional education; (c) actively contributes to research needs of the profession; and (d)
provides oral health services in the field of study for the public; each which the specialty applicant
must demonstrate would not be satisfactorily met except for the contributions of the specialty
applicant.
The AAOP and orofacial pain specialists have actively contributed to new knowledge with scientific studies and
publications in its well respected 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 many other granting agencies. Clinical and research advances in the field of
orofacial pain have led to the development of evidence-based diagnostic and management strategies for
patients with orofacial pain conditions. This research has helped define underlying mechanisms, diagnostic
criteria, etiology, treatment efficacy, surgical implant outcomes, and many other areas of essential knowledge
to define the field of Orofacial Pain. The vast majority of these publications and sponsored research on
orofacial pain disorders in the past years has been completed by orofacial pain specialists and researchers,
and not general dentists or other dental specialists. Yet, there is still a strong need for more research in
Orofacial Pain as determined by the recent National Academy of Science Committee on Temporomandibular
Disorders (March, 2019)

Requirement 5: A proposed specialty must directly benefit some aspect of clinical patient care.
For the past 30 years, the AAOP has 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 1 includes a list of evidence-based treatments used by
Orofacial Pain Dentists (All references for systematic review of these treatments are included in Appendix
IVc).

8
 Table 1. Characteristics and scientific evidence of different treatments of orofacial pain by ABOP
certified Orofacial Pain Dentists (See Appendix IVc. Systematic Review of RCTs for Treatment of
Orofacial Pain and Temporomandibular Disorders including References.)

Intervention Scientific Basis Evidence-based Treatments covered by health plansa

Self- Systematic reviews of Preventive medicine counseling
management exercise and cognitive- Exercise
training behavioral therapies Habit-reversal
Mindfulness based stress reduction
Biofeedback, relaxation, meditation
Cognitive-behavioral therapy
Intra-oral splints Systematic reviews of Full coverage stabilization at night;
intra-oral splints Repositioning splints at night.
Immediate quick splints short-term
Anterior bite plane short-term
Medications Systematic reviews of NSAIDs
pain, muscle relaxant, Acetaminophen
and sleep medications Tricyclic medications
Muscle relaxants
Sleep medications
Migraine medication
Neuropathic medication
Physical therapy Systematic review Therapeutic exercises
evidence of therapeutic Mobilization
exercises, mobilization, Ultrasound
and modalities EGS, TENS and micro-current
Iontophoresis
Injection and Systematic reviews of Dry needling
needle therapy acupuncture, dry Trigger point injections
needling, and injections Botox injections
Steroid joint injections
Arthrocentesis
Dental care Some clinical trials but no Occlusal equilibration
systematic reviews
TMJ and Facial Some clinical trials but no Need to meet criteria for surgery for disk repair,
Surgery systematic reviews arthroscopic surgery, and discectomy, total joint prosthesis
as performed by Oral and Maxillofacial Surgeons

a. Clinical trials and systematic reviews show evidence of efficacy with less risk of adverse events
b. Clinical trials, case series, and some systematic reviews show low evidence of efficacy with higher risk of
adverse events

Table 2. The lifetime prevalence and need for treatment of orofacial pain disorders compared to caries and
periodontal disease. This prevalence is comparable to the annual prevalence and need for treatment of the
most dental disorders including caries and periodontal disease, and missing teeth.(5-21)
Orofacial Pain Disorders % of Population
Temporomandibular 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%
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 Neurosensory/ chemosensory disorders (e.g. taste, paresthesias, numbness) 0.1%
Oromotor disorders (e.g. occusal dysethesias, dystonias, dyskinesias, severe 4.2%
bruxism)
Total Prevalence of Orofacial Pain Disorders 30% to 40%

Requirement 6: Formal advanced education programs of at least two years accredited by the
Commission on Dental Accreditation must exist to provide the special knowledge and skills required
for practice of the proposed specialty.
The AAOP is affiliated with 13 formal (two or more years)
advanced education programs in Orofacial Pain that have
been established in accredited Dental Schools to train
future specialists in Orofacial Pain as documented in
Table 3. The total first year enrollments in all programs
beginning the program in July of 2018 is 35. The number
of graduates in the past five years has been 62. With at
least 10 million people with a severe orofacial pain
disorder that requires care, there are over 9,750,000
people left untreated by OFP dentists and estimates the
need of 10,000 more OFP dentists (See adjacent Figure
1). This is comparable to the number of oral and maxillofacial surgeons and endontists in practice. Support for
a specialty in orofacial pain will increase the number of specialists and also highlight the importance of training
other dentists to care for those patients with less complex orofacial pain disorders.

Table 3. List of Advanced Education Programs in Orofacial Pain

CODA # of residents / Length Certificate /
School Financial Program Director
Accred. year (years) Degree
Eastman
Dr. Junad Kahn
Institute for Oral Yes 3-Jan 3 Certificate Tuition
Health
Certificate or
University of Tuition or
Yes 2 3 Master of Dr. Jeffrey Okeson
Kentucky Stipend
Science
Massachusetts
General Yes 3-Jan 2 Certificate Stipend Dr. Jeffry Shaefer
Hospital
University of
Michigan– Dr. Lawrence
Yes 1 2 Certificate Stipend
Michigan Ashman
Medicine
Certificate or
University of
Yes 2 2 Master of Stipend Dr. Shanti Kaimal
Minnesota
Science
2
Naval Certificate
*Limited to
Postgraduate Yes 3 with Master of Stipend Dr. Steve Hargitai
Federal Service
Dental School Science
Dentists
Stipend
University of
Yes 1 2 Certificate depending on Dr. Pei Feng Lim
North Carolina
funding
4 Masters
Rutgers School Master of
4 Advanced 3
of Dental Yes Dental Tuition Dr. Gary Heir
Education in 1
Medicine Science
Orofacial Pain

10
 Certificate or
Dr. Yoly Gonzalez-
SUNY Buffalo Yes 2 3-Feb Master of Tuition
Stucker
Science
Tufts U. School Certificate or
of Dental Yes 2 3-Feb Master of Tuition Dr. Chao Lu
Medicine Science
3/year Certificate,
Tuition or
UCLA Yes 2 domestic 3-Jan Master, Dr. Robert Merrill
Stipend
1 international PhD
Certificate,
USC Yes 2 2+ Master, Stipend Dr. Glenn Clark
PhD
USC– Master of
No 20/yr 3 Tuition Dr. Glenn Clark
Hybrid/Online Science

In summary, recognition of Orofacial Pain as a specialty should be a high priority for the profession of
Dentistry. It will improve access to quality care and help address the chronic pain and opioid crisis as dentists
collaborate with colleagues in medicine and other healthcare professions. By supporting this application, the
National Commission has an opportunity to expand the Profession of Dentistry to help the millions of patients
who are currently suffering from chronic 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 clinicians 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 who will receive training beyond that which is provided in the undergraduate dental
curriculum, as well as the experience, and credentialing to provide high quality care, and provide a referral
source for professional colleagues.

A specialty in Orofacial Pain will set a standard for reliability and accountability of dentistry in the field of
Orofacial Pain and maintain compatibly with current standards practiced in pain medicine, physician clinics,
medical centers and hospital practices. A specialty in Orofacial Pain will raise the standards of the clinical
community and improve pre-doctoral education with properly trained faculty. In addition, a specialty in Orofacial
Pain will increase public confidence, increase the confidence of insurers and availability of coverage, and
increase the recognition of Orofacial Pain dentistry by medical colleagues, thereby increasing access to care.

The ADA must take a position in support of this specialty to provide leadership and a strong foundation for
growth of this promising field in order to serve and protect the public and the profession.

11
Introduction to the Application
A survey of 805 individuals in the general population with a persistent pain disorder, by Robert Starch
Worldwide (4), revealed that more than four out of 10 people have yet to find adequate relief, saying their pain
is not well managed— despite having the pain for more than 5 years and switching doctors at least once. This
survey suggests that there are millions of people living with severe uncontrolled pain. Russell Portenoy, MD,
Past President of the American Pain Society. “This is a great tragedy. Although not everyone can be helped, it
is very likely that most of these patients could benefit if provided with state-of-the-art therapies and improved
access to pain specialists when needed”.

Chronic pain has become a national health care crisis. It is the primary reason to seek care, the leading cause
of disability and addiction, and the primary driver of healthcare utilization, costing more than cancer, heart
disease, and diabetes.(1-5) As a result, the nationwide chronic pain and opioid crisis is having a devastating
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 have more than quadrupled
and is now over 40,000 deaths per year; a greater number than deaths from motor vehicle accidents.4 It is
estimated that the cost to our communities and governments is at least $80 billion annually, with the financial
impact on individuals and families even greater.(22-30) The human toll is enormous.

To reverse the chronic pain and opioid crisis, health care leaders including the Institute of Medicine, the
National Pain Strategy, the Institute for Health Care Improvement, the Institute for Clinical System Integration,
and U.S. Department of Health and Human Services Pain Management Best Practices Inter-Agency Task
Force have recommended that health professionals, including dentists, improve recognition, training, and
treatment of pain conditions. (1-5) Dentistry has taken a leading role in addressing this crisis by developing the
field of Orofacial Pain into a dental specialty.

With this application, it is important to emphasize that the pursuit of specialty in this field is motivated primarily
by access to care issues– patients with chronic orofacial pain disorders have historically been poorly treated by
all disciplines of health care including Dentistry. Many studies of chronic orofacial pain patients have found that
these patients have a high number of previous clinicians (a mean of 5.3) and many years with pain (mean of
4.2 years) prior to seeing an orofacial pain dentist (6-12). Treatment for these patients within the existing
structure of dental or medical specialties is either not provided or inadequate, resulting in the suffering of
millions.

There is a need both by the ADA and potential new dental specialty certification commissions for an objective
process in determining whether recognition of a new dental specialty is warranted. The objective process that
has been established ensures a new specialty can make substantial improvements in quality and access to
care by addressing patients’ specific needs beyond what is currently offered by general dentists and existing
dental specialists. This is the premise of this application.

This application will show the reviewers that Orofacial Pain is a field of dentistry where advanced knowledge
and skills are essential to maintain or restore orofacial health and well-being and that this knowledge and skill
set do not exist in the current structure of dentistry. The field of Orofacial Pain is a large clinical field with
millions of patients who have not fared well in our existing system of specialty care. In addition, there are tragic
cases where, because of the lack of a specialty in Orofacial Pain, treatment for ominous conditions, missed by
unaware clinicians, have let to dire and fatal consequences due to misdirected or delayed treatment. Dentists
in the field of Orofacial pain have dedicated themselves for several decades to improving this situation.

For these reasons, we ask you to look not only at how carefully the field of Orofacial Pain has clearly met each
requirement but also what this will mean to the millions of patients who are currently suffering from chronic
orofacial pain disorders and may not be receiving adequate care. It is they who will thank you for helping them
receive high quality, accessible and, most importantly, successful care. Please help us help them.

The Field of Orofacial Pain

12
Orofacial Pain as a specialty is the discipline of dentistry whose focus is the assessment, diagnosis and
treatment of patients with chronic orofacial pain and dysfunction disorders, oromotor and jaw behavior
disorders, and chronic head, neck, and facial pain, as well as the pursuit of knowledge of the underlying
pathophysiology and mechanisms of these disorders. Examples of orofacial pain disorders included in this field
are neuropathic orofacial pain disorders, neurovascular orofacial pain disorders, chronic regional pain
syndrome, complex masticatory and cervical neuromuscular pain disorders, primary headache disorders, pain
from complex temporomandibular joint disorders, burning mouth, pain secondary to orofacial cancer and AIDS,
orofacial dyskinesias and dystonias, associated sleep disorders, and other complex disorders causing
persistent pain and dysfunction of or referred to the orofacial structures.

It is important to note that this field does not include acute pain from disorders such as pulpitis, periodontal
disease, surgical treatment of TM joint disorders or nerve injuries, impacted 3rd molars, dental hypersensitivity,
and other dental disorders that are part of most dentists’ or dental specialists’ practices. The field also does not
include treatment or prevention of acute pain and anxiety from dental surgical or operative procedures.

In the past 20 years, there have been many developments in the field of chronic pain and specifically Orofacial
Pain that have led to this application for specialty status. Scientific improvements in our understanding of the
epidemiology, basic mechanisms, etiology and diagnostic and treatment strategies for chronic orofacial pain
disorders have fueled development of safe and effective treatments for these patients. With over 3 million
people each year needing treatment for chronic orofacial pain, clinical practice in the field has accelerated at a
greater pace than anticipated. Universities have responded to this need by establishing orofacial pain clinics in
many Dental School and accredited 2-year advanced education programs in Orofacial Pain in 12 Dental
Schools. More than 25-35 Orofacial Pain dentists are graduating from these programs every year. The
American Academy of Orofacial Pain has established an examination and credentialing process for orofacial
pain dentists through the development of the American Board of Orofacial Pain. Since 1994, 295 dentists have
passed this rigorous process and are focusing their careers in Orofacial Pain.

With these developments, most other major national dental organizations have recognized this field. The
National Institutes of Dental and Craniofacial Research (NIDCR) has broadened its research mission in the
field by changing its name to reflect the expansion of dental research into the craniofacial structures. NIDCR
has also released a number of requests for proposals to expand research in Orofacial Pain, has sponsored 2
international congresses in Orofacial Pain, and supported a recent Technology Assessment Conference on
Temporomandibular Disorders. The American Association of Dental Schools have also held several
educational conferences in Orofacial Pain and have established pre-doctoral, post-doctoral, and continuing
education standards in this field. The United States Armed Forces have also established Orofacial Pain as an
advanced field of Dentistry and recruit dentists specifically for Orofacial Pain specialty training. Numerous other
countries including Sweden, Korea, Costa Rica and Brazil have also designated this field as an advanced field
of Dentistry that meets the requirements of a dental specialty. The International Association for the Study of
Pain (IASP) dedicated 2013-2014 as the Global Year Against Orofacial Pain.

The rationale for seeking specialty status for Orofacial Pain.

While there are many benefits to establishing Orofacial Pain as a specialty, it is important to recognize that
there are virtually no disadvantages to this recognition. The principal rationales for seeking specialty status for
Orofacial Pain include:

a. To ensure that the public is both served and protected by:

1) The attendant recognition of a standard of care for Orofacial Pain through establishing ADA accreditation
standards for Orofacial Pain programs and national recognition of the American Board of Orofacial Pain as the
credentialing Board in Orofacial Pain.
2) Increased accountability of organized Dentistry in the field of Orofacial Pain.
3) Keeping dentistry compatible with the current standards practiced in pain medicine within physician clinics,
medical centers and hospital practices.
4) Ensuring minimal training standards for dentists graduating from Orofacial Pain training programs. This will:

13
 i. raise the standards of the clinical community,
ii. directly improve pre-doctoral education in this field by contributing properly trained faculty,
iii. increase public confidence in this currently unregulated field,
iv. increase the confidence of insurers and, thus, the availability of coverage, and
v. increase the recognition of Dentistry in this field by medical colleagues.

b. To ensure that Dentistry maintains its high profile and role in the rapidly evolving field of pain
science by:
1) Maintaining a broad definition of the scope of Dentistry.
2) Complying with the ADA recommendations to have “proficiency in the diagnosis and treatment of pain
problems related to the head and neck region” as described in the Guidelines for Teaching the Comprehensive
Control of Pain and Anxiety in Dentistry at the Advanced Education Level.
3) Maintaining a standard in clinical pain science in Dentistry at least equivalent to that in Medicine.
4) Requesting that organized Dentistry recognize the de facto specialty of Orofacial Pain that has been
recognized by Dental School Deans who have supported two-year full-time advanced education and clinical
programs in Orofacial Pain for many years.
5) Empowering centers of expertise in Orofacial Pain in Dentistry, through ADA accreditation.
6) Improving competitiveness in this field for federal research and training funding.
7) Encouraging the number of faculty lines in Orofacial Pain in Schools of Dentistry.

c. To support graduate education in the field and accept two years of full-time study as the minimum
required for competency in Orofacial Pain, as per the consensus opinion of the National Consensus
Document on Curriculum Guidelines for the Development of Graduate Programs in
Temporomandibular Disorders and Orofacial Pain (31-32).
This will help to:
 Ensure availability of qualified experts in Orofacial Pain to all regions of the United States. This will be the
core of practitioners eligible to take the Orofacial Pain Board examinations in this initiation period.
 Ensure a flow of excellently qualified candidates into the field by national recognition of
 specialty graduates.
 Ensure a source of highly qualified clinical and clinician-scientist Orofacial Pain faculty to staff centers of
advanced clinical care and research, and help prepare future general practitioners and other specialists to
understand this field.
 Assures a high level of standardization and quality
 Assures that all program graduates will achieve the same levels of competency

d. To recognize the dentists who focus their careers and training on treating orofacial pain disorders.
A specialty in Orofacial Pain does not exclude the general practitioner or other dental specialist in diagnosing
and managing simple or more complex aspects of specific orofacial pain disorders but instead, this
acknowledges that significant benefit can be obtained from co-treatment with an Orofacial Pain dentist. Τhis
enables patients, insurers, and hospital boards or multidisciplinary centers to identify practitioners with
extended training, testing, and a board-certified level of understanding experience in treating multifactorial
orofacial pain conditions. In turn, a knowledgeable and experienced resource will be established for health care
providers to obtain consultation and treatment as needed for their patients with orofacial pain conditions.

e. Define the Scope of Practice of Dentistry for Dental Profession.

In the past years, Dentistry has seen its scope of practice infringed upon by many other health providers. In
medicine, otolaryngology and plastic surgery continue to expand their scope of practice into orofacial
structures. Dental hygiene has expanded its scope of practice into dentistry with administration of local
anesthetics and other changes. Denturists and dental laboratories continued to offer low cost dentures to the
population. With this application, the American Dental Association has an opportunity to implement their
strategic plan by officially defining a scope of practice of the field of Orofacial Pain in a scientifically responsible
manner. This can be done without jeopardizing the practice of general dentistry or any existing dental
specialty. By supporting a specialty of Orofacial Pain by the ADA Commission, the necessary structure and
14
procedures will be established to ensure that clinicians who limit their practice in this field will be well trained,
knowledgeable, and experienced. A specialty in orofacial pain will strengthen the strategic plan of the ADA to
expand the concept and scope of Dentistry and become an example of encouraging a closer relationship
between Dentistry and Medicine.

As noted by the Starch survey (4), the millions of people with these disorders coupled with the lack of adequate
care for them by existing practitioners have made this a major consumer problem in our country. The ADA and
its National Commission is the major leadership body for Dentistry and has the responsibility to address major
consumer issues in Dentistry and lead Dentistry into the 21st century. The large field of Orofacial Pain currently
exists independent of the ADA and other dental specialties. A review of advances in the field of Orofacial Pain
provide the rationale for recognition of the Orofacial Pain as a specialty. This also demonstrates that the field of
Orofacial Pain has met all of the requirements for ADA specialty status.

f. To support the sponsoring Academy of Orofacial Pain’s longstanding international leadership role
sufficiently to:
• Spawn and support international sister academies around the world that convene around the United States
founding organizations.
• Establish ADA recognized diagnosis and treatment standard guidelines based on scientific and expert based
consensus.

g. Support the Development of the Specialty of Orofacial Pain. The clinicians and researchers in the field
of Orofacial Pain have spent the past several decades dedicated to developing the specialty of Orofacial Pain.
However, it is as important that the Commission member reviewers and the profession of dentistry understand
additional needs for Orofacial Pain as a specialty that are equally important to meeting the requirements.
Dentistry needs to continue to evolve to meet the needs of the public, particularly when other health
professionals do not address the needs of these patients, and providing care is a natural extension of the
knowledge and skills of the Dentist. Thus, there are many rationales for supporting the specialty of Orofacial
Pain. Here are just a few of the important reasons for the need for the specialty of Orofacial Pain;
 Addressing the opioid crisis
 Complexity of orofacial disorders
 Lack of growth in orofacial pain specialty training programs
 Need for dental faculty to teach pre-doctoral study, general dentists and other dental specialist on basic
knowledge and skills in this area.
 Prevent the proliferation of non-evidence-based and unethical care for orofacial pain disorders
 Expand and integrate dentistry and medicine for pain conditions
 Expand and improve research in the field of Orofacial Pain
 Improve the understanding of orofacial pain disorders by all health professionals
 Improve outcomes of care for care for orofacial disorders
 Improve Collaboration between dentists and Orofacial Pain Dentists
 Public health efforts for preventing chronic orofacial pain and related addiction, disability, and long-term
healthcare use

For these and many other reasons, there is a need to expand access to quality evidence-based care for
patients with orofacial pain disorders by training more specialists in orofacial pain, teaching all dentists and
other health professionals to understand care for these patients, and focus our public health efforts to prevent
chronic pain and related addiction, disability, and ongoing dependency on the healthcare system. For these
reasons, the AAOP, ABOP, and the Universities and advanced education programs have developed the field
to meet all of the requirements of the ADA and the National Commission. The requirements are described in
more detail in the next sections.

15
Requirements for Recognition of Dental Specialties and National Certifying Boards for Dental
Specialists Application for the field of Orofacial Pain.

Requirement 1: In order for an area to become and/or remain recognized as a dental specialty, it must
be represented by a sponsoring organization: (a) whose membership is reflective of that proposed or
recognized dental specialty; (b) in which the privileges to hold office and to vote on any issue related
to the specialty are reserved for dentists who either have completed an advanced education program
accredited by the Commission on Dental Accreditation in that proposed or recognized specialty or
have sufficient experience in that specialty as deemed appropriate by the sponsoring organization and
its certifying board; and(c) that demonstrates the ability to establish a certifying board.

The proposed dental specialty of Orofacial Pain is represented by the American Academy of Orofacial Pain
(AAOP) whose has a membership that is reflective of Orofacial Pain; have leadership privileges reserved for
Orofacial Pain dentists who either have completed an advanced education program accredited by the
Commission on Dental Accreditation in that proposed or recognized specialty or have sufficient experience in
that specialty as deemed appropriate by the sponsoring organization and its certifying board; and established
the American Board of Orofacial Pain as the single discrete board that provides a credentialing and
examination process in the field of Orofacial Pain.

Membership in the AAOP currently includes 486 orofacial pain dentists and other health professionals who
focus their careers in the field of Orofacial Pain. All potential candidates from any dental organization who has
a full time professional effort in Orofacial Pain and has practiced in the field for at least five years has been
notified by announcements, mailings, and advertisements of their eligibility to be a candidate for examination
with the American Board of Orofacial Pain and to apply for membership in the American Academy of Orofacial
Pain. The American Board of Orofacial Pain is the single discrete board that provides a credentialing and
examination process in the field of Orofacial Pain to ensure high quality of knowledge and experience of its
members using methods consistent with that of all dental and medical specialties (Appendix I). This process
has ensured that the Board and the Academy is representative of those dentists whose careers focus on the
total scope of Orofacial Pain. A survey of membership reveals that the vast majority of the membership
practices fulltime in the field of Orofacial Pain and are not practicing any other dental specialty. To date, 315
have passed the Board process and are certified as being diplomates and having achieved a level of
knowledge and expertise in the field of Orofacial Pain consistent with that of a specialist. No candidates were
grand-fathered as board certified.

The American Board in Orofacial Pain has been developed in coordination with their sister group in pain
medicine, the American Board of Pain Medicine in its efforts to establish board certification and specialty status
with the American Board of Medical Specialties. Both have operated in close communication in the
development of their curriculum and examination process. The curriculum goals of both Boards follow the
published postgraduate curriculum goals advocated by the American Pain Society and its parent body, the
International Association for the Study of Pain (IASP)(28). The primary goal of credentialing in Orofacial Pain is
to improve the standards of care administered to patients with chronic orofacial pain or difficult pain and
dysfunction problems, and to avoid inappropriate unsuccessful treatment and iatrogenic consequences of care.
It is important for the public to be able to recognize dentists who are competent in the broad knowledge and
skills necessary to provide high quality care rather than as a cloistered personal approach. The purpose of
credentialing in Orofacial Pain with ADA recognition is to set forth a process by which competent dentists
would be identified, trained, examined and appropriately recognized in the medical, dental and public
communities. There are over 40 annual graduates of full-time Orofacial Pain post-doctoral training programs in
the field. Their credibility and numbers would be notably strengthened by formal ADA recognition, and the
elevation of the current non-ADA recognized ABOP boards to ADA recognition.

1. Founding Date and Historical Development

a. Indicate the year in which the sponsoring organization was founded and briefly
summarize its development since that date.

16
American Academy of Orofacial Pain
The first meeting of the American Academy of Orofacial Pain was held in 1975 in New York City. The need for
an organization that would improve the quality of orofacial pain diagnosis and treatment and offer exchange of
information among the various authorities in the field was evident. The original name of the organization was to
be The American Academy of Craniomandibular Orthopedics. This name was subsequently changed in 1981
to The American Academy of Craniomandibular Disorders and then again to The American Academy of
Orofacial Pain in 1992 to reflect the focusing of the discipline to orofacial pain disorders. The basic objectives
of the Academy were to improve the knowledge of those interested in chronic orofacial pain disorders by
increased communication and exchange of scientific information as well as to stimulate the profession towards
greater awareness of these disorders and their treatment. The first scientific meeting was held in 1976 in
Colorado Springs, Colorado. In 1984, the first international affiliate, the European Academy of
Craniomandibular Disorders, was officially recognized. Subsequently recognized International Academies were
the Asian Academy of Craniomandibular Disorders (1989), The Australian Academy of Craniomandibular
Disorders (1989), and The Ibero-Latin American Academy of Craniomandibular Disorders (1991).

The First International Symposium of Craniomandibular Academies was held in Chicago in February of 1992.
On June 11, 1986, at the First Annual Scientific Meeting of the European Academy on Craniomandibular
Disorders an agreement was reached between the American and European Academies and Quintessence
Publishing Company to form a new scientific journal, The Journal of Orofacial Pain. The American Academy of
Orofacial Pain also published the first edition of its written parameters in Orofacial Pain in 1989 and a
subsequent edition in 1992 and 1996. In addition, members from the AAOP began the process of establishing
the American Board of Orofacial Pain in 1989. In 1991, the AAOP in conjunction with the American Association
of Dental Schools and the University of New Jersey College of Medicine and Dentistry brought together
experts in Orofacial Pain and established the first guidelines for pre-doctoral, post-doctoral, and continuing
education in the field. In 1997, the AAOP in conjunction with the American Academy of Head, Neck, and Facial
Pain sponsored the first application for specialty status for the field of Orofacial Pain. Subsequently, an effort
has been made to continue to collaborate on the issues that are of joint interest including the specialty
application.

b. Describe the current mission of the organization.

The American Academy of Orofacial Pain, an organization of health care professionals, is dedicated to
alleviating pain and suffering through the promotion of excellence in education, research and patient care in
the field of orofacial pain and associated disorders. The current missions of the American Academy of
Orofacial Pain include:
1. To establish criteria for the diagnosis and treatment of chronic orofacial pain disorders.
2. To stress the significant incidence of chronic orofacial pain disorders for both medical and dental
professions.
3. To provide a base for annual meetings for the dissemination of research and treatment for orofacial pain.
4. To support the Journal of Orofacial Pain and Headache stressing research and current studies on orofacial
pain disorders.
5. To encourage and stress the study of orofacial pain disorders at pre-doctoral and post-doctoral levels of
dental education.
6. To provide a common meeting ground for worldwide authorities on orofacial pain disorders.
7. To encourage hospitals and dental schools to establish centers for treatment of orofacial pain disorders.
8. To encourage research that evaluates equipment and procedures in the field.
9. To publish guidelines for practice standards, treatment and research directions for third
party involvement.
10. To organize a speaker's bureau for the purpose of disseminating pertinent information on orofacial pain
disorders to the other health professionals.

2. Officers
A. Identify the current officers of the sponsoring organization.
American Academy of Orofacial Pain Officers include the following;

17
Past-President ........................................ Jennifer P Bassiur DDS
Columbia University, Director
Center for Oral, Facial and Head Pain
New York, NY

President.................................. Jay Mackman, DDS

TMJ & Orofacial Pain Treatment Centers of WI
2626 North 76th Street, Suite 101
Wauwatosa, WI 53213

President-Elect………………………….… Jeff Shaefer DDS

Director Orofacial Pain Center
Harvard University
Massachusetts General Hospital
Boston, Massachusetts

Past Council Chair……………………… Ghabi A Kaspo DDS

Facial Pain and Sleep Center, PLC
3144 John R Road, Suite 100, Troy, MI 48083

Council Vice-Chair…………………….…Gary D Klasser DMD

Louisiana State University Health Sciences Center
LSU School of Dentistry
1100 Florida Avenue, Box 140, New Orleans, LA 70119

Secretary-Treasurer............................. Paul L Durham MS, PhD

Missouri State University
Distinguished Professor, Director
524 North Boonville Avenue
Springfield, MO 65806 USA

Secretary-Elect……………………………..Robert W Mier DDS

TMJ & Orofacial Pain Treatment Centers of Wisconsin
6730 S Harvard Dr
Franklin, WI 53132

Executive Director................................... Kenneth S Cleveland

174 S. New York Ave.
POB 478, Oceanville, NJ 08231

3. Membership
a. Provide an analysis of the trends in membership over the past ten years.
The active membership of the AAOP includes those dentists who focus their careers in Orofacial Pain and
have at least 5 years of training and/or experience in the field. The membership has been steadily increasing
over the past few years demonstrating the increasing interest among dentists and the increase demand for
services in the field. The trend in membership in the American Academy of Orofacial Pain for last 30 years has
been steadily increasing beginning in 1999 with 199 members and increase about 1- to 20 every year to the
member now stands at 486 members. Table 4 provides an analysis of the trends in membership in the AAOP.

Table 4. AAOP 10 Year Membership Summary

Membership Type/Date 3/10 3/11 3/12 3/13 3/14 3/15 3/16 3/17 3/18
Active/Fellow 376 378 410 412 405 423 469 484 476
18
 Honorary Member 4 4 4 4 4 4 4 4 4
Student/Initiatory 14 15 23 36 52 48 63 40 42
Life Fellow 54 59 60 62 64 64 65 70 67
Affiliate 43 49 53 61 72 66 0 NA NA
Member Pending 4 3 2 0 3 5 0 0 4
Retired Member 1 1 0 1 1 2 1 4 4
TOTAL 496 504 552 566 601 606 601 598 595

The membership of the American Academy of Orofacial Pain consists of Active, Life, Honorary and Initiatory
members, and is by invitation only. The qualifications of each class of membership shall be provided for herein
and detailed here.

Active Members.
Active members shall possess the following qualifications. They shall:
1) Be members in good standing for a period of at least (5) consecutive years in their respective National
Professional Association before being eligible for proposal to membership. (Initiatory membership excluded)
2) Must be a licensed dentist (D.D.S., D.M.D.)
3) Be recognized by their professional colleagues as ethical practitioners in their prospective professions.
4) Have demonstrated a minimum of five (5) years exceptional understanding of Orofacial Pain disorders
through graduate or post graduate training, research, or clinical experience.
5) Be willing to work within the Academy objectives (guidelines) to promote the best interest and ideals of the
Academy.
6) Must be a permanent resident of Canada or USA or be a member of one or the international sister
academies.
Regular attendance at meetings and payment of dues is a requirement for maintenance of active membership
in the Academy.

Initiatory Members
Initiatory Membership shall be granted to a participant or recent graduate of an Academy accredited, full-time
post-doctoral university residency program in Orofacial Pain.
1) the duration of this membership shall be five (5) years, after which the Initiatory member shall become
eligible for Active Membership under the same provisions of Section 2. Nothing in this provision shall prevent
an Initiatory Member from becoming an Active Member under Section 2 with less than 5 years as an Initiatory
Member.
2) Initiatory Members’ dues are to be set yearly according to the actual expenses for the journal subscription
and meeting costs.
3) The initiatory Membership shall become effective upon an application of the resident enrolled in a current
Orofacial Pain program. Application shall be made to the AAOP Post-Doctoral Subcommittee of the Education
committee.
4) The same requirements for Active Membership shall apply except for the clause (a)
and (c)
5) The Initiatory Members shall have rights, except the right to vote, and duties of
membership including attendance requirements.

Regular attendance at meetings is a requirement for maintenance of Initiatory membership in the Academy. If
a member is absent from three (3) consecutive annual meetings termination of his affiliation with the Academy
will be considered by the council. A two-thirds (2/3) vote of the council will be required for separation. Members
will be notified after missing two (2) consecutive meetings. (f) Be willing to work within the Academy objectives
(guidelines) to promote the best interest and ideals of the Academy. (g) Must be a licensed dentist
(D.D.S.,D.M.D.).

Life Members
19
Life membership may, at the discretion of council, be granted active members in good standing, due to ill
health or other reasons have retired from active participation in their profession. Upon attaining seventy (70)
years of age any active member in good standing may request that council transfer him to the life membership.
Life members in good standing shall have all privileges of their former status of active membership with no
dues required. If the life member (under the age of 70 years) resumes active practice or full-time academics in
the field of Orofacial Pain Disorders, the Life member will automatically be reinstated into the category of
Active Membership upon a vote by the membership committee.

Honorary Members.
Honorary members may be granted to persons who have made outstanding contributions to their professions
even though they may not be directly involved in the active practice of treating orofacial pain disorders.

b. Demonstrate that the organization's membership is representative of the proposed or recognized dental
specialty.
The American Academy of Orofacial Pain(AAOP) limits their membership to those practitioners who focus their
careers in Orofacial Pain. All potential candidates from any dental organization who has a full time professional
effort in Orofacial Pain, who has practiced in the field for at least five years, and meets the eligibility criteria to
become a member of the AAOP has been notified by announcements, mailings, and advertisements of their
eligibility to be a candidate for examination with the American Board of Orofacial Pain and to apply for
membership in the American Academy of Orofacial Pain.

This process has ensured that the Board and the Academy is representative of those dentists whose careers
focus on the total scope of Orofacial Pain. A 2009 survey of AAOP members have indicated that about 70% of
active members practice fulltime in the practice in Orofacial Pain. In contrast, a recent practice survey of 405
general dentists and dental specialists in the Upper Midwest indicated that only 9% of general dentists and 7%
of dental specialists has more than a 4% of their practices in this field and many of those who do are members
of the AAOP (Appendix III).

The eligibility criteria for active membership includes;

(a) Be members in good standing for a period of at least five (5) consecutive years in their respective
National Professional Association before being eligible for proposal to membership.
(b) Be recognized by their professional colleagues as ethical practitioners of their respective professions.
This shall be interpreted as behavior consistent with the Academy Code of Conduct.
(c) Have demonstrated a minimum of five years of an exceptional understanding of the diagnosis and
treatment of orofacial pain disorders through graduate school or post-graduate
training or clinical experience.
(d) Be willing to work within the Academy objectives as published in the Academy Guidelines to promote
the best interest and ideals of the Academy. Regular attendance at meetings is a requirement for
maintenance of active membership in the Academy.
(e) Must be a licensed dentist (D.D.S., D.M.D.)
(f) Be a permanent resident of Canada, Mexico of USA or be a member of one of the other international
sister academies.

A review of the scientific articles, chapters, and textbooks listed in the reference list demonstrates the breadth
and depth of member involvement in Orofacial Pain. Additionally, all the directors and faculty of formal post-
doctoral Orofacial Pain programs listed in response to requirement 6 are AAOP members and ABOP eligible or
certified.

Supporting Documentation:
Appendix III Summary data from Orofacial Pain Practice Survey

4. Other National Dental Organizations

Identify other national dental organizations whose objectives are advancement of this area of dental

20
practice.
There are currently no other organizations whose major objectives are advancement of the field of Orofacial
Pain as defined in this specialty application. It is important to note that all dentists have a responsibility to be
familiar with orofacial pain disorders and there are other dental organizations that represent general dentists
who have an interest in TMD and orofacial pain. However, the American Academy of Orofacial Pain is the sole
organization whose primary interest is advanced education and board certification of dentists to become
specialists in orofacial pain disorders. Currently, the AAOP is also the only organization affiliated with both a
validated board certification examination process, the ABOP, and has CODA accredited advanced education
programs. The American Academy of Craniofacial Pain (formerly the American Academy of Head, Neck, and
Facial Pain) and the American Equilibration Society have strong interest in further development of the aspects
of the field of Orofacial Pain and have been supportive of the development of this specialty in the field based
on previous co-sponsorship of applications to the ADA. Furthermore, the American Academy of Craniofacial
Pain has strong interest in the field being a specialty and has collaborated in the preparation and submission of
past ADA applications in the field. However, due to the importance of submitting this application from an
organization affiliated with a validated board and CODA approved advanced education programs, the AAOP is
currently the only organization meeting the requirements for and submitting this application. We appreciate the
support from these other organizations in efforts toward educating dentists and encouraging improved access
to care for those patients who suffer from orofacial pain disorders.

5. Activities
Describe and assess the sponsoring organization's specific efforts to promote the improvement of
quality in the field (i.e. continuing competence, parameters of care, recertification, continuing
education requirements, etc.)
One of the founding principles of the AAOP was the promotion of continuing research, education, and
evidence-based care for patients with orofacial pain in dentistry. Annual meetings have provided a forum at
which experts in the field have disseminated knowledge to dentists worldwide. Moreover, members provide the
overwhelming majority of continuing education courses offered in Orofacial Pain in this country, as well as write
and edit the majority of the articles appearing in the Journal of Orofacial Pain. The publications by our
members and the Academy have focused on several major aspects of Orofacial Pain including evidence-based
clinical guidelines that have advanced the field and resulted in improved evidence-based orofacial pain care for
patients worldwide. Most of the standard texts in Orofacial Pain are also the products of our members.

A high level of competence in the discipline of Orofacial Pain has been established through the certification
process by the American Board of Orofacial Pain. The American Academy of Orofacial Pain has established
Standards for Advanced Specialty Education Programs in Orofacial Pain that have been approved by the ADA
Commission of Dental Accreditation, which certifies programs in Orofacial Pain in a manner consistent with the
certification of graduate programs in recognized specialties by the ADA CODA. The American Academy of
Orofacial Pain has supported research for the past 40 years. This research has clarified many issues related to
diagnosis and management and has been the basis for developing consensus guidelines for the diagnosis and
management of orofacial pain disorders. The scientific advances in the field are discussed later in section 8 of
this requirement. Based on much of this research, the members have developed and published guidelines that
outline principles for diagnosis, evaluation, and treatment of orofacial pain disorders that are consistent with
that used in other areas of the body and the International Headache Society's Classification of Headache,
Cranial Neuralgias, and Facial Pain. The development of scientifically based guidelines has brought changes
in insurance reimbursement for treatment of these disorders. A number of states have clarified insurance
reimbursement for OFP by passing legislation that prohibits discrimination against patients with these
problems. Although the laws differ somewhat from state to state, they generally ensure that insurance
companies provide the same coverage for surgical and non-surgical treatment of orofacial pain disorders that it
provides for treatment of any other pain problem in the body and does so under the patient's medical plan. This
applies whether the treatment is administered or prescribed by a physician, dentist, or other licensed health
care provider.

21
Due to the lack of recognition of the specialty of Orofacial Pain, there has also been a proliferation of non-
evidence-based strategies for their care marketed directly to the patient by dentists, physicians, and other
clinicians to increase revenue. This includes the following;
1) Use of long-term medical treatments that have questionable long-term efficacy including opioid analgesics
and repeated interventions such as joint injections, nerve blocks, and manipulation.
2) Use of electronic surface EMG, jaw tracking and other untested diagnostic tests that have no evidence of
reliability and validity for TMD and orofacial pain conditions have been promoted to increase revenue for
the provider.
3) Dental splints used 24 hours per day 7 days per week or partial coverage splints that change the occlusion
permanently and create malocclusions that requiring expensive orthodontics, prosthodontic dental care, or
jaw surgery to correct the malocclusion and allow normal function again.

In contrast, orofacial pain dentists provide evidence-based rehabilitation care, which integrates patient self-
management training with evidence-based rehabilitation treatments to prevent chronic pain and addiction while
helping the health care system prevent the devastating escalation to chronic pain and addiction. Clinical trials
and systematic reviews have shown that the long-term outcomes of patient-centered rehabilitation approaches
such as splints, exercise, physical therapy, cognitive-behavioral training, mindfulness, and relaxation are
excellent and able to prevent long-term chronic pain, addiction, and disability in many patients.

Recognition of the field of orofacial pain in dentistry has been accepted by numerous other regulating bodies in
the profession. They have consistently agreed that this field warrants specialty status as evidenced by the
following developments;
a) In this country, the United States Air Force and Navy have established Orofacial Pain as a specialty and
recruit dentists for Orofacial Pain specialty training programs to ensure an adequate number of qualified
providers is available to provide care for their personnel. Each of the Air force, Army, and Navy have all sent
dentists to University graduate programs for specialty training in Orofacial Pain over the past 15 years. This
decision was based on the fact that this field requires advanced training that is not provided by any other
specialty.
b) The American Association of Dental Schools have co-sponsored several educational conferences on
orofacial pain. They have supported standards for both pre-doctoral and post-doctoral advanced education
programs that have been used to develop the standard for graduate programs in the field.
c) The Swedish Dental Society was one of the first countries to recognize this field as a specialty over a
decade ago after considerable epidemiological research demonstrated orofacial pain disorders as highly
prevalent and lacking in adequate treatment.
d) Canadian Dental Association has recently recognized Orofacial Pain as a specialty despite the fact there are
few practicing Orofacial Pain dentists in the country. This change was enacted as a joint specialty with Oral
Medicine and Oral Pathology due to the limited number of each of these specialists in Canada.
e) The Brazilian Dental Association has also recognized Orofacial Pain as a specialty and is establishing more
graduate programs in the field. This has also happened in Costa Rica, Australia, and Korea.

The American Academy of Orofacial Pain along with the members have been instrumental in these legislative
changes. Guidelines for pre-doctoral, post-doctoral, and continuing dental education in the field have been
developed by members at national conferences and submitted and approved by the CODA. The American
Association of Dental Schools worked with the AAOP in recommended goals and objectives for didactic,
laboratory, and clinical pre-doctoral courses in Orofacial Pain to be taught in all dental schools. In addition, the
AAOP has established guidelines for continuing education courses in the field as well as advanced education
training programs. Continuing education guidelines help set standards for quality education programs for
dentists who have not had this training in dental school. It is recommended when possible to participate in
courses with practical experience by recognized specialists in the field. The post-doctoral guidelines
recommend that university advanced education programs be a degree program (M.S. or Ph.D.) and include
significant patient care, multidisciplinary didactic courses in clinical sciences and neurosciences, clinical
rotations in other medical and dental clinical areas, and research activities associated with orofacial pain.

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6. Describe and assess the sponsoring organization's ability to establish a certifying board that
possesses the essential characteristics of a board that grants certification in a recognized dental
specialty.
The American Board of Orofacial Pain (ABOP) is modeled after the certifying boards of the ADA recognized
dental specialties and has become the accepted board for dentists in the field of Orofacial Pain. The ABOP
meets all of the Requirements for Recognition of Dental Specialties and National Certifying Boards for Dental
Specialists and all of the requirement for dental board certification by the American Board of Dental
Specialties. Currently there are 325 diplomates of the ABOP. The ABOP uses a "Standards for Advanced
Specialty Education Programs in Orofacial Pain" to evaluate advanced education Orofacial Pain training
programs and is consistent with the content to the “standards" of education and experience approved by the
Commission on Dental Accreditation for recognized specialties. These requirements include the successful
completion of two or more years of educational training program accredited by the Commission on Dental
Accreditation and completion of study at an institution approved by the ADA. In addition, to improve access to
care, potential candidates without advanced education certificates may qualify to take the ABOP certification
examination, provided they have equivalent training of advanced education specialty training programs by
having at least five years of clinical experience in Orofacial Pain and 400 hours of formal didactic education
that covers each of the knowledge areas of the CODA approved orofacial pain curriculum to be eligible to
taking the Board.

History of the American Board of Orofacial Pain. In 1989, the American Academy of Orofacial Pain (AAOP)
formed an Ad Hoc committee to assess the need and define the process for a national standardized board
examination in the field of Orofacial Pain. The committee reviewed the examination content of existing dental
specialties and determined that there was a clear absence of item concentration consistent with the current
knowledge base of Orofacial Pain. The item sufficiency level was determined by reviewing pre-doctoral and
post-graduate curriculum content, emerging national practice standards, research activities, and publications.
Also, medical specialty training programs and board examination content was reviewed to determine possible
overlap since the general field of Pain Management encompassed both dentistry and medicine.

Concurrently and independent to the committee's effort was a joint national task force established by the
American Pain Society (APS) to determine the need for board certification by the different health care
disciplines. The APS had appointed the AAOP as the dental representative. The task force's conclusion clearly
showed the need to organize and standardize a demonstrated minimal competency examination process for
each profession. As a result of these findings, the AAOP funded the creation of a totally independent
organization to form a national board certification examination.

In 1993, the American Board of Orofacial Pain (ABOP) was incorporated in the state of California with its sole
mission of developing and administering a proficiency examination in Orofacial Pain. The Board contracted
with Knapp & Associates, an independent health care testing service, to provide the guidance in creating
validated standardized examinations. The board of directors was selected to carry out the tasks assigned by
Knapp & Associates. Some of these tasks included providing mailing lists of all organizations with a primary
focus of Orofacial Pain, developing reading lists, identifying academic components such as curriculum
guidelines, recognized full time researchers, NIDCR activities, and establishing an examination council.

Since the ABOP decided not to exempt any individual from taking the examination, a multi-leveled question
development process was implemented such that no person was able to see questions in advance of taking
the examination. A national practice survey was conducted to determine the appropriate subject matter and
degree of importance. This data allowed the construction of an examination blue print which determined the
actual question content in terms of number, subject, degree of difficulty, etc. Test question writers were
selected for geographic balance, acknowledged expertise in their subject area, and willingness to follow the
question writing format prescribed by the testing service. Each question required two reference sources from
refereed journals and texts. Once assembled, the examination was statistically normalized according to
national testing criteria. The first examination was given on October 8, 1994 and subsequently each February.

23
The ABOP is governed by a Board of Directors who establishes the examination date and location, reviews
disciplinary matters, appoints an Examination Council Chairperson, and determines the annual budget. The
Examination Council is responsible for conducting the annual question writing drive and meeting with the
testing service to edit and add new questions to the data bank. The Council is appointed by the Chairperson
and must be geographically balanced. The examination content continues to be determined by the examination
blueprint.

The Board of Directors and the Examination Council cannot alter this format without conducting another
survey. In other words, no individual or group of individuals can alter the question distribution, difficulty level or
general categories. This prevents examination variance from year to year. The ABOP holds its annual question
drive for diplomates from March to October. Then, the Examination Council meets with the testing service to
refine and edit all new items so that an examination can be generated with a certain percentage of new
questions. The tests are scored and normalized by the testing service. Under no circumstances does any
Diplomate or officer play a role in the scoring process. Every 5 years, the ABOP carries out a national survey
to review the consistency of the examination, question items, and topic distribution with the current knowledge
of Orofacial Pain. Additionally, the testing service carries out a statistical and time purging of the question items
that are no longer regarded as "current". The re-certification effort assures a credentialing and scoring process
based on the most current didactic and clinical knowledge base.

Supporting Documentation: Appendix Ic ABOP Constitution and Bylaws

7. Provide written parameters of care for the specialty.

The current written parameters of care for the specialty as approved by the AAOP is included in the publication
entitled, "Orofacial Pain: Guidelines for Assessment, Diagnosis, and Management (DeLeeuw and Klasser,
Quintessence Publishing Company, 2018). We are happy to provide you with a copy of these written
parameters for the field. Written parameters of care for the specialty have evolved as a result of numerous
efforts by members over the past 15 years and the newest revision was completed in 2018. The American
Dental Association initially developed guidelines for temporomandibular disorders in the "Report on the
President's Conference on The Examination, Diagnosis, And Management of TM Disorders" in 1983.

The American Academy of Orofacial Pain then published the first edition of its written parameters in 1989 and
a subsequent 5 more editions. This document was developed by a consensus panel after an exhaustive
assessment of the scientific literature. The guidelines are strategies designed to provide clinicians with a basis
for providing scientifically based diagnosis and management to educate clinicians, improve patient outcomes,
enhance quality assurance, and reduce inappropriate treatment and the cost of orofacial pain care. All
references used have been scientifically based. The members also continue to establish the standards of care
for the field of Orofacial Pain in many institutions and journals.

8. Scientific Advances
a. Describe and assess how the knowledge gained through research activities has transferred to the
practice in this field.
During the past 40 years, a number of scientific advances have helped improve the knowledge base in the field
of Orofacial Pain. These advances have been made by many AAOP members and published peer reviewed
original articles in its official journal, the Journal of Oral & facial Pain and Headache. However, many members
also publish in a variety of prestigious, peer reviewed dental and health care journals. The journals in the field
include; Journal of Oral & and Facial Pain and Headache, Journal of Craniomandibular Practice, Pain,
Advances in Pain Research and Therapy, Clinical Journal of Pain, The Pain Forum, Journal of Pain and
Symptom Management. Journal of Musculoskeletal Pain, Journal of Back and Musculoskeletal Pain,
Headache, and Cephalgia. Other journals that publish occasional articles for general dentists and dental
specialties, but Orofacial Pain is not the focus of the journal include, Journal of Dental Research, Archives of
Oral Biology. Journal of Oral Medicine, Oral Pathology, and Oral Surgery Journal of the American Dental
Association Journal of the Canadian Dental Association Dental Clinics of North America Ear, Nose, and
Throat, Journal Otolaryngology, Archives of Physical Medicine and Rehabilitation, American Journal of

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Physical Medicine, and Rehabilitation Journal of Oral and Maxillofacial Surgery, Journal of Prosthetic Dentistry,
Scandanavian Dental Journal, Journal of Oral Rehabilitation, Swedish Dental Journal, American Journal of
Orthodontics and Maxillofacial Orthopedics.

Among the many advances in orofacial pain, 3 areas standout as critically important to the development of the
field and improvement of patient care. These include;
1) the neurobiology of pain modulation that has shaped our current concepts of orofacial pain diagnosis and
opened avenues of treatment;
2) the concept of chronic versus acute pain;
3) the application of interdisciplinary teams to management of the chronic pain patient.

1. Neurobiology of Pain Transmission and Modulation. Basic research based on animal experiments has
elucidated considerable knowledge about the neurophysiology, neuroanatomy, and neuropharmacology of
pain. Findings from these experiments suggest that similar mechanisms occur in humans and have
implications for patient care. Although understanding the pain response is more complicated than just
understanding the neurobiology, the pain experience and its modulation does involve the noxious (nociceptive)
stimulus, the stimulation of nociceptors, the peripheral and central neurologic pathways, modulation of pain,
and the perception of, and, reaction to pain (31). Physical pain is meant to be a protective mechanism for
humans, arising from a variety of nociceptive stimuli that are potentially destructive to the cells and receptors of
the surrounding body structures. These nociceptive stimuli activate nociceptors of different types that overlap
and interconnect to form a finely divided net, protecting tissues from injurious agents. Mechanical deformation,
extreme temperatures, and many endogenous substances have been found to stimulate nociceptors directly
(31, 44, 45). Endogenous substances including substance P and others are also released from peripheral
tissue stores during inflammation and act on the nociceptors to sensitize them further to thermal, chemical, or
mechanical stimuli (31, 45-49). Analgesics such as aspirin can block some of the chemical mediators
(prostaglandins) to decrease sensitization of nociceptors at the periphery (46).

Advances have been made in identifying the many other aspects of the pain and inflammatory processes
involving neurochemicals such as bradykinin, histamine, serotonin, CGRP, leukotrienes, substance P, and
norepinephrine in injury states have led to new pharmacological agents (47). Drugs such as the tricyclic
antidepressants and gabapentin have opened up new approaches to the clinical treatment of pain. Following
stimulation of nociceptors by a noxious agent, an afferent nerve impulse is generated and transmitted through
the peripheral nerves to the central nervous system (CNS). Once the pain message has reached the CNS,
transmission and modulation of pain involves many structures within the spinal cord, brain stem, thalamus, and
cerebral cortex as well as functional CNS subsystems such as the limbic system (50). Under normal
conditions, this afferent activity signals pain, the system responds, the injury site heals, and the signal system
returns to normal due to the plasticity of the nervous system. However, if the noxious stimulus is of sufficient
intensity or duration, the central wide dynamic range neurons (WDR) that receive the peripheral activity
become sensitized through activation of the NMDA receptor on their cell surface.

This action is driven by the neurotransmitter, glutamate, which is released from the pre-synaptic c-polymodal
nociceptors (51-53). When the NMDA receptor is activated, calcium flows into the post-synaptic cell, setting off
a cascade of events involving formation of nitric oxide and c-fos oncogene activity (54, 55). Nitric oxide (56) is
thought to diffuse to pre-synaptic terminals to cause further release of glutamate and other excitatory
neurotransmitters (51, 57). C-fos activity is known to be present after painful stimulation and may cause a
change in the genetic phenotype of the WDR neuron wherein it loses its ability to discriminate between low
frequency mechano-stimulation and high frequency noxious stimulation. As this occurs, the WDR neuron
responds to all stimulation with an output in the pain frequency range (58). In addition, with the central changes
that are involved in chronic pain, there is a loss of segmental inhibitory inter neurons or “off-on” cells that are
part of the descending pain inhibitory system. These anatomic, neurochemicals, physiologic, and genetic
changes are responsible for chronic pain and account to a large extent for the peripheral symptoms of
allodynia and hyperalgesia (58).

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Understanding these scenarios is essential for the dentist involved in pain management by activating
descending pain inhibition systems or blocking transmission sites through, for example, centrally acting
medication such as tricyclic antidepressant drugs and anti-neuropathic medications. All of these structures
interact with each other through complex neural connections that involve ascending and descending pathways
for transmitting and inhibiting pain transmissions and, thus, affect the quality and intensity of the pain
experience. These pain pathways are characterized by the chemistry of their putative neurotransmitters. Since
the identification of serotonin as an inhibitory neurotransmitter, dramatic advances have been made by the
discovery of other endogenous neurotransmitters such as the opioid peptides, beta-endorphin and met-
enkaphalin (59, 60) acting both centrally and peripherally, plus other neurotransmitter systems such as
noradrenergic antagonist and agonist, dopaminergic, and intersegmental GABA systems, and hence routes for
pain medication therapy.

These and other neurotransmitters have been traced to receptor sites throughout the body, and are also
represented in the trigeminal pathways. They are believed to be integrally involved in this network of pain
modulating mechanisms (61) in head neck and orofacial pain. In the ascending pathways to the CNS,
modulation of pain can occur at the lower CNS centers in the spinal cord where they receive signals from the
afferent pain fibers with cell bodies in the dorsal root ganglia or in the trigeminal system, the trigeminal ganglia
(62). Before traversing to higher CNS levels, they synapse in different layers of the dorsal horn or brain stem,
particularly the substantia gelatinosa. These centers are believed to be the site of pain modulation as originally
proposed by the gate theory of pain control (63). This theory suggests that by stimulating faster larger diameter
A-beta fibers, they inhibit the transmission of pain via slower small c-fibers by "closing the gate" in the
substantia gelatinosa. Although many features of the gate theory have since been updated, it provided a
conceptual basis to explain how pain can be influenced by counter stimulation such as transcutaneous
electrical nerve stimulation and acupuncture.

These understandings have opened up additional avenues of pain therapy. Descending pain inhibitory systems
in pain modulation can be modified by other neurobiologic systems in their action at the dorsal horn and
several other CNS sites including the cortex, periaquaductal gray of the midbrain, the raphe nucleus with
serotonergic neurons, the locus ceruleus with noradrenergic neurons, and parts of the reticular formation (31,
64). In these systems, activity in the cortex and higher CNS centers can send descending signals that inhibit
the afferent pain pathways and, thus, influence the degree of pain perception and reaction. The limbic and
reticular systems interact with the signaling and help explain the neurobiochemical nature of emotional
overlays. These systems help explain the diverse effects of expectation, anxiety, and depression on pain, as
well as the efficacy of distraction, hypnosis, and other cognitive strategies on reducing pain. Hence the
importance of integrating treatments such as cognitive-behavioral therapy and pharmacotherapy for clinical
depression in an Orofacial Pain practice to address the complexity of chronic pain.

Therefore, the pattern generating mechanism theory proposed by Melzack (65) suggests that the pain
experience is influenced by multiple factors that can inhibit or facilitate the pattern of nociceptive input
experienced by an individual. This pattern of pain, particularly with chronic pain, is influenced by factors
involved with descending control such as past learning, expectations, and anxiety or factors involved with
ascending control such as physical therapy modalities, medication, or inflammation. Pain control can then be
enhanced by intervening with multiple factors using a multi-modal treatment approach (66). Understanding
these avenues has given us powerful physical, psychological, and pharmaco-therapeutic tools to stimulate or
inhibit specific receptors thereby blocking pain or shutting down the signaling. Modern understanding of
receptors involved also permits us to understand certain side effects and select alternate drugs that activate
different receptor pathways. With appropriate training, pain therapy is no longer a hit or miss therapeutic
exercise even though it is still an incomplete science. Pain therapy is no longer limited to non-steroidal and
narcotic analgesics. Instead, there is a large armamentarium of pharmacological, counter stimulation,
behavioral, psychosocial, and rehabilitation therapies that work more directly on the pain mechanisms
peripherally and centrally. The medications are not without side effects and the training in proper use and
management of side effects: selection dependent on the patients’ psychologic profile and medical problems is
paramount.

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This type of treatment is preferably conducted in a multidisciplinary pain center, which no other existing dental
specialty provides. The understanding of Orofacial Pain in Dentistry is, thus, considerably broader than dental
and TMD conditions that can cause pain (67, 68). Orofacial pain to many dentists implies TMD while the reality
is that only complex TMD is a small part of the overall problem which includes treatment of central neuropathic,
inflammatory neurogenic, neurovascular, and centrally mediated neuromuscular pain and many co-morbid pain
conditions. During the past ten years, scientific advances have been made with a significant impact on the
understanding and management of orofacial pain disorders. Neuropathic and neurogenic orofacial pain
conditions are complex, difficult to diagnose, and are commonly confused with dental and TMD conditions (69).
Neuropathic pain can be the consequence of any dental or surgical intervention in a few individuals in which
peripheral nerves are affected, injured, sensitized, or altered during otherwise normal restorative, endodontic,
non-surgical and surgical, periodontal, oral surgery, or implant procedures (70-71).

A greater understanding of neuropathic pain mechanisms (nerve injury pain) has led to more accurate
diagnosis and treatment of prior undiagnosed toothache and oral pains. Treatment of these conditions requires
an understanding of peripheral and central sensitization and how to modify this with appropriate pharmaco-
therapeutics that have peripheral or central actions (51, 57, 58, 72). In addition, the role of the sympathetic
nervous system in some neuropathic pain conditions that have not responded to treatment has become clearer
(73, 74): more is now known about the adrenergic receptors involved in maintaining chronic pain states and
what adrenergic agonist or antagonist medications are useful in altering sympathetic activity to stop this pain
(75). Insight into the mechanisms of orofacial neurogenic inflammation has led to a more accurate diagnosis
for tooth site pain that is non-odontogenic and non-neuropathic in nature (52, 54).

Unfortunately, “toothache” from neurogenic dysregulation of the serotonin system often results in unnecessary
tooth oriented procedures and finally extraction: and still the pain remains. The tooth site pain is partially the
result of serotonin receptor activation of c-fiber depolarization (54). The treatment for this pain condition
requires an understanding and use of medications used to treat neurovascular pain (“migraine”). Abortive
migraine medications such as sumatriptan and dihydroergotamine give instant relief of this “toothache”, and
prophylactic medications such as beta blockers and calcium channel blockers are used to treat this condition
over a longer time period. Specialty knowledge and training is required to treat these conditions currently
because of lack of understanding of these types of conditions in the general dental and medical community.

2) Acute versus Chronic Pain

A second important advance has been in the conceptualization of chronic pain as a distinctly different and
more complex experience than acute pain (76). Acute pain is temporary and often self-limiting, has a specific
observable cause and purpose, and generally has no persistent psychological reactions. Chronic pain, in
contradistinction, is not self-limiting, appears permanent, often has no apparent cause, serves no discernible
biological purpose, and can create multiple psychological problems that can confound the patient and clinician
and perpetuate the problem. A patient with chronic pain may feel helpless and hopeless in his or her inability to
receive relief. Although some patients learn to live with pain, others become anxious or depressed with high
tension levels, sleep and appetite disturbances. They may focus much of their energy on analyzing the pain
problem and see multiple health professionals searching for an organic cure. Many clinicians make gallant
attempts with narcotic and non-steroidal analgesics drug regimes, surgical procedures, splints, or other
interventions but short-term failure frustrates the clinician and may add to the patient’s ongoing problems. Near
the end of this progression, some patients with chronic pain can have multiple drug dependencies, analgesic
rebound headache from a steady diet of over the counter and prescription analgesics, transformed migraine
headache, high stress levels, operant behaviors including chronic pain behavior, manipulation of medical,
dental and social systems, conflicts in relationships, disrupted lifestyles, impaired ability to perform vocational,
social or recreational functions, or perhaps become involved in litigation.

These patients often do not receive relief from existing specialty dental delivery systems and usually require a
multidisciplinary or interdisciplinary approach involving an Orofacial Pain practitioners. The ADA guidelines
recommend deferring irreversible or invasive procedures until the patient is functioning better somatically and

27
behaviorally (35). Chronic pain syndromes have been recognized in fields such as headache and low back
pain, and apply equally to orofacial pain. Studies of patients with chronic orofacial pain have found lifestyle
problems similar to that of other chronic pain syndromes (22, 24). For example, a 1986 Harris Poll (9) found
that head pain causes more missed work days among employed workers than any other type of pain. In
addition, research involving oral stress habits, stress-tension behavior, and depression suggests that each
plays some role in orofacial pain disorders (26, 27, 77, 78). Issues such as pain behavior, secondary gain and
operant learning have been identified as significant contributing factors that need intervention to achieve pain
management (23, 29). Other factors might be implicated in the perpetuation of chronic orofacial pain cycles (1,
25, 79) including postural habits, anxiety, caffeine intake, over the counter medication overuse, central spread
of pain and CNS sensitization, general involvement of the upper quarter complicating pain in the orofacial
region, systemic disease with pain corollaries, sleep disorders, and dental arch structural problems. These
theories have provided significant impetus to developing interdisciplinary teams.

Unfortunately, when organic sources of painful stimulus are absent or equivocal, medical or dental practitioners
may be drawn into treatment of more understandable or more discernable findings such as malocclusion or
temporomandibular joint noises rather than opening up to psycho-social and behavioral issues that may be
driving chronic pain. Chronic pain, sleep disturbance, depression, chronic myofascial pain, fibromyalgia, and
migraines all share some commonalities in neurochemistry as well as often combine as multi-factoral problems
in chronic pain patients. This reinforces the need for integrated therapy rather than compartmentalizing the
patient. Chronic pain rehabilitation programs have been applied to orofacial pain with success similar to clinics
for other types of pain (80). Although many patients can be treated by a single Orofacial Pain dentist,
interdisciplinary management teams naturally develop for complex patients (30, 81-83). The multiple factors in
complex pain patients affirm that single modalities may be too limiting and an integration of medical expertise
is often needed. The team does, however, require a leader. Pain management leaders are not abundant in
Medicine. Indeed, it is often difficult to find a neurologist or a psychologist with much interest or training in
chronic pain, or any experience managing orofacial pain. Therefore, the dentist pain manager will continue to
find him or herself in that important role, and needs both dental as well as medical pain management training
to communicate medically, discuss all differential treatment options, and integrate care in a medical as well as
dental setting. A management team enhances the overall potential for success by encouraging communication,
and allows various aspects of the problem to be addressed by different clinicians simultaneously. Please refer
to the Standards Document for Orofacial Pain in Appendix II, that recognizes and reflects the International
Association for the Study of Pain (IASP) requirement for multidisciplinary pain center programs. This
organization is not present in any other dental specialty program or standard, except Orofacial Pain.

3. The application of interdisciplinary and multi-disciplinary teams to management of the chronic pain patient.
Many authors have proposed that because of its multifactorial nature, chronic pain needs to be conceptualized
from a broader biopsychosocial model rather than the biomedical model traditionally used for acute problems
(24, 76, 81, 82). This paradigm shift suggests that patients should be assessed from a multidimensional
perspective determining both the physical diagnosis and the biological, behavioral, psychosocial, and
environmental contributing factors (1, 35, 84, 85). There have been advances in defining the domains involved
in chronic pain, and providing instruments to measure them (86-89). In the area of orofacial pain, risk
assessment) have been developed to assess multidimensional risk factors associated with Orofacial pain. In
addition, many Orofacial Pain and Pain Medicine centers use standard psychological assessment instruments
such as the MMPI for personality assessment screening for psychological problems, referral for psychology or
psychiatry pre-treatment or co-treatment. The MMPI, for example, can assist in patient management by
advising on the suitability of invasive procedures, making appropriate medication selections, and estimating
potential compliance with treatment. If an underlying primary clinical depression is identified, then this should
be managed first before starting rehabilitation therapy. Current approaches to management advocate a long-
term rehabilitation approach that addresses both the physical disorder and contributing factors on an equal and
integrated basis (81, 82). Issues such as pain behavior, secondary gain and operant learning have been
identified as significant contributing factors that need intervention to improve the problem (91, 92)

New approaches to management also follow these concepts by advocating a long term rehabilitation approach

28
that addresses both the physical disorder and contributing factors on an equal and integrated basis 81, 82).
Although most patients can be treated by a single dentist, the development of interdisciplinary management
teams have been developed for complex orofacial pain problems (30, 81-83). Traditionally, most treatment of
orofacial pain disorders varied according to the clinician's favorite theory of etiology. As a result, success of
treatment was often compromised by limited approaches that only addressed part of the problem. With a
broader conceptualization of orofacial pain disorders, the integration of knowledge and care from multiple
clinicians, particularly dentists, health psychologists, and physical therapists has also evolved. A management
team enhances the overall potential for success by allowing various aspects of the problem to be addressed by
different clinicians simultaneously. The biopsychosocial approach to medical and dental problems is well
established in the literature (26-30,41). The general implication of this model is that virtually all of the problems
confronted in dental practice are, in one way or another, an integration of biological, psychological, and
sociological phenomena. Biopsychosocial dentistry acknowledges that many patients presenting with dental
concerns may not be able to be “cured”, and consequently develop psychosocial problems. Physical symptoms
may be caused or exacerbated by emotional distress, as well as organic disease may cause conflicts in
adjustment resulting in secondary psychological dysfunction.

The interdisciplinary/team approach to treatment and prevention has been documented to be the most
comprehensive approach to providing the most well-rounded individualized treatment program for patients(28-
31,83). These issues become important regularly during patient care, and pain management dentists in
particular must be trained in recognition and appropriately directing psychological and behavioral treatment
including: substance abuse; mood disorders; body image concerns; suicidal ideation; stress / anxiety;
disorders; spouse abuse; compliance problems; patient education; cognitive deficits; personality issues;
unrealistic expectations; psychopharmacologic medication recommendations; relapse prevention.

Services provided in a Orofacial Pain Clinic have also included but not limited to: a) assessing the impact a
patient’s pain problem has on the patient’s psychosocial functioning and behavior; b) the impact that
psychosocial factors and behaviors may have on the patient’s ability to respond to a physical medicine regime;
c) providing various treatments to patients to reduce behavioral problems (biofeedback, relaxation training,
Cognitive-Behavioral Training, stress management, surgical preparation); d) training residents to make
appropriate psychiatric referrals as well as how to incorporate psychological treatment recommendations in
their patient care; e) psychometric testing for patient treatment planning; f) coordinating various treatment
recommendations and specialties, g) dealing with suicidal patients, substance abuse, and mood disorders, as
well as many other services in treating patients and educating residents. In current programs, it has become
evident that patients with problems in all aspects of the dental school curriculum have benefited from the
presence of an interdisciplinary Orofacial Pain center within the dental school. The majority of dental schools
have Orofacial Pain clinics within them.

b. Provide an analysis of current scientific challenges central to advancing this field.

Several conferences and publications in the past 5 years have documented the scientific challenges that are
central to advancing the field. Although the details of many advances in Orofacial Pain are included in section
8a on Scientific advances, the scientific challenges as developed by these conferences are summarized here.
For further details of these recommendations, please refer to the individual references cited. 1) Broadening the
Scope, Long Range Research Plan for the Nineties. Back in 1989, the Dr. Harald Loe, Director of NIDR
convened a panel of experts to outline the long-range goals for research in dentistry into the 2000s. In this
vision, he states "Thus, we enter the nineties with the conviction that dental research will no longer be
dominated by the two diseases that have colored public perception for the past 100 years: dental caries and
periodontal diseases. Instead, our vision is expanded to include all the disease and disorders that affect the
oral and facial tissues across the life span".

Orofacial pain disorders and other oral sensory and motor functions are featured as an area that is "solid in
past advances but rich in potential for discovery of new methods for diagnosis and management". The general
areas that are recommended for research include; 1) anatomy, physiology and chemistry of pain, 2)
inflammation and nerve injury, 3) orofacial pain management and outcome, and 4) diagnosis, assessment, and

29
treatment of chronic orofacial pain conditions. 2) Orofacial Pain and Temporomandibular Disorders: Advances
in Research and Therapy, 1993 The American Academy of Orofacial Pain and the NIDR co-sponsored the
1993 Scientific Congress on Orofacial Pain. This Congress featured many of the most distinguished scientist in
the field and developed research recommendations for advancing the field of Orofacial Pain. These were
published by Fricton and Dubner in Orofacial Pain and Temporomandibular Disorders (116). These
recommendations covered all areas of orofacial and included: 1) the need for a better understanding of
prevalence and impact of orofacial pain disorders; 2) mechanisms of orofacial pain and it's modulation; 3)
orofacial pain assessment, diagnosis, and classification; 4) diagnostic strategies for temporomandibular
disorders, and 5) outcome and clinical trials associated with all strategies for management of orofacial pain
(Temporomandibular Disorders and Related Pain Conditions: Report of an NIH/NIDR Conference. IASP Press.
1995.)

The National Institutes of Craniofacial and Dental Research, the National Institute of Arthritis and
Musculoskeletal and Skin Diseases, the Office Research on Women's' Health, and Food and Drug
Administration organized a workshop to synthesize available information from both the United States and
abroad on temporomandibular disorders and associated conditions. One of the purposes of the conference
was to identify major research needs in the field. The papers based on this workshop were published by
Sessle, Bryant, and Dionne in Temporomandibular Disorders and Related Pain Conditions (34). These
recommendations detailed the state of knowledge and specific areas that need research and include: 1)
muscle pain and pathophysiology, 2) temporomandibular joint disk displacements, 3) degenerative and
inflammatory temporomandibular joint disorders, 4) diagnosis and assessment of temporomandibular
disorders, 5) epidemiology and health services research related to TMD, 6) temporomandibular joint structure,
function, and repair, 6) therapeutic approaches to TMD, and 7) biostatistical analysis of clinical research. 4)
Technology Assessment Conference Statement on Management of Temporomandibular Disorders. The most
recent conference included the Technology Assessment Conference Statement on Management of
Temporomandibular Disorders sponsored by the National Institute of Dental Research in 1996 and chaired by
Judith Albino, Ph.D.(NIDR consensus statement from Technology Assessment Conference, USPHS
publication, 1996)

This independent panel of experts outside of the field of orofacial pain were presented with the most recent
advances in a specific area, in this case, management of one specific type of orofacial pain:
temporomandibular disorders. The panel concluded that although there has been significant advances in the
understanding of management of TMD, considerably more research is needed. The areas of recommendation
include: 1) the biological basis for diagnosing TMD, 2) reliable and valid classifications of TMD, 3)
understanding underlying pathophysiology, 4) longitudinal studies on natural history of TMD and risk factors, 5)
health services research on cost and impact, 6) improving our knowledge of outcomes through randomized
clinical trials, and 7) underlying basic research in TMD.

The National Academies of Sciences, Engineering, and Medicine Committee on Temporomandibular Disorders
(TMD) to gather information, explore the current state of knowledge, and identify priorities for advancing basic,
translational, and clinical research on TMD and improve evidence-based treatment and clinical management
for patients with TMD. They are hosting a public workshop on March 28 – 29, 2019 in Washington, DC. This
workshop is part of the committee’s broader effort to review and estimate the public health significance of
TMDs, including prevalence, incidence, burden and costs; and review challenges to data collection and
reliability.

Some of the challenges addressing the field of TMD and orofacial pain include;
 Evaluate the evidence base for assessment, diagnosis, treatment, and management of acute and chronic
TMD. Recognizing that TMDs are diverse and multifactorial conditions influenced by genetics, sex and
gender, environmental, physiological, and psychological factors, this effort will:
o Address patient heterogeneity and challenges to patient stratification to better target therapies toward
patients.
o Identify similarities and differences between chronic TMD, other chronic pain states (as well as chronic

30
 overlapping pain conditions), and other joint disorders such as phenotypic features that might predict
responsiveness to treatments.
o Identify and characterize other non-pain comorbidities that diminish quality of life, including those that
affect etiology and influence resilience, such as nutritional challenges and other neurological, metabolic,
and mental health conditions (e.g. anxiety, depression).
o Examine the evidence-base for defining chronic TMD as a multi-system disorder that necessitates
multidisciplinary research and interventions.
 Identify barriers to appropriate patient-centered TMD care, in the presence and absence of an evidence
base, and strategies to reduce these barriers along the continuum of TMD pain. This effort will:
o Evaluate elements and outcomes of patient-centered TMD care.
o Identify challenges to dissemination and implementation of evidence-based treatments and prevention
strategies that are safe and effective.
o Determine and characterize health inequities in clinical TMD management.
 Review the state of science for TMD and provide an overview of basic, translational, and clinical research
for TMD. This effort will:
o Examine existing or emerging TMD animal models and their preclinical utility.
o Identify gaps and opportunities in TMD research relating to central and peripheral mechanisms,
genetic/epigenetic contributions, heterogeneity of molecular mechanisms, joint mechanics,
neuroimmune processes, endocrine influences, role of the microbiome, and endogenous mechanisms
of resilience.
o Assess the intersection of sex differences in immune/neuroimmune and inflammatory responses in
chronic TMD with other autoimmune diseases that are more prevalent in females or males.
o Assess progress on identification and validation of targets and biomarkers (genetic, neuroinflammation,
neuroimaging, proteomic, behavioral, etc.) for use in establishing risk, diagnoses, treatment, outcomes,
and reoccurrence.
o Identify potential approaches to using artificial intelligence for pattern recognition in patient datasets
(e.g., genetic, biological, psychological, social traits, electronic health records, and patient-reported
outcomes) to distinguish disease subtypes, develop individualized clinical decision support, and predict
patient responses.
o Identify new and rapidly evolving tools and technologies with potential to significantly advance
research, diagnosis, and treatment of TMD.
 Identify opportunities and challenges for development, dissemination, and clinical implementation of safe
and effective clinical treatments for orofacial pain, including pharmacological agents, regenerative
medicine, behavioral interventions, and complementary and integrative approaches.
 Identify scientific and clinical disciplines needed to advance TMD science and the development,
dissemination, and implementation of safe and effective treatments; as well as strategies to enhance
education and training in these disciplines.
 Identify multi-disciplinary/inter-disciplinary research approaches necessary in the short-and long-term to
advance basic, translational, and clinical TMD research and to improve the assessment, diagnosis,
treatment, and management of TMDs.

U.S. Department of Health and Human Services: National Institutes of Health (Office of the NIH Director and
the National Institute of Dental and Craniofacial Research), This committee’s report including its conclusions
and recommendations is due to be released in Spring 2020.

c. Describe how the organization has fostered research training.

The members and organizations of the AAOP have been active in fostering research training and scientific and
clinical advances in the field. Several Ph.D. programs in Orofacial Pain and Neurosciences (University of
Minnesota, University of Kentucky, University of New York at Buffalo, LSU, University of New Jersey, UCLA,
and others) have been developed by members to stimulate research and develop faculty in the field. Many
members also participate as faculty for these research training programs. In addition, the AAOP has annually
brought together nationally known researchers in the various disciplines of Orofacial Pain to present their most
recent research at national meetings. These AAOP meetings also sponsor scientific abstracts to allow
31
presentation of the most recent research by investigators all over the world. The AAOP has a strong history of
supporting research and research training in other ways also including;
1) Holding annual national scientific meetings and international meetings every 3 years.
2) Participating with NIDCR in sponsorship of scientific meetings such as the Management of TMD
Technology Assessment Conference.
3) Promoting graduate research in Orofacial Pain and related areas through the annual sponsorship of
scientific abstracts.
4) Members obtaining grants and conducting research.
5) Membership in AAOP encourage scientific publications.
6) The AAOP providing funds for research and have a peer review process.
7) Members collaborating with the AADR neurosciences section and NIDCR intramural Pain Research
Center.
8) The AAOP publishing the Journal of Orofacial Pain to stimulate research.
9) AAOP investigators serving as research mentors to graduate students and new members and
participate as members of peer review panels for granting agencies such as the National Institutes
of Health (NIH) and the American Fund for Dental Health.
10)The requirement by the American Academy of Orofacial Pain's "Standards for Advanced
Education Programs in Orofacial Pain" that all Orofacial Pain graduate degree programs include ongoing
review of current research and participation in original research.
11) The collaboration with international organizations in Orofacial Pain to promote world-wide standards of
practice and education.
12) The development of standards for disability assessment in the field of Orofacial Pain.
13) Collaborating on T=the National Academies of Sciences, Engineering, and Medicine Committee on
Temporomandibular Disorders (TMD) to gather information, explore the current state of knowledge, and
identify priorities for advancing basic, translational, and clinical research on TMD and improve evidence-
based treatment and clinical management for patients with TMD

9. Other Information
Provide any other information which demonstrates that the sponsoring organization meets the
definition as described in this standard.
This standard has been met as noted in the previous discussion based on the fact that members of the
specialty of orofacial pain have been recognized by medicine, health psychology, physical therapy, and other
fields. For example, Dr. William Maixner DDS, PhD is current President of the American Pain Society and Dr.
James Fricton DDS, MS is President of the International Myopain Society and integrally involved in leading the
campaign to prevent chronic pain and addiction.

The campaign includes members of the International Association for the Study of Pain (IASP), the International
MYOPAIN Society (IMS), National Fibromyalgia and Chronic Pain Association (NFMCPA), and the Institute for
Healthcare Excellence have developed a multi-level strategy to help transform healthcare to relieve and
prevent chronic pain and addiction with patient-centered transformative healthcare solutions. The International
Association for the Study of Pain (IASP) works to support research, education, clinical treatment, and better
patient outcomes for all pain conditions with the goal of improving pain relief worldwide.

These organizations include over 7,000 members representing over 130 countries, 91 national chapters, and
Special Interest Groups (SIGs) including Orofacial Pain. These groups foster the exchange of ideas and
education to advance the field of pain science. Here is a summary of the campaign. It is now Chronic pain is
the big elephant in the room of healthcare as the top reason to seek care, the #1 cause of disability and
addiction, and the primary driver of healthcare utilization costing more than cancer, heart disease,
and diabetes. Chronic pain often results from patient-centered risk factors such as poor ergonomics, repetitive
strain, inactivity, prolonged sitting, stress, sleep disorders, anxiety, depression, abuse, and others that increase
peripheral and central pain sensitization. Health professionals’ primary role in managing pain conditions should
be guiding, coaching, and assisting patients with day-to-day self-management of pain (Institute of Medicine
2011). Transformative care integrates self-management training with treatment using a team and technology

32
(4-Ts) to improve long-term successful outcomes. The Campaign for Preventing Chronic Pain and Addiction
helps health professionals, patients, and the healthcare system implement transformative care. The Campaign
is promoting training of health professionals in Transformative Care for Pain Conditions that integrates patient
training in self-management with evidence based treatments using teams and technology.

II. Requirement 2:
A proposed specialty must be a distinct and well-defined field which requires unique knowledge and
skills beyond those commonly possessed by dental school graduates, as defined by the Commission
on Dental Accreditation’s Accreditation Standards for Dental Education Programs.

a. Definition
Orofacial Pain is the discipline of dentistry which includes the assessment, diagnosis and treatment of patients
with acute and chronic orofacial pain and dysfunction disorders, oromotor and jaw behavior disorders,
obstructive sleep disorders, and chronic head, neck, and facial pain, as well as the pursuit of knowledge of the
underlying pathophysiology and mechanisms of these disorders. Specifically, the field includes diagnosis and
treatment of orofacial pain disorders including neuropathic orofacial pain disorders, neurovascular orofacial
pain disorders, chronic regional pain syndrome, masticatory and cervical neuromuscular pain disorders,
primary headache disorders, pain from temporomandibular joint disorders(TMD), pain secondary to orofacial
cancer and AIDS, orofacial dyskinesias and dystonias, orofacial sleep disorders, and other complex disorders
causing persistent pain and dysfunction of the orofacial structures.

It is important to note that this field does not include acute pain from disorders such as pulpitis, periodontal
disease, surgical treatment of TM joint disorders or nerve injuries, impacted 3rd molars, dental hypersensitivity,
oral lesions, and other acute pain disorders that are part of many dentist’s or dental specialist’s practices. The
field also does not include treatment or prevention of anxiety from dental surgical or operative procedures.

The specialty of orofacial pain requires unique knowledge and skills beyond those commonly possessed by
dental school graduates because they have negligible time in dental school pre-doctoral didactic curriculum.
The baseline curriculum and training in orofacial pain disorders in the revised 2019 ADA pre-doctoral dental
standards is minimal. The most recent standards included in the July 1st, 2019 Revision of Standards 2-8 and
3-1 were reviewed. There are generally no clinical requirement standards for Orofacial Pain diagnosis and
treatment. Thus, the field is distinct and well defined in comparison to the definition of all other specialties in
dentistry.

b. Advanced knowledge. Compare and contrast the pre-doctoral accreditation standards with the
advanced knowledge required for the practice of the specialty, especially with regard to the level of
knowledge required.

Table 5 shows a comparison of the pre-doctoral curriculum in the revised 2019 CODA accreditation dental
standards with that of post-doctoral Orofacial Pain standards. This table illustrates that the knowledge and
skills in the field of Orofacial Pain is largely under-represented in the pre-doctoral curriculum of most dental
schools. Pre-doctoral curriculums do include content areas that are not part of the scope of Orofacial Pain such
as treatment of pulpitis and periodontal disease, dental anatomy and occlusion, local anesthesia and
conscious sedation, acute pain control, and routine treatment of TMD disorders. However, there are generally
no clinical requirement standards for treatment of orofacial pain disorders. In contrast, the Orofacial Pain
practitioner differs from both the pre-doctoral student and the existing dental specialists in being trained to treat
orofacial pain disorders and not just to triage them. As described in the following documents, the curriculum
primarily require exposure to and recognition of orofacial pain disorders for either referral or for consideration
of dental treatment for other problems:
 The most recent standards included in the July 1st, 2019 Revision of Standards 2-8 and 3-1 and the rest of
the 2019 standards were reviewed. In this document, it states that in 2-24, at a minimum, graduates must
be competent in providing oral health care within local anesthesia, and pain and anxiety control, including

33
 consideration of the impact of prescribing practices and substance use disorder but no reference to
orofacial pain conditions.
 The ADA “Guidelines for Teaching the Comprehensive Control of Pain and Anxiety in Dentistry” are
defined as the application of various physical, chemical and psychological modalities to the prevention and
treatment of preoperative, operative, and postoperative patient anxiety and pain.
 This broadens the scope in the pre-doctoral and specialties curricula but is predominantly oriented around
the acute pain model, anesthesia, and anxiety control. There is only mention of recognition of orofacial pain
disorders but no mention of treatment.

Table 5. The table lists the disorders that require advanced knowledge and skills for diagnosis and
management and whether they are either included in the 2019 pre-doctoral CODA curriculum standards or
treated in clinical practice in the community based on the clinical practice survey of 311 general dentists
(Appendix III).

The 2019 Commission on Dental Accreditation of the American Dental Association Pre-doctoral Dental
Education Standard states that the mission of a pre-doctoral dental education program requires goals that
include the preparation of a dentist who possesses the competencies within the scope of general dentistry and
that early specialization is not permitted until the student has achieved a standard of minimal clinical
competency in all areas necessary to the practice of general dentistry, requiring a “curriculum of at least four
academic years of instruction or its equivalent.” The areas that imply some knowledge and skills are needed in
orofacial pain are highlighted in bold.

The 2019 Pre-doctoral Standards for Biomedical Sciences include;

Standard 2-12 Biomedical science instruction in dental education must ensure an in-depth understanding of
basic biological principles, consisting of a core of information on the fundamental structures, functions and
interrelationships of the body systems.
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Standard 2-13 The biomedical knowledge base must emphasize the oro-facial complex as an important
anatomical area existing in a complex biological interrelationship with the entire body.
Standard 2-14 In-depth information on abnormal biological conditions must be provided to support a high level
of understanding of the etiology, epidemiology, differential diagnosis, pathogenesis, prevention, treatment and
prognosis of oral and oral-related disorders.

In contrast, 2019 Curriculum Standards for the Development of Post-doctoral Programs in Orofacial Pain (31-
32) state that "a minimum of two years full time training, including a 50 percent clinical proportion, is required
for minimal competency in this field of Orofacial Pain". It is not possible to achieve this in the general dental
training curriculum. Currently, there is insufficient curriculum time available in the pre-doctoral curriculum and
limited numbers of faculty trained in Orofacial Pain to teach the broader aspects of management of orofacial
pain disorders to pre-doctoral students.

Dentists in the general practice of dentistry are briefly trained or not trained at all in didactic aspects of
differential diagnosis of orofacial pain and treatment competency training is primarily in the practice of dental
procedures, including management of acute dental pain problems, acute anxiety management of the dental
and surgical patient (ADA Guidelines for teaching the comprehensive control of pain and anxiety in dentistry)
and management of pain through local anesthesia and some exposure to use of general anesthesia.

In contrast, graduates of two years or more advanced education programs in Orofacial Pain are expected to
become the authoritative resource academically, educationally, and clinically for chronic orofacial pain patients
whether working in a dental or medical environment. Because temporomandibular disorders are a component
of many dental patients, students are exposed to this in most pre-doctoral and existing specialty programs.
Routine management of TMD is not considered to be part of the domain of Orofacial Pain dentists. However, it
is proposed that the Orofacial Pain advanced education program graduates will have received the greatest
didactic and clinical experience in the management of these patients and will become the critically needed
educators in our pre-doctoral and existing post-doctoral program curricula. They will be especially essential if
the ADA Council on Dental Education adopts the proposed standards for pre-doctoral education in TMD.

Pre-doctoral didactic courses are commonly offered in temporomandibular disorders and jaw behavior
disorders such as bruxism in some schools, but the curriculum has minimum exposure to chronic pain,
orofacial pain disorders, and oromotor disorders. The goals are generally diagnostic familiarity and to
encourage awareness of wider diagnostic and treatment possibilities, and to understand the sequencing and/or
limitations of normal dental procedures in tackling these kinds of multifactorial problems. There are no clinical
requirements for pre-doctoral training in Orofacial Pain. Whereas, pre-doctoral students may be exposed to
didactic presentations about chronic pain, they do not obtain experience and are not competent in the
evaluation, diagnosis, management, treatment, and interdisciplinary care for chronic pain patients.

Most dental schools do not provide exposure to patient care for orofacial pain patients in the pre-doctoral
curriculum except by observation rotations, selectives, or electives in some institutions. Some pre-doctoral
clinical experience may be acquired in the recognition of temporomandibular disorders and risk management
practice of dental procedures in dental patients who have some positive orofacial pain findings. Areas of
dental practice that are fundamental to general dentistry have to be taught to competency standards measured
by competency testing “to assess the degree to which each student has mastered published objectives”. There
are no pre-doctoral objectives or competency level standards for Orofacial Pain. Graduates of the dental pre-
doctoral curriculum generally are not exposed to chronic pain patients and are not trained to any level of
competency to treat such patients for whom chronic pain problems are the primary complaint. Through
continuing education, many general dentists increase their expertise in the management of TMD problems in
their dental patients, which may include other orofacial pain problems on limited basis. However, they cannot
replace the necessary core pain neuroscience background, and especially not the problem oriented use of
medical, physical medicine, pharmaco-therapeutic, and behavioral sciences in a multidisciplinary environment
experience that an accredited orofacial pain specialty program does provide.

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c. Advanced skills.
Compare and contrast the advanced skills and levels of competency/proficiency expected of a
graduate of the specialty, especially with regard to the level of skill required.

The areas that imply some skills are needed in orofacial pain are highlighted in bold. The 2019 Pre-doctoral
Accreditation Standard 2-24 states;
At a minimum, graduates must be competent in providing oral health care within the scope of general dentistry,
as defined by the school, including:
a. patient assessment, diagnosis, comprehensive treatment planning, prognosis, and informed consent;
b. screening and risk assessment for head and neck cancer;
c. recognizing the complexity of patient treatment and identifying when referral is indicated;
d. health promotion and disease prevention;
e. local anesthesia, and pain and anxiety control, including consideration of the impact of prescribing
practices and substance use disorder;
f. restoration of teeth;
g. communicating and managing dental laboratory procedures in support of patient care;
h. replacement of teeth including fixed, removable and dental implant prosthodontic therapies;
i. periodontal therapy;
j. pulpal therapy;
k. oral mucosal and osseous disorders;
l. hard and soft tissue surgery;
m. dental emergencies;
n. malocclusion and space management; and
o. evaluation of the outcomes of treatment, recall strategies, and prognosis

In these standards, there is reference to “oral related disorders”, “recognizing the complexity of patient
treatment and identifying when referral is indicated”, “local anesthesia, and pain and anxiety control including
consideration of the impact of prescribing practices and substance use disorder”, and “oral mucosal and
osseous disorders” are included. However, there is no reference to orofacial pain disorders.

Pre-doctoral clinical competency testing is usually limited to the restorative, periodontal and oral pathologic
areas that are subsequently tested for minimal competency in State Board and regional examinations. There is
no clinical competency testing in orofacial pain diagnosis and management. This experience is generally
limited to exposure to a TMD patient or in risk management in pre-doctoral student dental patients that have
the complication of some TMD complaints or findings. The general dentist should be able to practice risk
management dentistry in regards to TMD, atypical facial and tooth pain, and some neuropathic pain disorders
complaints and findings. The pre-doctoral dental curriculum does not prepare the general dentist to become a
practitioner accepting referrals for management of chronic orofacial or head and neck pain problems since or
she will not have received clinical training to competency in Orofacial Pain diagnosis and treatment in the
general pre-doctoral curriculum.

Behavioral Sciences Standards include;

2-16 Graduates must be competent in the application of the fundamental principles of behavioral sciences as
they pertain to patient-centered approaches for promoting, improving and maintaining oral health.
2-17 Graduates must be competent in managing a diverse patient population and have the interpersonal and
communications skills to function successfully in a multicultural work environment.

In contrast, the practice of orofacial pain management requires the ability to work side by side with health
psychologists in the behavioral and psychopharmacological management of these patients. The Orofacial Pain
dentist must be competent in conducting a behavioral and psychosocial interview, initial screening, selection of
psychometric instruments such as risk assessment, depression, and addiction, and subsequent referral,
recognition of underlying signs of clinical depression or other behavioral abnormalities including medication
abuse, and sleep disturbance. Orofacial Pain Dentists must be able to communicate professionally with health

36
care psychologists and work as a team member in interdisciplinary programs. They need to make treatment
decisions or modify treatment approaches, set up contingency based treatment contracts for behavioral
problem patients, and tailor centrally acting pain medications (many of which have psycho-
pharmacotherapeutic properties) to the psychological profiles. None of these competencies are discussed or
deliver in pre-doctoral dental curricula.

The graduates of Orofacial Pain post-doctoral programs must be competent in complete head, neck, and
neurological evaluations and be competent in head and neck diagnostic strategies including orofacial and
cervical tomographic, CT, MRI, Scintigraphy, arthrography, and other imaging examinations. The pre-doctoral
graduates must be able to "order and interpret appropriate laboratory and other diagnostic tests" This is
generally related to baseline medical screening. In contrast, the graduates of Orofacial Pain post-doctoral
programs must be competent in medical laboratory examination including ongoing tests to monitor therapeutic
dosing of medications that they are prescribing and to rule out changes indicating adverse or iatrogenic
medical effects. In addition, it is recommended that they have exposure to MRI, SPECT, PET, thermography,
EMG, EKG, and other diagnostic tests.

The 2019 Orofacial Pain Standards require competency in evaluation, diagnosis and treatment of all orofacial
pain disorders, and to act as authoritative sources for the above. The Commission on Dental Accreditation
requires each institution to define pre-doctoral graduating competencies for student performance in all
essential areas, 5-43, which implies some flexibility between institutions, but little standardization of curriculum
or competencies in Orofacial Pain. These include "Graduate Minimum Competencies" that may pertain to the
pain and dysfunction patient, namely: "A. examine and evaluate the patient B. identify and record the oral
problems presented C. prescribe a sequential treatment plan, and the majority of care required by the patient
D. recognized when to refer, and to coordinate care provided by others, "(5-44). It is also stated that "The
general practitioner understands the indications and contraindications for contemplated treatment and is able
to recognize when the scope of treatment is beyond his/her capability” (5-45). This implies the need for
advanced education centers for referral of the complex orofacial pain patient and an educational center to train
such experts, such as Orofacial Pain post-doctoral programs. Standards 5-47H and 5-50 direct that the pre-
doctoral student must be able to make appropriate decisions on modification of the plan for dental treatment
based on the comprehensive evaluation of the patient. This pertains to and can be applied to the problem of
risk management regarding orofacial pain cases in the practice of general dentistry. This is the predominant
problem numerically in general dental practice. Whereas it is estimated that although 2% of the population will
require complex treatment for chronic orofacial pain problems, the prevalence of otherwise more benign TMD
problems is closer to 25- 35%. This finding may be warning signs for potential aggravation of TMD in patients
for whom extensive dentistry is proposed and warrants screening the complex patients before proceeding with
treatment. "All pre-doctoral students receive appropriate didactic and clinical instruction to achieve competency
in control of pain and anxiety, clinical pharmacology and management of related complications", 5-57 and 5-
59. This requirement as written is predominantly related to the management of acute pain problems, local and
general anesthesia.

To put the pre-doctoral exposure into perspective, the same guidelines document specifies that it takes a
minimum of 2 years of full-time study in the field of Orofacial Pain to achieve minimal competency in this field
(32) and it is therefore not possible to achieve this in the general dental pre-doctoral training curriculum.
Orofacial Pain post-doctoral programs also require students to directly evaluate and treat the complex orofacial
pain problems including masticatory and cervical neuromuscular pain disorders, pain from complex
temporomandibular joint disorders including failed TMJ surgery and rheumatic disease, neurovascular pain
disorders, neuropathic pain disorders, chronic regional pain syndrome, orofacial cancer and AIDS pain,
dystonias and dyskinesias and other complex or atypical pain and dysfunction disorders of orofacial structures.
These are complex disorders that have negligible time in dental school pre-doctoral didactic curricula.
Orofacial Pain clinicians are required to develop skills to treat the chronic orofacial pain patient include head
and neck examination techniques, cranial nerve screening examination, triage for underlying orofacial and
brain pathology, use of laboratory medicine and tests, differential diagnosis and assessment of orofacial pain
disorders, neuroblockade testing and treatment, interpretation of orofacial, head and neck and TMJ imaging,

37
physical medicine modalities, orthotics, neurosensory stents, pharmacotherapy, monitoring drug abuse, opioid
and other drugs overuse and chemical dependency issues, and cognitive-behavioral and interdisciplinary
methods of pain management.

Although these are general categories of skills and may be used in the context of other dental disease, there is
not reference to the use of them for orofacial pain disorders. 5-63 directs the pre-doctoral experience in the
management of dental emergencies, but this includes predominantly dental pulpal, periodontal, traumatic or
arising from treatment failures. The pre-doctoral student does not obtain clinical training in the emergency
management of primary headache, neuropathic pain, neuromuscular pain of central origin, neurovascular pain
and pain behavior. Pre-doctoral graduates are "competent inpatient assessment and diagnosis, 5-46, and to
conduct a medical and dental comprehensive work up and evaluation of problems" 5-47. This enables them to
carefully screen patients with complex medical or orofacial pain problems and to make the necessary referrals.
In contrast, the post-doctoral Orofacial Pain programs teach residents to perform a work-up of sufficient
medical competency and dental competency to accept referrals in a clinic, hospital setting or a pain treatment
team and evaluate and implement management strategies as necessary.

d. Other information that demonstrates compliance with this criterion.

The scope of the curriculum necessary to conduct an evaluation, diagnosis and treatment of the chronic
orofacial pain patient is exemplified in the AAOP’s treatment guidelines, Orofacial Pain: Guidelines for
Assessment, Diagnosis, and Management. (6), the American Academy of Orofacial Pain Standards for
Advanced Specialty Education Programs in Orofacial Pain (Appendix II), and the International Association for
the Study of Pain's Core Curriculum for Professional Education in Pain Guidelines (120). This provides clear
documentation that the knowledge required to achieve competency in this field in Dentistry and is well beyond
that required in the ADA pre-doctoral accreditation standards, and that the material is so broad and in-depth
that it is unlikely that it could ever be incorporated within a four-year pre-doctoral curriculum.

In summary, it is clear that Orofacial Pain meets each of the requirements #2 in that it is a distinct and well-
defined field which requires unique knowledge and skills beyond those commonly possessed by dental school
graduates as defined by the Commission on Dental Accreditation’s Accreditation Standards for Dental
Education Programs.

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III. Requirement 3:
The scope of the proposed specialty requires advanced knowledge and skills that: (a) in their entirety
are separate and distinct from the knowledge and skills required to practice in any recognized dental
specialty and (b) cannot be accommodated through minimal modification of a recognized dental
specialty. Review the Commission on Dental Accreditation's (CODA) accreditation standards for
advanced specialty education programs and the ADA's approved definition of each recognized
specialty and the definition of dentistry.

a. Advanced Knowledge
(1) Compare and contrast the accreditation standards of each of the recognized dental specialties with
the advanced knowledge required for the proposed specialty, especially with regard to the level of
knowledge required.
(2) Provide a listing of the unique and distinct body of knowledge for the proposed specialty and
contrast this listing with the unique and distinct bodies of knowledge of each recognized specialty.

b. Advanced Skills
(1) Compare and contrast the accreditation standards of each of the recognized dental specialties
with the advanced skills required and levels of competency/proficiency expected of a graduate of the
proposed specialty.
(2) Identify the advanced skills (techniques and procedures) required for practice of the proposed
specialty that are not included within the scope of other recognized specialties.
(3) Provide a listing of the unique and distinct skills for the proposed specialty and contrast them to
the unique and distinct fields and bodies of knowledge of each recognized specialty.

Introduction. We reviewed the 2019 published Commission on Dental Accreditation's (CODA) accreditation
standards for each of the advanced specialty education programs and compared this to the Orofacial Pain
standards. Based on this review, we conclude that the scope of Orofacial Pain as a dental field requires
advanced knowledge and skills that are; a) separate and distinct from the knowledge and skills required to
practice in any recognized dental specialty and b) cannot be accommodated through minimal modification of a
recognized dental specialty.

This review provides clear objective evidence of minimal overlap between the field of Orofacial Pain and any
existing dental specialty including newly approved Dental Anesthesiology. These include the following
objective evidence:
a) The definitions and the scope of practice of each existing specialty is distinctly different and;
b) A review of clinical practices and referral preferences of dental specialists found that these patients are not
treated in dental specialist practices and, instead, prefer to refer to an Orofacial Pain dentist,
c) the knowledge and skills in most current 2019 published accreditation documents of each specialty are
different with that of Orofacial Pain and cannot be accommodated through minimal modification of a
recognized dental specialty.
d). Other evidence of a distinction between the definition of Orofacial Pain and existing dental specialties

The rationale for this position is included in the following discussions;

A. Definitions for Existing Dental specialties compared with Orofacial Pain.

The field and scope of the established Dental Specialties is officially defined by the ADA Commission on
Dental Accreditation according to the Advanced Specialty Education Standards documents. None of these
definitions of dental specialties include diagnosis and treatment of orofacial pain disorders within the definition
of their scope and purpose. Their emphasis defines their primary discipline, as does the practice of that
discipline. The following definition of ADA specialties was approved and Adopted by the National Commission
on Recognition of Dental Specialties and Certifying Boards May 2018.

Dental Anesthesiology: Dental anesthesiology is the specialty of dentistry and discipline of anesthesiology

39
encompassing the art and science of managing pain, anxiety, and overall patient health during dental, oral,
maxillofacial and adjunctive surgical or diagnostic procedures throughout the entire perioperative period. The
specialty is dedicated to promoting patient safety as well as access to care for all dental patients, including the
very young and patients with special health care needs. (Adopted March 2019)

Dental Public Health: Dental public health is the science and art of preventing and controlling dental diseases
and promoting dental health through organized community efforts. It is that form of dental practice which
serves the community as a patient rather than the individual. It is concerned with the dental health education of
the public, with applied dental research, and with the administration of group dental care programs as well as
the prevention and control of dental diseases on a community basis. (Adopted May 2018)

Endodontics: Endodontics is the branch of dentistry which is concerned with the morphology, physiology and
pathology of the human dental pulp and peri-radicular tissues. Its study and practice encompass the basic and
clinical sciences including biology of the normal pulp, the etiology, diagnosis, prevention and treatment of
diseases and injuries of the pulp and associated peri-radicular conditions. (Adopted May 2018)

Oral and Maxillofacial Pathology: Oral pathology is the specialty of dentistry and discipline of pathology that
deals with the nature, identification, and management of diseases affecting the oral and maxillofacial regions. It
is a science that investigates the causes, processes, and effects of these diseases. The practice of oral
pathology includes research and diagnosis of diseases using clinical, radiographic, microscopic, biochemical,
or other examinations. (Adopted May 2018)

Oral and Maxillofacial Radiology: Oral and maxillofacial radiology is the specialty of dentistry and discipline
of radiology concerned with the production and interpretation of images and data produced by all modalities of
radiant energy that are used for the diagnosis and management of diseases, disorders and conditions of the
oral and maxillofacial region. (Adopted May 2018)

Oral and Maxillofacial Surgery: Oral and maxillofacial surgery is the specialty of dentistry which includes the
diagnosis, surgical and adjunctive treatment of diseases, injuries and defects involving both the functional and
esthetic aspects of the hard and soft tissues of the oral and maxillofacial region. (Adopted May 2018)

Orthodontics and Dentofacial Orthopedics: Orthodontics and dento-facial orthopedics is the dental specialty
that includes the diagnosis, prevention, interception, and correction of malocclusion, as well as neuromuscular
and skeletal abnormalities of the developing or mature orofacial structures. (Adopted May 2018)

Pediatric Dentistry: Pediatric Dentistry is an age-defined specialty that provides both primary and
comprehensive preventive and therapeutic oral health care for infants and children through adolescence,
including those with special health care needs. (Adopted May 2018)

Periodontics: Periodontics is that specialty of dentistry which encompasses the prevention, diagnosis and
treatment of diseases of the supporting and surrounding tissues of the teeth or their substitutes and the
maintenance of the health, function and esthetics of these structures and tissues. (Adopted May 2018)

Prosthodontics: Prosthodontics is the dental specialty pertaining to the diagnosis, treatment planning,
rehabilitation and maintenance of the oral function, comfort, appearance and health of patients with clinical
conditions associated with missing or deficient teeth and/or oral and maxillofacial tissues using biocompatible
substitutes. (Adopted May 2018)

Definition of Orofacial Pain. Orofacial Pain is the proposed specialty of dentistry which includes the
assessment, diagnosis and treatment of patients with orofacial pain and dysfunction disorders, oromotor and
jaw behavior disorders, orofacial sleep disorders, head and neck pain, as well as pursuit of knowledge of the
underlying pathophysiology and mechanisms. The field includes treatment of neuropathic orofacial pain
disorders, neurovascular orofacial pain disorders, chronic regional pain syndrome, masticatory and cervical

40
neuromuscular pain disorders, primary headache disorders, pain from temporomandibular disorders, pain
secondary to orofacial cancer and AIDS, orofacial dyskinesias and dystonias, orofacial sleep disorders, and
other disorders causing persistent pain and dysfunction of the orofacial structures.

Furthermore, Orofacial Pain does not include diagnosis and management of conditions that are included in the
scope of practice for any existing dental specialties including surgical treatment of the temporomandibular joint,
surgery of the trigeminal nerve, correction of malocclusions, treatment of pulpitis, dentinal hypersensitivity,
burning mouth, anxiety and acute pain related to operative procedures, or diagnosis or treatment of oral soft
tissue pain. It also does not include skills of prosthodontic or restorative dentistry, orthodontics, any oral
surgery procedure, endodontic procedures, periodontal surgery or treatment, or diagnosis or treatment of soft
tissue lesions with exception of diagnosis and treatment of temporomandibular disorders. Orofacial Pain also
does not include acute pain control and sedation and does not overlap with Dental Anesthesiology. It also
does not include treatment of pain from pulpitis, pulpal disease or dental hypersensitivity there is no overlap
with Endodontics. Since the field does not include pain from gingival, periodontal or other soft tissue disease,
there is no overlap with Periodontics. Since Orofacial Pain does include restorative dental treatments, there is
no overlap with Prosthodontics. Since the field does not include pain from 3rd molars and other teeth, surgical
treatment of temporomandibular disorders or nerve injuries, or acute pain and anxiety from dental surgical or
operative procedures, there is no overlap with oral and maxillofacial surgery and dental anesthesiology. Since
the field does not include pain from soft tissue lesions or burning mouth, there is no overlap with Oral
Pathology. Since the field does not include orthodontic or orthopedic movement of teeth, there is no overlap
with Orthodontics. Since the field does not include care of dental needs for children, there is no overlap with
Pediatric dentistry. In conclusion, with regard to definition of each specialty, there is clear evidence that there is
no actual or perceived overlap between the field of Orofacial Pain and any existing specialty.

B. Comparison of the clinical practices and referral preferences of dentists.

A comparison of the practice patterns between dentists in the community with those dentists practicing in field
of Orofacial Pain also provide clear evidence that there is no perceived overlap in clinical practice with any
existing specialty. Figures 2, 3, and 4 presents results from the 2009 practice survey of 96 dental specialists in
reviewing their practice patterns for patients with orofacial pain disorders (Appendix III). Figure 2 shows that
when asked “do you treat or refer patients with these orofacial pain disorders?”, the vast majority of patients
(mean of 89%) who present with orofacial pain disorders to a dental specialist are referred out of the practice.
When asked; “Do you currently or would you refer to an Orofacial Pain dentist?”, the results were similar.
Figure 3 shows that a mean of 95% of dental specialists prefer to refer patients to an Orofacial Pain dentists.
Figure 4 shows that the major reasons for referral of these patients among all dentists in the survey was not
being sufficiently trained (77%) and these patients were too complex (64%). In addition, these dental
specialists also supported an ADA specialty in orofacial pain by a 4 to 1 margin.

As most dentists know, patients with orofacial pain disorders are often time-consuming and frustrating for
current dental specialists so they have little interest in providing care for them. These patients may have
behavioral, psychosocial, and addiction issues, require sophisticated multi-and inter-disciplinary treatment, and
generate services that are typically submitted through medical insurance with different diagnosis codes,
procedure codes, and health plan contracts than the rest of dentistry. These patients can be a burden on
dental practices and, thus, explains why many of these patients are shuffled from one dentist to another and
why the vast majority of general dentists and dental specialists choose to refer versus treat these patients.

41
Figure 2. The percentage of patients with orofacial pain disorders presenting to a general dentist(n=311) or
dental specialist office(n=96) who are treated versus those who refer to another specialists (Appendix III).

Figure 3. The percentage of general dentist(n=311) or dental specialists(n=96) who either currently do or
would prefer to refer these patients to an orofacial pain dentist if they were available (Appendix III).

Figure 4. The reasons that general dentists(n=311) and dental specialists(n=96) state for referring these
patients instead of treating them.

42
C. Comparison of Advanced Knowledge and Skills
We completed a comparison of knowledge and skills associated with the 2019 CODA curriculum standards for
advanced education program in each of the recognized dental specialties with that of the field of Orofacial
Pain. The advanced knowledge and skills in these documents includes no reference to orofacial pain
disorders and minimal reference to temporomandibular disorders. Thus, curriculum content and training in
orofacial pain disorders as described above is not represented in any of the existing specialties with no overlap
with their ADA curriculum and board standards. Table 6 lists a summary of the results of a comparison of
2019 curriculum standards for advanced education program in the clinical dental specialties with that of
advanced knowledge and skills required in diagnosis and management of orofacial pain disorders that are
included in the field of Orofacial Pain (2). As noted in the Table 5, the existing dental specialties do not
reference these conditions except for surgery or care for non-complex splint treatment for temporomandibular
disorders.

Table 6. Reference to diagnosis and treatment of orofacial disorders in 2019 CODA Accreditation
standards for existing dental specialties.
Advanced Ortho Prosth Endo Perio Oral Surg Pedo Dent
Knowledge and Anesth
skills for;
neuropathic No No No No No, except No No
orofacial pain except for for surgical
disorders diagnosis of repair of
orofacial trigeminal
pain nerve
neurovascular No No except for No No No No
orofacial pain diagnosis of
orofacial
disorders pain
chronic regional except for
No No diagnosis of No No No No
pain syndrome
orofacial
pain
masticatory and No No No No No No
except for except for except for except for
No
cervical
neuromuscular non-complex non-complex non-complex non-complex
splint splint splint splint
pain disorders treatment treatment treatment treatment
primary headache No No No No No No
disorders No
pain from No No No No No No No
temporomandibular except for except for except for except for except for except for
joint disorders non-complex non-complex diagnosis of non-complex surgical non-complex
splint splint orofacial splint treatment splint
including failed treatment treatment pain treatment treatment in
surgery and children
rheumatic diseases
pain secondary to No No No No No No No
orofacial cancer
and AIDS
orofacial No No No No No No No
dyskinesias and
dystonias
orofacial sleep No No No No No No No
disorders

Comparison of Advanced Knowledge and Skills for Each Specialty.

The 2019 accreditation standards for each of the recognized specialties make no reference to the advanced
43
knowledge and skills required for diagnosis and management of orofacial pain disorders with the exceptions
noted in this section. Curriculum guidelines for Orofacial Pain advanced education program require a minimum
of full-time skills training of two years for graduate, or post-doctoral study in the field of Orofacial pain. This
includes a minimum 50% time in Orofacial pain clinical training (estimated 1800 hours), with the remainder in
didactic subjects designed to build a core knowledge of medicine, neuroscience, pain science, neuro-
psychopharmacology, and behavioral sciences. Knowledge must be brought to a medical competency
standard to permit treatment as well as diagnosis for multiple pain conditions and to qualify the graduate to
work in a multidisciplinary medical and dental community. Most of the established dental specialties have been
required to move to a three-year curriculum because of the amount of skill training in their own disciplines (e.g.
Orthodontics, Periodontics, Prosthodontics, etc.) and cannot qualify their graduates to be pain referral
providers for orofacial pain disorders.

The International Association for the Study of Pain has published a set of required skills for pain treatment
facilities laying down the requirements for a multidisciplinary pain center. This is not fulfilled in current clinical
models utilized by the existing dental specialties, but rather is the operational model for the established
Orofacial Pain Programs and clinics across the country. It is the experience of Universities with Orofacial Pain
program that establishment of these post-doctoral programs enhances the existing dental specialty programs
by increasing the level of pain expertise available for crossover patients. Orofacial Pain programs bring
additional populations and pool of patients into their dental school and are not competing with the established
specialties for patients or procedures. Although general practice dentists and established dental specialties
need to be able to evaluate the functional masticatory status to avoid iatrogenic problems, they are not trained
in the assessment and treatment of chronic or complex orofacial pain and dysfunction whether it is from TMD
or another orofacial pain disorder. Furthermore, orofacial pain disorders are not included in treatment patterns
of either general dental practices and dental specialists as illustrated in Table 7 relative to 12 Orofacial Pain
Disorders.

Table 7. Treatment and Referral Practice Patterns for Orofacial Pain (OFP) Dentists (n=120), General
Dentists (n=329) and Dental Specialists (n=97) Relative to Twelve Orofacial Pain Disorders.
Group OFP Dentist General Dentist Dental Specialist
Practice Patterns Practice Patterns Practice Patterns
Orofacial Pain Percent Percent Percent Percent Percent Percent
Disorders Treated Referred Treated Referred Treated Referred
Neuromuscular pain
disorders 99.1 0.9 12.1 87.9 11.0 89.0
Temporomandibular
disorders 94.9 5.1 9.5 90.5 19.1 80.9

Cervical Muscle
Pain 70.7 29.3 7.9 92.1 5.2 94.8
Benign Primary
Headache 75.8 24.2 19.9 80.1 10.5 89.5

Neurovascular Pain
65.0 35.0 2.2 97.8 7.5 92.5
Neuropathic Pain
66.9 33.1 2.9 97.1 2.6 97.4
Sympathetically
Mediated Pain 51.8 48.2 8.2 91.8 4.2 95.8
Atypical Dental and
Facial Pain 79.0 21.0 9.7 90.3 13.4 86.6
Oral cancer and
AIDS pains 31.9 68.1 2.7 97.3 5.6 94.4

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 Dyskinesias and
Dystonias 43.0 57.0 3.3 96.7 1.4 98.6
Orofacial Sleep
Disorders 65.3 34.7 17.0 83.0 4.1 95.9

As noted earlier, surgical treatment of TM joint or trigeminal nerve injury are not included in the domain of the
Orofacial Pain specialty. In addition, the occlusal treatment modalities including prosthodontic, orthodontic, and
orthognathic surgery that are taught in existing specialties are insufficient to treat complex orofacial pain
disorders according to our current understanding of these disorders. Like medicine, the profession of dentistry
is now expanded to utilize a myriad of pain inhibition systems including the psycho-physiologic system,
serotoninergenic, dopaminergenic, neurovascular, neurogenic, neuromuscular components well beyond the
training in any existing specialty. Current specialties exist for the proper evaluations, treatment and training of
dentists in management of 1) dental supporting tissues (Periodontics), 2) restoration of dental hard tissues and
missing dentition (Prosthodontics), 3) management of occlusal dysmorphology (Orthodontics and Oral and
Maxillofacial Surgery), 4) oral pathology and disease (Oral Pathology and Oral and Maxillofacial Surgery, 5)
public health (Public Heath), 6) acute pain and pulpal disease (Endodontics), and 7) pain and anxiety from
procedures (Dental Anesthesiology.

In the Restorative, Periodontics, Orthodontics and Endodontics specialties, this is mostly directed to a triage in
order to be able to proceed with dental therapy, or to differentiate tooth site pain problems of pulpal,
periodontal or dental trauma origin. Treatment of pulpal, periodontal, or dental trauma is cute pain is not
included in the Orofacial Pain accreditation standards. Oral and maxillofacial surgery is involved in surgical
treatment of the temporomandibular joint, coronoid process, and neuropathic pains from nerve injury. As noted
above, TMJ or neural surgery is not included in the Orofacial Pain curricular standards. Oral and maxillofacial
surgery, orthodontics, and prosthodontics are involved in the advanced knowledge of structural reconstruction
or rehabilitation of the occlusion.

As noted above, reconstruction or rehabilitation of the occlusion is not included in the Orofacial Pain
accreditation standards. Several of the specialties have had to extend from two to three years to accommodate
their own curricular programs. As a result, they do not have sufficient curriculum time to fulfill the minimal 24
months guideline for advanced training in Orofacial Pain. The Curriculum Guidelines for Post-doctoral
Programs in Orofacial Pain were published after review and approval for publication by the Council on Dental
Accreditation. In contrast to the operational Orofacial Pain programs, none of the Standards documents for the
exiting specialty programs contain the necessary curriculum content for the management of chronic pain
patients as per any of the following documents:

 The American Academy of Orofacial Pain, Orofacial Pain: Guidelines for Assessment, Diagnosis, and
Management. 3rd Edition, Quintessence Publishing Company, 2018 (6) (Appendix II)
 The American Academy of Orofacial Pain, Standards for Advanced Specialty Education Programs in
Orofacial Pain, 2018
 The IASP Core Curriculum for Professional Education in Pain Guidelines published by the International
Association for the Study of Pain, 2nd edition. IASP 909 NE 43rd. St., Suite 306; Seattle, WA 98105-6020,
USA, 1996.(120)

In contrast to the operational Orofacial Pain programs, none of the 2019 Standards documents for the existing
specialty programs have competency level requirements for knowledge and skills of Orofacial Pain. The
Advanced Education Standard requirements in orofacial pain are presented as line items from the accreditation
standards for each of the eight dental specialties as follows, followed by text discussion. The individual dental
specialty accreditation guidelines are reviewed and contrasted under the following headings:
 Summary
 Advanced Knowledge (didactic);
 Advanced skills (clinical);
45
  Response: (pertaining to Orofacial Pain comparisons);
 Complementary Activity (discussion on the potential benefits of Orofacial pain trained specialists to the
Dental Specialty).

DENTAL PUBLIC HEALTH

Summary. In the Dental Public Health 2019 accreditation standards, there is no reference to required
knowledge and skills of the diagnosis and management of orofacial pain disorders and therefore no
competencies.

Advanced Knowledge (didactic). In Public Health, the 2019 standards 4-2 states; The program must provide
instruction at the advanced level in the following:
a. Epidemiology;
b. Biostatistics;
c. Behavioral science;
d. Environmental health; and
e. Health care policy and management

Advanced Skills (clinical): Community issues predominate and the community is served as a patient rather
than individuals.

Response: There is no evidence that the Dental Public Health curriculum includes sufficient course work to
comply with the accepted orofacial pain post-doctoral guidelines, or to in anyway treat the individual pain
patient. Dental public health is the science and art of preventing and controlling dental diseases and promoting
dental health through organized community efforts and serves the community as a patient rather than the
individual. There is much need for public health efforts to prevent chronic pain and addiction including orofacial
pain disorders.

Complementary Activity: With an Orofacial Pain specialty, there will be an increase in team research on the
epidemiology and public health efforts of orofacial pain disorders, testing better measures of outcome,
prevention of chronic pain and addiction, better interface with third party communities; and to move toward
improved etiologic understanding with more basic research and improved diagnosis and management with
long term prospective clinical studies.

In summary, considering all this information, there is no overlap or conflict of the specialty of Dental Public
Health with the specialty of Orofacial Pain. The presence of the field of Orofacial Pain is beneficial and
complimentary to the field of Dental Public Health

ENDODONTICS
Summary. In the Endodontics 2019 accreditation standards, there is no reference to required knowledge and
skills of the diagnosis and management of orofacial pain disorders and therefore no competencies. Orofacial
Pain dentists also support Endodontic clinical practice by providing support for differential diagnosis of orofacial
pain disorders, preventing unnecessary or explorative endodontic treatment, and manage non-endodontic
orofacial pain. The standards are reviewed and any reference to orofacial pain disorders in the standards is
bolded when applicable.

Advanced Knowledge (didactic): In Endodontics 2019 standards 4-5 Instruction must be provided in:
a. Anatomy (gross and micro) of soft and hard tissues of the head and neck;
b. Embryology;
c. Infectious and immunologic processes in oral health and disease;
d. Pathophysiology of pulpal/periradicular disease;
e. Wound healing;
f. Oral medicine and oral pathology;
g. Pharmacotherapeutics;

46
h. Research methodology and statistics;
i. Neurosciences; and
j. Biomaterials.

Advanced Skills (clinical): Endodontics 2019 standards Section 4-8 state that the educational program must
provide in-depth instruction and clinical training so that students/residents are competent in:
a. Diagnosis, treatment planning and prognosis;
b. Non-surgical and surgical endodontic treatment and retreatment;
c. A variety of endodontic techniques;
d. Outcome evaluation;
e. Radiography and other diagnostic imaging technologies, including use of Limited Field of View (LFOV) Cone
Beam Computed Tomography (CBCT);
f. Management of endodontic treatment of medically compromised patients;
g. Emergency treatment for endodontic conditions;
h. Management of patients with orofacial pain and anxiety;
i. Preparation of space for intra-radicular restorations in endodontically treated teeth;
j. Communication with patients and health care professionals; and
k. Use of magnification technologies.

Section 4-9 states; The educational program must provide in-depth instruction and clinical training in:
a. Vital pulp management;
b. Endodontic management of developing permanent teeth;
c. Revascularization/regenerative endodontics;
d. Intracoronal bleaching procedures; and
e. Endodontic management of traumatic dental injuries.

An understanding and clinical “competency” is only required in management of patients with orofacial pain and
anxiety; The skills developed in the Endodontic program are typically to triage out non-pulpal/ non-peri-
radicular pain and pathology, and to recognize endodontic specific pain, diagnose and treat endodontic pain.
In-depth didactic and clinical proficiency is required in the management of the endodontic patient in all phases
including behavioral management.

Response: Since there is no reference to required knowledge and skills of the diagnosis and management of
orofacial pain disorders. There is a reference to management of patients with orofacial pain and anxiety that
occurs during endodontic treatment. Endodontics is limited to dental pain versus screening out non-dental
causes of orofacial pain, in order to appropriately conduct endodontic treatments. There is no evidence that the
Endodontic curriculum includes sufficient course work to comply with the accepted orofacial pain post-doctoral
guidelines, or to treat the chronic orofacial pain patient.

Complementary Activity: The Orofacial Pain programs and specialist provide an important complementary
service to Endodontics and the problem orofacial pain patient when the response to endodontic procedures is
problematic or the source of pain is unclear. In the practice survey, Endodontists referred 95% of those
patients with chronic orofacial pain, preferably to an Orofacial Pain dentist. The Orofacial Pain dentist has the
training and experience not only in the diagnosis but also in the definitive treatment of tooth site pain of non-
odontogenic origin including: treatment of neuritis, peripheral neuropathies, centrally mediated pains including
deafferentation pain and atypical odontalgia, traumatic and trigeminal neuralgia, pre-trigeminal neuralgia,
sympathetically mediated and independent pains, and referred pain from muscles, facial migraine, and other
disorders. There is no other medical or dental specialty that has training in this treatment. Reciprocally, the
Endodontic specialist is important for referral from the Orofacial Pain dentist since by prevalence the pulpal
and periapical pathology is common.

In summary, considering all this information, there is no overlap or conflict of the specialty of Endodontics with
the specialty of Orofacial Pain. The presence of an Orofacial Pain dentist is beneficial and complimentary to

47
the practice of Endodontics.

ORAL & MAXILLOFACIAL PATHOLOGY

In the Oral and Maxillofacial Pathology 2019 accreditation standards, there is no reference to required
knowledge and skills of the diagnosis and management of orofacial pain disorders and therefore no
competencies. Orofacial Pain dentists and programs can support Oral and Maxillofacial Pathology by referring
patients with oral lesions for diagnosis and management. The standards are reviewed and any reference to
orofacial pain disorders in the standards is bolded when applicable.

Advanced Knowledge (didactic): The Oral and Maxillofacial Pathology 2019 accreditation standards states
that this field is a clinical and laboratory science that investigates the causes, processes, and effects of
orofacial, and oral hard and soft tissue pathology.
4-2.1 Students/Residents must study and assume initial major responsibility for reports and diagnosis on an
adequate volume of surgical specimens of sufficient variety to obtain competence in surgical oral and
maxillofacial pathology.
4-3.1 Training in diagnostic oral cytopathology must be provided to the students/residents

Advanced Skills (clinical): This specialty is primarily a diagnostic discipline involving clinical oral medicine,
plus biopsy and laboratory diagnosis of tissue material. It is also the source for ADA credentialed oral medicine
clinicians through the clinical wing of their training. The Oral and Maxillofacial Pathology 2019 accreditation
standards state that:
4-4.1 The program must provide adequate training in the clinical manifestations of oral and systemic diseases.
4-4.2 Training must include attendance at tumor boards, clinical assessment of patients, selection of
appropriate laboratory studies and their interpretation, evaluation of medical and drug status, administration of
systemic and local medications, and participation in multi-disciplinary treatment planning.
4-4.3 Oral and maxillofacial pathology students/residents must not spend a significant portion of their clinical
training in the routine activities of a screening/emergency clinic.
4-5.1 An acceptable program must provide for a substantial period, of at least six (6) months duration, of
residency-level training in anatomic pathology as part of an active, hospital-based pathology department or
other laboratory facility in a program accredited and approved by the ACGME.
4-6.1 A program must provide for training in a laboratory medicine program accredited by the ACGME.
4-7.1 A program must provide training in interpretation of diagnostic imaging, including plain film, magnetic
resonance imaging (MRI) and computed tomography (CT). Students/Residents must have the opportunity to
interpret an adequate volume of material to obtain competence in identifying the imaged features of disease.

Response: There are no advanced knowledge and skills for treatment of orofacial pain disorders included in
the 2019 ADA advanced education standards or requirements in Oral and Maxillofacial Pathology and
therefore no competency requirement or credentialing in Orofacial Pain. This specialty requires a high
proficiency in the anatomic evaluation (clinical, gross and microscopic) of diseases, but not in the longer-term
pain management of patients. Practice is described as including research and diagnosis of diseases using
clinical, radiographic, microscopic, biochemical, or other examinations. It is therefore a separate discipline from
the proposed Orofacial Pain specialty discipline.

Complementary Activity: The Oral and Maxillofacial Pathology specialist is an important member of the
multidisciplinary team along with the Orofacial Pain dentist each contributing to the treatment planning of
complex or chronic pain patients but with different responsibilities and competencies. The Orofacial Pain
dentist is responsible for integrated management and long-term treatment and rehabilitation of chronic pain
patients. The clinical Oral Medicine wing of the Oral and Maxillofacial Pathology specialist training is important
in providing an exposure of the Orofacial Pain student to the differential diagnosis and triage of other pain
producing oral diseases treated in oral diagnosis and oral medicine centers. This source of expertise is
important to the Orofacial Pain dentist due to cross over in experiences with some chronic dental pain
disorders such as atypical facial pain, burning tongue, and xerostomia for which a triage of pathology is
required versus co-management of pain medication side effects.

48
In summary, considering all this information, there is no overlap or conflict of the specialty of Oral and
Maxillofacial Pathology with the specialty of Orofacial Pain. The presence of an Orofacial Pain dentist is
beneficial and complimentary to the practice of Oral and Maxillofacial Pathology.

ORAL & MAXILLOFACIAL SURGERY

In the Oral and Maxillofacial Surgery 2019 accreditation standards, there is no reference to required knowledge
and skills of the diagnosis and management of orofacial pain disorders and therefore no competencies.
Orofacial Pain dentists and programs can support the specialty of 0ral and Maxillofacial Surgery (OMFS) by
managing orofacial pain disorders and referring them for surgical treatment of orofacial disorders such as
nerve injury neuropathic pain and temporomandibular joint surgery. The standards are reviewed and any
reference to orofacial pain disorders in the standards is bolded when applicable.

Advanced Knowledge (didactic): The Oral and Maxillofacial Surgery 2019 standard 4-1 The program must
provide training in application to the medical sciences with 4-1.1 stating that instruction must provide
comprehensive understanding of pathology as well as understanding and application of the biomedical and
clinical sciences, as these relate to patient care.
Standard 4-5 states Instruction must be provided in the basic biomedical sciences at an advanced level
beyond that of the pre-doctoral dental curriculum. These sciences must include anatomy (including growth and
development), physiology, pharmacology, microbiology and pathology. This instruction may be provided
through formal courses, seminars, conferences or rotations to other services of the hospital. 4-5.1 Instruction in
anatomy must include surgical approaches used in various oral and maxillofacial surgery procedures.

Advanced Skills (clinical): The 2019 standard 4-6 states; A formally structured didactic and clinical course in
physical diagnosis must be provided by individuals privileged to perform histories and physical examinations.
Resident competency in physical diagnosis must be documented by qualified members of the teaching staff.
This instruction must be initiated in the first year of the program to ensure that residents have the opportunity to
apply this training throughout the program on adult and pediatric patients.
Standard 4-6.1 Patients admitted to oral and maxillofacial surgery service must have a complete history and
physical examination. The majority of these examinations must be performed by an oral and maxillofacial
surgery resident.
Standard 4-7 states: the program must provide a complete, progressively graduated sequence of outpatient,
inpatient and emergency room experiences. The residents’ exposure to major and minor surgical procedures
must be integrated throughout the duration of the program.
In addition to providing the teaching and supervision of the resident activities described above, there must be
patients of sufficient number and variety to give residents exposure to and competence in the full scope of oral
and maxillofacial surgery. The program director must demonstrate that the objectives of the standards have
been met and must ensure that all residents receive comparable clinical experience.
Standard 4-8 states; The program must ensure a progressive and continuous outpatient surgical experience,
including preoperative and postoperative evaluation, as well as adequate training in a broad range of oral and
maxillofacial surgery procedures involving adult and pediatric patients. This experience must include the
management of dentoalveolar surgery, the placement of implant devices, traumatic injuries and pathologic
conditions, augmentations and other hard and soft tissue surgery, including surgery of the mucogingival
tissues. Faculty cases may contribute to this experience, but they must have resident involvement.
Standard 4-8.1 states; Dental implant training must include didactic and clinical experience in comprehensive
preoperative, intraoperative and post-operative management of the implant patient.
Standard 4-9 states; The off-service rotation in anesthesia must be supplemented by longitudinal and
progressive experience throughout the training program in all aspects of pain and anxiety control. The
ambulatory oral and maxillofacial anesthetic experience must include the administration of general
anesthesia/deep sedation for oral and maxillofacial surgery procedures to pediatric, adult, and geriatric
populations, including the demonstration of competency in airway management.
Standard 4-11 states; For each authorized final year resident position, residents must perform 175 major oral
and maxillofacial surgery procedures on adults and children, documented by at least a formal operative note.

49
For the above 175 procedures there must be at least 20 procedures in each category of surgery. The
categories of major surgery are defined as: 1) trauma 2) pathology 3) orthognathic surgery 4) reconstructive
and cosmetic surgery. Sufficient variety in each category, as specified below, must be provided. Surgery
performed by oral and maxillofacial surgery residents while rotating on or assisting with other services must not
be counted toward this requirement.
Standard 4-13 states; In the pathology category, experience must include management of
temporomandibular joint pathology and at least three other types of procedures.
Standard 4-13.1 states; Pathology management includes, but is not limited to, major maxillary sinus
procedures, treatment of temporomandibular joint pathology, salivary gland/duct surgery, management of
head and neck infections, (incision and drainage procedures), and surgical management of benign and
malignant neoplasms and cysts.
Standard 4-15.1 states; Reconstructive surgery includes, but is not limited to, vestibuloplasties, augmentation
procedures, temporomandibular joint reconstruction, Oral and Maxillofacial Surgery Standards
management of hard and soft tissue maxillofacial defects, insertion of craniofacial implants, facial cleft repair,
peripheral nerve reconstruction and other reconstructive surgery.

Response: Standard 4-13 includes both temporomandibular joint pathology and reconstruction and peripheral
nerve reconstruction but no reference to diagnosis or non-surgical management of orofacial pain disorders.
The specialty of OMFS is therefore not overlapping or conflicting with the field of Orofacial Pain clinical practice
and requirements which are 100% non-surgical chronic pain management and treatment. An important
premise of medical practice is for there to be some separation between surgical and non-surgical care as in
neurology and neurosurgery, non-invasive, invasive, and surgical cardiology, etc., so that there is neither over
commitment or under use of non-surgical or surgical approaches, and that the benefit is patient driven. In the
consideration for the application of Orofacial Pain for specialty recognition, it is important for no group to claim
to be the whole team.

Complementary Activity: The current history in university and hospital centers with OMFS & Orofacial Pain
programs: the record clearly shows separation and that the specialty of OMFS is not in any way overlapped or
conflicted by the Orofacial Pain centers in operation or by the proposed specialty of Orofacial Pain, which is
100% non-surgical chronic pain management and treatment. Similarly, neither is General or Specialty surgery
in Medical Centers conflicted with medical pain management services, and commonly finds great comfort and
benefit in working with pain management teams. In fact, both are complementary to the greater success of all
disciplines involved, and more importantly to patient outcome. The specialty of OMFS will benefit greatly by
having experts in chronic pain treatment and rehabilitation for co-treatment of certain oral and maxillofacial
surgery patients pre- and post-surgery, and in receiving more appropriate referrals for surgical treatment from
a new source. In the practice survey, OMFS referred 78% of those patients with orofacial pain disorders and
preferred to send them to an Orofacial Pain dentist.

The Orofacial Pain program services are set up as more multidisciplinary services incorporating at least
additional physical therapy and psychology services along with either an attending neurologist, pain medicine
physician, internist, or anesthesiologist in one physical center, one combined medial record, and team
conferences. This fulfills the guidelines for multidisciplinary pain centers and clinic according to the IASP 1990
(International Association of the Society for Pain, parent body to the American Pain Society) whereas this is
not fulfilled or required by Oral and Maxillofacial Surgery standards. Some incidental experience can be
obtained during hospital rotations and rounds programs. Behavioral management in the training Standards for
Oral and Maxillofacial surgeons is only applied to acute pain and anxiety management, compared to the
extensive use of psychometrics, psycho-physiological models, behavioral therapies and psychotropic
medications in Orofacial Pain programs. Therefore, there is no conflict or duplication in practice or in training.

The presence of an Orofacial Pain program in an institution, or nearby Orofacial Pain dentists should increase
the number of patients referred to OMFS for pain from 3rd molar impactions, TM joint and trigeminal nerve
procedures because the pool of pain and dysfunction patients coming into expert care will increase. The
referrals from Orofacial Pain to surgery comes with more correct inclusion criteria for surgical consideration,

50
and this should improve authorization for surgery, treatment outcome and patient participation. Orofacial pain
dentists refer all cases involving surgery to the oral and maxillofacial surgeon in a similar manner to
orthodontics referring orthognathic surgery patients to the oral and maxillofacial surgeon. The trained Orofacial
Pain dentists triage and refer all cases involving actual pathology to the oral surgeon, or to the oral and
maxillofacial pathologist as appropriate. The Orofacial Pain programs and specialty practices provide a new
resource to assist Oral and Maxillofacial Surgery practice by providing assistance in the pre- and post-surgical
management of musculoskeletal problems and rehabilitation following TMJ, orthognathic and trauma surgery
of the orofacial region.

The Orofacial Pain dentist also provides the dental community with experts in the interdisciplinary management
of orofacial pain disorders in difficult post-surgical problems, particularly multiple surgery patients, and
neuropathic pain diagnosis and treatment occurring idiopathically and post-surgically. Plus, it brings the
resource of additional pain and rehabilitation professionals and therapists. These components of care and the
longitudinal care of pain and dysfunction are not performed by oral surgery services or included in Oral and
Maxillofacial Surgery training standards. The onsite presence of clinical psychology faculty in the Orofacial
Pain program may also be extremely useful in the screening and management of some potential OMFS
patients, especially where elective and esthetic procedures are requested.

In summary, considering all this information, there is no overlap or conflict of the surgical specialty of Oral and
Maxillofacial Surgery with the specialty of Orofacial Pain, which is all non-surgical. The presence of an
Orofacial Pain dentist is beneficial and complimentary to the practice of Oral and Maxillofacial Surgery.

ORTHODONTICS AND DENTOFACIAL ORTHOPEDICS

In the Orthodontics and Dentofacial Orthopedics 2019 accreditation standards, there is no reference to
required knowledge and skills of the diagnosis and management of orofacial pain disorders and therefore no
competencies. Craniofacial growth and skeletal orthopedics is studied including problems affecting orofacial
esthetics, form and function, but temporomandibular disorders are not specified in the standards. The
standards are reviewed and any reference to orofacial pain disorders is bolded when applicable.

Advanced Knowledge. In Orthodontics, the 2019 standards 4-2 states: A graduate of an advanced dental
education program in orthodontics must be competent to:
a. Develop treatment plans and diagnosis based on information about normal and abnormal growth and
development;
b. Use the concepts gained in embryology and genetics in planning treatment;
c. Include knowledge of anatomy and histology in planning and carrying out treatment; and
d. Apply knowledge about the diagnosis, prevention and treatment of pathology of oral tissues.

Advanced skills. Orthodontic Standard 4-3 Clinical Sciences include;

4-3.1 Orthodontic treatment must be evidence-based. (EBD is an approach to oral health care that requires the
judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patient’s
oral and medical condition and history, with the dentist’s clinical expertise and the patient’s treatment needs
and preferences.)
4-3.2 An advanced dental education program in orthodontics and dentofacial orthopedics requires extensive
and comprehensive clinical experience, which must be representative of the character of orthodontic problems
encountered in private practice.
4-3.3 Experience must include treatment of all types of malocclusion, whether in the permanent or transitional
dentitions, and should include treatment of the primary dentition when appropriate.
4-3.4 A graduate of an advanced dental education program in orthodontics must be competent to:
a. Coordinate and document detailed interdisciplinary treatment plans which may include care from other
providers, such as restorative dentists and oral and maxillofacial surgeons or other dental specialists;
b. Treat and manage developing dentofacial problems which can be minimized by appropriate timely
intervention;
c. Use dentofacial orthopedics in the treatment of patients when appropriate;

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d. Treat and manage major dentofacial abnormalities and coordinate care with oral and maxillofacial surgeons
and other healthcare providers;
e. Provide all phases of orthodontic treatment including initiation, completion and retention;
f. Treat patients with at least one contemporary orthodontic technique;
g. Manage patients with functional occlusal and temporomandibular disorders;
h. Treat or manage the orthodontic aspects of patients with moderate and advanced periodontal problems;
i. Develop and document treatment plans using sound principles of appliance design and biomechanics;
j. Obtain and create long term files of quality images of patients using techniques of photography, radiology
and cephalometrics, including computer techniques when appropriate;
k. Use dental materials knowledgeably in the fabrication and placement of fixed and removable appliances;
l. Develop and maintain a system of long-term treatment records as a foundation for understanding and
planning treatment and retention procedures;
m. Practice orthodontics in full compliance with accepted Standards of ethical behavior;

Standard 4-4 States: The orthodontic graduate must have understanding of:
a. Biostatistics;
b. History of Orthodontics and Dentofacial Orthopedics;
c. Jurisprudence;
d. Oral Physiology;
e. Pain and Anxiety Control;
f. Pediatrics;
g. Periodontics;
h. Pharmacology;
i. Preventive Dentistry;
j. Psychological Aspects of Orthodontic and Dentofacial Orthopedic Treatment;
k. Public Health Aspects of Orthodontics and Dentofacial Orthopedics;
l. Speech Pathology and Therapy;
m. Practice Management; and
n. The variety of recognized techniques used in contemporary orthodontic practice.

Response. There is no requirement to diagnose and treat orofacial pain disorders with orthodontics. The only
interface with pain in the orthodontic Standards is in management of functional occlusal and
temporomandibular disorders; and treatment of acute pain and anxiety control. This is unrelated to the
proposed Orofacial Pain specialty skills. There are no Standards indicating a tertiary treatment requirement for
orofacial pain disorders in orthodontics. There are no requirements for developing skills for the diagnosis or
treatment of orofacial pain disorders, head and neck pain, neural, neuropathic, neuromuscular, neurovascular,
vascular, autonomic pain, sleep disorders or the psycho-behavioral issues of chronic pain in the Orthodontic
Standards.

The orthodontist should recognize and promptly respond to any TMD or pain problems arising during
orthodontics or following orthodontic care. Due to the prevalence of TM joint findings, orthodontists may need
to manage routine TMD findings (TM joint, local muscle problems and jaw behavior habits) in patients requiring
orthodontics, particularly for prevention of risk and aggravation of the TMD during orthodontic treatment. In
other words, special patient care Orthodontics is needed in patients with chronic TMD and/or orofacial pain. An
active Orthodontic approach to treatment of orofacial pain can be listed as a modality-oriented clinic as defined
by the IASP and does not qualify as a multidisciplinary clinic or a comprehensive approach to orofacial pain. In
contrast, the Orofacial Pain dentist practices in a multidisciplinary clinic and at a higher level of proficiency.

Complimentary. Since orthodontics is primarily involved in orthopedic diagnosis and treatment of the dental-
alveolar structures and malocclusion, the inherent tissue adaptation involving the dental, alveolar, skeletal,
muscular, and TM joint structures during function is important. Orthodontic treatment has the capability to
reduce the adaptation demands on the stomatognathic system and to improve the important occlusal stability
on mandibular closure. Therefore, orthodontic specialty training is intimately interested in the co-management

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of normal temporomandibular joints and the prior screening out of problem TM joints that may be affected by
otherwise normal planned orthopedic/orthodontic treatment.

Conversely problems may arise during periods of instability during treatment which can present as myofascial
and TMJ articular disturbances. It is therefore important for the orthodontist to understand the functional jaw
and TM joint systems, to carefully screen for problems pre, during and post treatment, to diagnose TMJ
problems, and to be competent in initiating treatment or make appropriate referrals if problems arise. However,
the 1983 Presidents Guidelines on TMD advises against initial irreversible therapy for patients with principal
TMJ complaints because it is unclear how much structural variation is etiologic for or may develop as a result
of the initial presentation. The ADA guidelines strongly suggest deferring irreversible or invasive therapies until
there has been some improvement in symptoms using more reversible means and then reassess for structural
treatment needs when they have resolved.

Thus. it may be appropriate for an orthodontist to seek second opinion on how to manage or step around an
underlying milder form of TM joint problem during performance of orthodontics care (risk avoidance). With
more overt symptoms that the orthodontist may prefer to refer the patient to an Orofacial Pain dentist to treat
the disorder before orthodontic treatment is commenced. A natural collaboration quickly develops between the
two disciplines to support the care of the patient. The orthodontist may also encounter patients who have
local/peripheral routine temporomandibular disorders and it may be commonplace for the Orthodontist to
provide care for non-surgical and non-orthodontic treatment of orthodontic patients with selective pre-treatment
TMD complaints.

PEDIATRIC DENTISTRY
In the 2019 CODA pediatric dentistry accreditation standards, there are no standards included for orofacial
pain diagnosis and treatment and therefore there are no competencies. Craniofacial growth is studied including
problems affecting orofacial esthetics, form and function, but temporomandibular disorders are not specified.
The standards are reviewed and reference to orofacial pain disorders is bolded when applicable.

Advanced Knowledge: The 2019 Pediatric Dentistry standards 4-4 states Biomedical sciences must be
included to support the clinical, didactic and research portions of the curriculum. The biomedical sciences may
be integrated into existing curriculum designed especially for the pediatric dentistry program. Instruction must
be provided at the understanding level in the following biomedical sciences:
a. BIOSTATISTICS and CLINICAL EPIDEMIOLOGY: Including probability theory, descriptive statistics,
hypothesis testing, inferential statistics, principles of clinical epidemiology and research design;
b. PHARMACOLOGY: Including pharmacokinetics, interaction and oral manifestations of chemotherapeutic
regimens, pain and anxiety control, and drug dependency;
c. MICROBIOLOGY: Including virology, immunology, and cariology;
d. EMBRYOLOGY: Including principles of embryology with a focus on the developing head and neck, and
craniofacial anomalies;
e. GENETICS: Including human chromosomes, Mendelian and polygenic patterns of inheritance, expressivity,
basis for genetic disease, pedigree construction, physical examination and laboratory evaluation methods,
genetic factors in craniofacial disease and formation and management of genetic diseases;
f. ANATOMY: Including a review of general anatomy and head and neck anatomy with an emphasis on the
infant, child and adolescent; and
g. ORAL PATHOLOGY: Including a review of the epidemiology, pathogenesis, clinical characteristics,
diagnostic methods, formulation of differential diagnoses and management of oral and perioral lesions and
anomalies with emphasis on the infant, child, and adolescent.

Standard 4-5 states; Didactic instruction in behavior guidance must be at the in-depth level and include:
a. Physical, psychological and social development. This includes the basic principles and theories of child
development and the age-appropriate behavior responses in the dental setting;
b. Child behavior guidance in the dental setting and the objectives of various guidance methods;
c. Principles of communication, including listening techniques, including the descriptions of and

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recommendations for the use of specific techniques, and communication with parents and caregivers;
d. Principles of informed consent relative to behavior guidance and treatment options;
e. Principles and objectives of sedation and general anesthesia as behavior guidance techniques, including
indications and contraindications for their use in accordance with the AAPD guidelines and The Teaching of
Pain Control and Sedation to Dentists and Dental Students of the American Dental Association (ADA); and
f. Recognition, treatment and management of pharmacologic-related emergencies.

Standard 4-7 Didactic Instruction: Didactic instruction in craniofacial growth and development must be at the in-
depth level with content to enable the student/resident to understand and manage the diagnosis and
appropriate treatment modalities for malocclusion problems affecting orofacial form, function, and esthetics in
infants, children, and adolescents. This includes but is not limited to an understanding of:
a. Theories of normative dentofacial growth mechanisms;
b. Principles of diagnosis and treatment planning to identify normal and abnormal dentofacial growth and
development;
c. Differential classification of skeletal and dental malocclusion in children and adolescents;
d. The indications, contraindications, and fundamental treatment modalities in guidance of eruption and space
supervision procedures during the developing dentition that can be utilized to obtain an optimally functional,
esthetic, and stable occlusion;
e. Basic biomechanical principles and the biology of tooth movement. Growth modification and dental
compensation for skeletal problems including limitations; and
f. Appropriate consultation with and/or timely referral to other specialists when indicated to achieve optimal
outcomes in the developing occlusion.

Standard 4-9 Didactic instruction in oral facial injury and emergency care must be at the in-depth level and
include: Care of orofacial injuries in infants, children and adolescents as follows:
a. Evaluation and treatment of trauma to the primary, mixed and permanent dentitions, such as repositioning,
replantation, treatment of fractured teeth, and stabilization of intruded, extruded, luxated, and avulsed teeth;
b. Evaluation, diagnosis, and management of the pulpal, periodontal and associated soft and hard
tissues following traumatic injury;
c. Recognition of injuries including fractures of the maxilla and mandible and referral for treatment by the
appropriate specialist; and
d. Recognition, management and reporting child abuse and neglect and non-accidental trauma.
4-10 Clinical Experiences: Clinical experiences in oral facial injury and emergency care must enable
students/residents to achieve competency in:
a. Diagnosis and management of traumatic injuries of the oral and perioral structures including primary
and permanent dentition and in infants, children and adolescents; and
b. Emergency services including assessment and management of dental pain and infections.

Standard 4-13 Didactic instruction in prevention must be at the in-depth level and include:
a. The scientific basis for the etiology, prevention, and treatment of dental caries and periodontal and pulpal
diseases, traumatic injuries, and developmental anomalies;
b. The effects of proper diet nutrition, fluoride therapy and sealants in the prevention of oral disease;
c. Perinatal oral health and infant oral health supervision;
d. Scientific principles, techniques and treatment planning for the prevention of oral diseases, including diet
management, chemotherapeutics, and other approaches;
e. Dental health education programs, materials and personnel to assist in the delivery of preventive care; and
f. Diagnosis of periodontal diseases of childhood and adolescence, treatment and/or refer cases of periodontal
diseases to the appropriate specialist.

Standard 4-15 Didactic instruction must be at the in-depth level and include:
a. Restorative and prosthetic techniques and dental materials for the primary, mixed and permanent
dentitions;
b. Management of comprehensive restorative care for pediatric patients;

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c. Treatment planning for infants, children, adolescents and those with special health care needs; and
d. Characteristics of the dental home.
4-16 Clinical Experiences: Clinical experiences must enable students/residents to achieve competency in:
a. Diagnosis and treatment planning for infants, children, adolescents and those with special health care
needs; and
b. Provision of comprehensive dental care to infants, children, adolescents and those with special health care
needs in a manner consistent with the dental home.

Standard 4-18 Didactic instruction must be at the in-depth level and include:
a. Formulation of treatment plans for patients with special health care needs.
b. Medical conditions and the alternatives in the delivery of dental care that those conditions might
require.
c. Management of the oral health of patients with special health care needs, i.e.:
1. Medically compromised;
2. Physically compromised or disabled; and diagnosed to have developmental disabilities, psychiatric disorders
or psychological disorders.
3. Transition to adult practices

Standard 4-24 Didactic instruction must be at the understanding level and include:
a. Normal speech and language development and the recognition of speech and language delays/disorders;
the anatomy and physiology of articulation and normal articulation development; causes of defective
articulation with emphasis on oral anomalies, craniofacial anomalies, dental or occlusal abnormalities,
velopharyngeal insufficiency (VPI), history of cleft lip/palate and normal velopharyngeal function and the effect
of VPI on resonance; and
b. Fundamentals of pediatric medicine including those related to pediatric patients with
special health care needs such as:
1. Developmental disabilities;
2. Genetic/metabolic disorders;
3. Infectious disease;
4. Sensory impairments; and
5. Chronic disease.

Advanced skills. Pediatric Dentistry Standard 4-3 Clinical Sciences include;

Standard 4-6 Clinical experiences in behavior guidance must enable students/residents to achieve competency
in patient management using behavior guidance:
a. Experiences must include infants, children and adolescents including patients with special health care
needs, using:
1. Non-pharmacological techniques;
2. Sedation; and
3. Inhalation analgesia.

Standard 4-8 Clinical experiences must enable students/residents to achieve competency in:
a. Diagnosis of dental, skeletal, and functional abnormalities in the primary, mixed, and young permanent
dentition stages of the developing occlusion; and
b. Treatment of those conditions that can be corrected or significantly improved by evidence-based early
interventions which might require guidance of eruption, space supervision, and interceptive orthodontic
treatments. These transitional malocclusion conditions include, the recognition, diagnosis, appropriate referral
and/or focused management of:
1. Space maintenance and arch perimeter control associated with the early loss of primary and young
permanent teeth;
2. Transverse arch dimensional problems involving simple posterior crossbites;
3. Anterior crossbite discrepancies associated with localized dentoalveolar crossbite displacement and
functional anterior shifts (e.g. pseudo-Class III);

55
4. Anterior spacing with or without dental protrusion;
5. Deleterious oral habits;
6. Preservation of leeway space for the resolution of moderate levels of crowding;
7. Ectopic eruption, ankylosis and tooth impaction problems; and
8. The effects of supernumerary (e.g. mesiodens) and/or missing teeth.

Standard 4-12 Clinical experiences in oral diagnosis, oral pathology, and oral medicine must enable
students/residents to achieve competency in:
a. Pediatric oral and maxillofacial radiology and appropriate procedures of
radiation hygiene; and
b. Treatment of common oral diseases in infants, children and adolescents.

Standard 4-14 Clinical experiences must be of sufficient scope, volume and variety to enable
students/residents to achieve competency in application of prevention in clinical practice.

Standard 4-25 Clinical experiences must expose students/residents to pediatric medicine:

a. Advanced education students/residents in pediatric dentistry must participate in a pediatric medicine rotation
of at least two (2) weeks duration which is the student’s/resident’s principal activity during this scheduled
period
1. This rotation may occur in a variety of settings i.e., Emergency Department, subspecialty clinics, multi-
disciplinary team clinics and general pediatrics; and
2. The rotation must include exposure to obtaining and evaluating complete medical histories, parental
interviews, system-oriented physical examinations, clinical assessments of healthy and ill patients, selection of
laboratory tests and evaluation of data, evaluation of physical, motor and sensory development, genetic
implications of childhood diseases, the use of drug therapy in the management of diseases, and parental
management through discussions and explanation.

Response: There is no requirement for the diagnose and treatment orofacial pain disorders in the 2019
Pediatric Dentistry standards. The only reference is related to chronic disease, trauma and fracture of the
mandibular or maxilla, and oral habits. Yet, the prevalence of TMD and orofacial pain in the pediatric dental
population (< 12-15 years of age) is similar to young adults so the experience and need for such training is
self-evident. The pediatric referral experience to Orofacial Pain centers is mostly for TMD and injury in the <12
year old patient. Pediatric Dentistry curriculum does require an understanding of sensory impairment (4-3.2 B
1d) which enables screening for more serious neurologic pathology or pain due to pathology. The incidence
of migraine or head pain with migraine components increases notably after menarche and cases begin to be
referred to Orofacial Pain dentists or medical centers. TM joint dysfunction starts to be more prevalent
beyond15 years of age and referrals are more commonly made by pediatric dentists concerned about findings
of early or benign TMJ disorders such as clicking of the TMJ rather than due to an overt TMJ pain complaint.
A significant exception can be the young patient with painful TMJ restriction or locking which can often be
treated conservatively and with success if referred promptly at early stage. Hence the importance of a support
network between Orofacial pain providers and Pediatric Dentistry.

Complimentary Activity. Orofacial Pain dentist requires competency and proficiencies in the evaluation,
diagnosis, management and treatment of a wide range of orofacial pain and dysfunction disorders in children,
adolescents, and adults. Pediatric dentistry shares some training standards in the medical evaluation of
patients, hospital experience, exposure to interdisciplinary care experience, anxiety and pain control but this is
primarily limited to acute pain and trauma circumstances. This also includes training in pharmacology but not
the understanding of the chronic pain inhibition systems or the use of psychopharmacologic drugs. Pediatric
dental training in behavioral management is provided in order to perform dental procedures but unlike Orofacial
Pain, not with respect to oral habit behavior. There are no curriculum standards mentioning orofacial pain or
TMD in Pediatric Dentistry. The lower prevalence of orofacial pain disorders and also of TM joint problems in a
pediatric population would be insufficient to develop competency. It is expected that the Pediatric Dentistry
programs would rely on centers of expertise found in an Orofacial Pain program or with orofacial pain trained

56
specialists for the co-management of those patients in a manner comparable to how Pediatric Dentistry
currently interacts with other established dental specialty programs/

PERIODONTICS
In the Periodontics 2019 CODA accreditation standards, there is no reference to the knowledge and skills of
diagnosis and management of orofacial pain disorders to a competency level. Orofacial Pain dentists can
support Periodontal clinical practice without overlapping in either advanced knowledge or skills. The standards
are reviewed and reference to orofacial pain disorders is bolded when applicable.

Advanced Knowledge. In the Periodontics 2019 standards, section 4-3 biomedical knowledge states:
Formal instruction in the biomedical sciences must enable students/residents to achieve the following
competencies:
a. Identification of patients at risk for periodontal diseases and use of suitable preventive and/or interceptive
treatments;
b. Diagnosis and treatment of patients with periodontal diseases and related conditions according to scientific
principles and knowledge of current concepts of etiology, pathogenesis, and patient management; and
c. Critical evaluation of the scientific literature.

4-4 Formal instruction must be provided to achieve in-depth knowledge in each of the following areas:
a. Gross, surgical and ultrastructural anatomy;
b. Microbiology with emphasis on periodontal diseases;
c. Inflammatory mechanisms and wound healing with emphasis on periodontal diseases;
d. Infectious processes in oral and periodontal diseases;
e. Immunology with emphasis on oral and periodontal diseases;
f. Oral pathology;
g. Etiology, pathogenesis, histopathology, and natural history of periodontal diseases;
h. Epidemiology, including risk assessment, of periodontal diseases;
i. Genetics, epigenetics and the concepts of molecular biology as they relate to oral and periodontal diseases;
j. Biostatistics, research design and methods; and
k. Behavioral sciences especially as they affect patient behavior modification and communication skills with
patients and health professionals.

Advanced Skills. In the Periodontics 2019 standards 4-5 The educational program must provide training to
the level of competency for the student/resident to:
a. Collect, organize, analyze and interpret data;
b. Interpret conventional and three-dimensional images as they relate to periodontal and dental implant
therapy;
c. Formulate diagnoses and prognoses;
d. Develop a comprehensive treatment plan;
e. Understand and discuss a rationale for the indicated therapy;
f. Evaluate critically the results of therapy;
g. Communicate effectively to patients the nature of their periodontal health status, risk factors and treatment
needs;
h. Communicate effectively with dental and other health care professionals, interpret their advice and integrate
this information into the treatment of the patient;
i. Integrate the current concepts of other dental disciplines into periodontics;
j. Organize, develop, implement and evaluate a periodontal maintenance program;
k. Utilize allied dental personnel effectively; and
l. Integrate infection control into clinical practice.

4-8 The educational program must provide clinical training for the student/resident to the level of competency.
This must include, but is not limited to, the following treatment methods for health, comfort, function and
esthetics:

57
a. Nonsurgical management of periodontal diseases, including:
1. Biofilm control;
2. Mechanical scaling and root planing therapy;
3. Local and systemic adjunctive therapy; and
4. Occlusal therapy.
b. Surgical management of periodontal diseases and conditions, including:
1. Resective surgery, including gingivoplasty, gingivectomy, periodontal flap procedures, osteoplasty,
ostectomy, and tooth/root resection;
2. Regenerative and reparative surgery including osseous grafting, guided tissue regeneration, the use of
biologics, and utilization of tissue substitutes, where appropriate; and
3. Periodontal plastic and esthetic surgery techniques including gingival augmentation, root coverage
procedures and crown lengthening surgery.

4-12 The educational program must provide instruction in the following interdisciplinary areas:
a. The management of orofacial pain to a level of understanding;
b. Orthodontic procedures in conjunction with periodontal therapy to a level of understanding;
c. Surgical exposure of teeth for orthodontic purposes, to a level of understanding; and
d. Management of endodontic-periodontal lesions to a level of understanding; treatment should be provided
in consultation with the individuals who will assume the responsibility for the completion of the case or
supervision of endodontics therapy.

Response. In the Periodontics 2019 CODA accreditation standards, there is no reference to the knowledge
and skills of diagnosis and management of orofacial pain disorders to a competency level. Proficiency is
required in the management of orofacial pain to a level of understanding, occlusal therapy that implies bite
adjustment and the use of occlusal bite-guard therapy mostly as part of periodontal treatment. Otherwise, only
familiarity is needed in the management of temporomandibular disorders and other orofacial pain conditions
and referral of these patients may be indicated. General periodontal clinical skills are extensive, and apply
mostly to the diagnosis and treatment of periodontal disease and implants for prosthetic purposes. Proficiency
requirements in comprehensive treatment planning and developing interaction skills and dialogue with other
professionals including Orofacial Pain Dentist. for determining courses of action in complex cases.

Complimentary Activity. Orofacial Pain dentists can support Periodontal clinical practice without overlapping
in either advanced knowledge or skills. Treatment of the occlusal interface and occlusal forces is important in
Periodontology so treatment often includes occlusal adjustment and selective grinding and the use of
stabilization and tooth splinting which may include bite guard therapy. This is not presented in the context of
management of temporomandibular disorders and complex or chronic orofacial pain. Instruction in the
diagnosis and management of temporomandibular disorders includes radiographic interpretation and
differential diagnosis; Symptomatic treatment including occlusal appliances is placed in a separate advanced
education standard but is only required at familiarity and competency level. It should be noted that the
Standard also requires referral for TMD treatment when indicated. A similar familiarity about other advanced
forms of therapy and coordination of this therapy with other disciplines must be provided, but specifics are not
given. There is no requirement for treatment of orofacial pain disorders

PROSTHODONTICS
In the Prosthodontics 2019 CODA accreditation standards, there is no reference to the knowledge and skills of
diagnosis and management of orofacial pain disorders to a competency level. There is reference to diagnosis
and splint treatment for temporomandibular disorders. Orofacial Pain dentists can also support Prosthodontics
clinical practice with referrals without overlapping in either advanced knowledge or skills. The standards are
reviewed and reference to orofacial pain disorders is bolded when applicable.

Advanced Knowledge (didactic): Standard 4-12 states Instruction must be provided at the understanding
level in each of the following
biomedical areas:

58
a. Oral pathology;
b. Applied pharmacology; and
c. Oral microbiology

Standard 4-13 states Instruction must be provided at the understanding level in each of the following clinical
areas:
a. Temporomandibular disorders and orofacial pain;
b. Evidence-based health care principles including identifying, appraising and applying available evidence;
c. Ethics and professionalism;
d. Pre-prosthetic surgery;
e. Geriatric considerations in prosthodontic care;
f. Maxillofacial prosthetics;
g. Medical emergencies;
h. Research methodology; and
i. Pain control and sedation.
Standard 4-14 Instruction must be provided at the understanding level in diagnostic and treatment planning
aspects of other recognized dental specialties as they relate to referral, patient treatment and prosthodontic
outcomes.
Standard 4-15 Students/Residents must receive didactic discipline-specific instruction including but not limited
to:
a. Craniofacial growth and development;
b. Biostatistics;
c. Intraoral photography;
d. Practice management;
e. Scientific writing;
f. Sleep disorders;
g. Teaching methodology including public speaking; and
h. Behavioral science.

Advanced Skills (clinical) In Prosthodontics, the 2019 standards 4-16 states: Students/Residents must be
competent at the advanced prosthodontic level in the treatment of clinical conditions associated with missing or
deficient teeth and/or oral and maxillofacial tissues using biocompatible substitutes by achieving clinical
competence in the following areas:
a. Patient assessment, including medical history, dental history, temporomandibular assessment, extra-oral
and intraoral examination, radiologic assessment and occlusal analysis;
b. Systemic, infectious and neoplastic disease screening, including patient education for prevention;
c. Diagnosis;
d. Risk assessment and prognosis;
e. Treatment planning;
f. Adjunct referral;
g. Patient Care;
h. Outcomes assessment;
i. Maintenance.

Standard 4-28 Students/Residents must be competent in the prosthodontic management of patients

with temporomandibular disorders and/or orofacial pain. The Intent: Students/Residents should recognize
signs and symptoms associated with temporomandibular disorders and/or orofacial pain. Students/Residents
should either provide appropriate treatment or refer, consistent with contemporary practice and the best
interest of the patient.

Response: Standard 4-13 and standard 4-28 Standard 4-13 states Instruction must be provided at the
understanding level for Temporomandibular disorders and orofacial pain and be competent in the
prosthodontic management of patients with temporomandibular disorders and/or orofacial pain. However, there

59
is no reference to proficiency in clinical training or treatment of orofacial pain disorders. Standard 4-28 does
state that the prosthodontics specialist does need to competently evaluate and co-manage temporomandibular
disorders present or arising in the prosthodontic patient. Prosthodontic treatment can impose rapid orthopedic
changes on the temporomandibular joint system and therefore has the capability, as does orthodontics, for
both favorable and unfavorable responses if there is joint inflammation, arthrosis or disc-condyle instability.
Hence the importance of a knowledge base in TM joint function in Prosthodontics. As in Orthodontics, this is a
type of special patient care where the potential problem can be articular within the TMJ. The prosthodontist is
also intimately involved with jaw behavior and jaw tension disorders in terms of prognosis of the prosthetic
outcome. Prosthodontics needs to be practiced with risk avoidance in patients with TM joint dysfunction and
peri-articular muscle pain. If pain symptoms are more overt or complex, the patient can be conveniently
referred for consultation and pre-treatment by an Orofacial Pain dentist who treats these patients. In the
practice survey (Appendix III), Prosthodontists referred 95% of those patients with orofacial pain disorders and
all of preferred to send them to an Orofacial Pain dentist. The Prosthodontic Standards require proficiency in
prosthodontic treatment of patients with TMD and or orofacial pain. These are modality based skills and
therefore differ considerably from the spectrum of diagnosis and treatment skills usually needed to treat
orofacial pain disorders patients.

Complimentary Activity. We appreciate the standards in prosthodontics for orofacial pain disorders because
it is focus on prevention and recognition of these disorders, appropriate management, and referral when
needed. Prosthodontic treatment may be necessary to stabilize a malocclusion caused by osteoarthrosis after
treatment of pain and maxillomandibular relationship has been stabilized. Primary treatment with prosthodontic
methods may have a selective application, namely in cases with notable mandibular instability, and therefore
definitely has a place in the mosaic of treatments. However, the 1983 ADA guidelines recommend deferring
invasive and irreversible structural treatment such as dental prosthetics until after the main symptoms are
under control. Reassessment of prosthetic needs would then be appropriate. Such cases and responsibilities
are more comfortably shared with the Orofacial Pain dentist. The belief in the relationship between occlusion
as a TMD etiology can be enhanced by anecdotal experience in a Prosthodontic office that tends to attract
referral of TMD patients who also have apparent occlusal deficits or problems. In fact, occlusal features only
explained a small percent of the variance, or co-factor difference, between TMD patients and normals in
studies from several authors (Crawford SD 2009, Kirveskari et al, 1989, Kirveskari et al, 1995, Pullinger and
Seligman 1999).

Caution must therefore be expressed before extrapolating this segment of experience to the entire orofacial
pain patient population because a high percent of the variance due to other physical, behavioral or
psychosocial issues may be overlooked. Hence, the definitive need for the Orofacial Pain dentist who is not
solely based on a specific dental specialty or modality. Dental occlusion can be notable on a case by case
basis; therefore, many prosthodontists are interested and knowledgeable in management of TMD pain and
dysfunction. The challenge is to work out the inclusion and exclusion criteria for prosthodontic treatment of the
selective TMD and orofacial pain patient and work as a team during their care. In cases of complex, chronic
orofacial pain that is multi-site and/or multi-system and has a more central component of pain, the expectation
for stabilization or resolution diminishes significantly if treatment is limited to structural or occlusal intervention.
It should also be noted that the Orofacial Pain dentist does not provide restorative dental care. Therefore, the
Orofacial Pain Dentist often needs to refer treated pain and dysfunction patients to an expert prosthodontist for
restoration of occlusal deficits secondary to TMJ osteoarthrosis, etc. As a result, the Prosthodontist and the
Orofacial Pain dentist are highly complementary, important to patient care, and mutually supporting, while
attracting a different pool of patients. In conclusion, the Advanced Education Standards for Orofacial Pain
demonstrate an extensive pain science component to the Biomedical curriculum and extensive clinical
requirements in chronic orofacial pain and chronic TMD, that is not found in any other Dental Specialty. This
clearly differentiates Orofacial pain as a separate discipline requiring separate training that cannot be
duplicated by expansion or combination of other dental disciplines.

DENTAL ANESTHESIOLOGY
In the Dental Anesthesiology 2019 CODA accreditation standards, there is no reference to the knowledge and

60
skills of diagnosis and management of orofacial pain disorders to a competency level. There is reference to
diagnosis and splint treatment for temporomandibular disorders. The standards are reviewed and reference to
orofacial pain disorders is bolded when applicable.

Advanced Knowledge (didactic): Standard 2-4 Didactic instruction at an advanced and in-depth level beyond
that of the pre-doctoral dental curriculum must be provided and include:
a) Applied biomedical sciences foundational to dental anesthesiology,
Intent: Instruction should include physiology, pharmacology, anatomy, biochemistry, pathology, physics,
pathophysiology, and clinical medicine as it applies to anesthesiology. The instruction should be sufficiently
broad to provide for a thorough understanding of the body processes related to anxiety and pain control.
Instruction should also provide an understanding of the mechanisms of drug action and interaction, as well as
information about the properties of drugs used.
b) Physical diagnosis and evaluation,
Intent: This instruction should include taking, recording and interpreting a complete medical history and
physical examination, and understanding the indications for and interpretations of diagnostic procedures and
laboratory studies.
c) Behavioral medicine,
Intent: This instruction should include psychological components of human behavior as related to the
management of anxiety and pain.
d) Methods of anxiety and pain control,
Intent: This instruction should include a detailed review of all methods of anxiety and pain control and pertinent
topics (e.g., anesthesia delivery devices, monitoring equipment, airway management adjuncts, and
perioperative management of patients).
e) Complications and emergencies,
Intent: This instruction should include recognition, diagnosis, and management of anesthesia-related
perioperative complications and emergencies.
f) Pain management, and
Intent: This instruction should include information on pain mechanisms and on the evaluation and
management of acute and chronic orofacial pain.
g) Critical evaluation of literature.

Advanced Skills (clinical) in 2019 Dental Anesthesiology Accreditation Standard 2-5 states that the program
must ensure the availability of adequate patient experiences in both number and variety that afford all residents
the opportunity to achieve the program’s stated goals and competency requirements in dental
anesthesiology. Examples of evidence to demonstrate compliance may include:
Records of resident clinical activity, including specific details of the variety, type, and quantity of cases treated
and procedures performed
2-6 The following list represents the minimum clinical experiences that must be obtained by each resident in
the program at the completion of training:
a) Eight hundred (800) total cases of deep sedation/general anesthesia to include the following:
(1) Three hundred (300) intubated general anesthetics of which at least fifty (50) are nasal intubations and
twenty-five (25) incorporate advanced airway management techniques. No more than ten (10) of the twenty
five (25) advanced airway technique requirements can be blind nasal intubations.
(2) One hundred and twenty five (125) children age seven (7) and under, and
(3) Seventy five (75) patients with special needs,
b) Clinical experiences sufficient to meet the competency requirements (described in Standard 2-1 and 2-2) in
managing ambulatory patients, geriatric patients, patients with physical status ASA III or greater, and patients
requiring moderate sedation; and
c) Exposure to the management of patients with chronic orofacial pain.

Standard 2-9 At the completion of the program, each resident must have the following experiences in the
administration of the full spectrum of anesthesia service for same-day surgery dental patients:

61
1. At least one hundred (100) cases of the experiences listed in Standard 2-6 in outpatient anesthesia for
dentistry that are supervised by dentist anesthesiologists.
2. Experience as the provider of supervised anesthesia care.
2-10 Residents must participate in at least four (4) months of clinical rotations from the following list. If more
than one rotation is selected, each must be at least one month in length.
a) Cardiology,
b) Emergency medicine,
c) General/internal medicine,
d) Intensive care,
e) Pain medicine,
f) Pediatrics,
g) Pre-anesthetic assessment clinic (max. one (1) month), and
h) Pulmonary medicine.

Responses: There is no reference to proficiency in clinical training or treatment of orofacial pain disorders
other than if it involves understanding pain management and rotating through pain medicine with the intent of
including information on pain mechanisms and on the evaluation and management of acute and chronic
orofacial pain.

Complimentary Activity. Dental Anesthesiology, like medical Anesthesiology is involved in pain and anxiety
control with pharmacological and behavioral methods. However, they can see patients with pain issues and
does need to know how to evaluate, provide initial pharmacological or neural anesthetic care and then refer the
patient to an Orofacial Pain Dentists. Some Dental Anesthesiologist are also trained in Orofacial Pain with a
dual specialty.

(2) Identify the advanced skills (techniques and procedures) required for practice of the specialty of
Orofacial Pain that are not included within the scope of other recognized specialties.

Any specialty shares some skills with other specialties, particularly evaluation and diagnostic skills. Although
most of the individual evaluation and diagnostic skills listed are not the exclusive domain of Orofacial Pain, the
skills of treatment of specific chronic complex orofacial pain disorders are unique and not included in the scope
of other recognized specialties. Structural dental or surgical treatments such as surgery, orthodontics, and
prosthodontics are not part of Orofacial Pain and are deferred until the patient is mostly asymptomatic, stable
and functioning well. Routine treatment skills for TMD such as splints, exercise and pharmacological
treatments are also not the exclusive domain of the proposed specialty of Orofacial Pain. Treatment of acute
pain and anxiety are also not emphasized in Orofacial Pain practice.

Table 8 focuses on those advanced treatment skills and procedures for the field of Orofacial Pain that are not
included in the scope of other recognized specialties and compares them to the skills required by other ADA
recognized specialties. Dental Anesthesiolgy is not included in the table but does include understanding and
use of many of these pharmacological treatments. In addition, the following is a list of advanced skills noted in
the Orofacial Pain Curriculum Standards that are a part of a specialized Orofacial Pain practice. Note that the
techniques and procedures that are likely also performed by other recognized specialties are italicized

Advanced Skills of Orofacial Pain

a. Conducting a comprehensive pain history interview.
b. Collect, organize, analyze and interpret data from medical, dental, behavioral, and psychosocial histories
and clinical evaluation to determine their relationship to the patient’s chronic orofacial pain complaints.
c. Performing clinical examinations and tests followed by the interpretation of the significance of the data as it
may relate to the patient’s chronic pain and associated dysfunction;
i) Clinical evaluation may include but is not limited to: 1) musculoskeletal examination of the head, jaw,
neck and shoulders; 2) jaw movement studies; 3) general evaluation of the cervical spine; 4) assessment of
TM joint function; 5) odontologic screening; 6) cranial nerve screening; 7) testing major reflexes; 8)

62
examination of structural variation including facial-skeletal and dental-occlusal relationships; 9) evaluation of
oral and dental hard and soft tissues; 10) posture evaluation; 11) general joint mobility or laxity; 12) general
presentation, gait, and demeanor; 13) signs of oral, head and neck stress related tension habits; and 14)
physical assessment including vital signs.
ii) Chairside clinical tests may include but are not limited to: 1) neurosensory testing; 2) neurosensory,
articular and myofascial diagnostic blockade; 3) jaw, muscle and tooth loading and provocation tests; 4) pulp
testing; 5) joint and muscle palpation; 6) spray and stretch responses; 7) mandibular position maneuvers; 8)
challenges to pain abortive medications as appropriate.

d) Order or refer for additional tests including but not limited to: 1) plane film or advanced imaging of the
orofacial, mandibular and cervical structures; 2) order or refer for brain imaging; 3) order or refer for
psychometric testing; 4) referral for psychological or psychiatric evaluation; 5) order laboratory medicine tests;
6) order or refer for diagnostic autonomic nervous system blocks, and systemic anesthetic challenges; 7)
evaluate pain from dental and oral soft tissue disease; 8) order additional consultations and screenings; and 9)
interpreting the significance of the collected data.

e) Establish a multidimensional differential diagnosis and an orderly (prioritized) problem list, using published
guidelines based on inclusion criteria for the following categories of orofacial pain disorders:
1) neuropathic orofacial pain disorders; 2) neurovascular orofacial pain disorders and headache; 3) associated
primary headache disorders; 4) chronic complex regional pain syndromes (I, II, III); 5) complex masticatory and
cervical neuromuscular and musculoskeletal disorders; 6) pain from chronic temporomandibular joint disorders;
7) pain secondary to orofacial cancer and AIDS; 8) orofacial neuromuscular dyskinesias and dystonias; 9)
orofacial sleep disorders; and 10) other disorders causing persistent pain and dysfunction of the orofacial
region.

f) Screen for diagnosis, triage, or referral to obtain appropriate consultation for other medical and dental
disorders that could be responsible for chronic orofacial, head and neck pain, including pain from: 1)
intracranial disorders including aneurysm, sentinel headache, exertional headache, cerebral vascular anomaly
or constriction, transient ischemic attacks, neoplasia, edema, intracranial pressure fluctuations, abscesses and
hematomas, and other secondary headaches; 2) symptomatic trigeminal neuralgia (intra or extracranial
pathology), acoustic neuroma, and MS, 3) CNS infections including bacterial meningitis; 4) associated
unexplained sensory or motor loss or change; 5) complex and chronic migraine; 6) otolaryngological disease
involving the ears including sensory loss, middle and inner ear problems (equilibrium and dizziness) , nose,
throat, salivary glands, oropharynx, larynx, sinuses, mastoid process, stylohyoid, palate, and related structures;
7) ophthalmologic disease involving the eye and surrounding structures including ruling out papilledema and
glaucoma when appropriate; 8) cervical and upper quarter joints and facets, vertebral artery compression,
thoracic outlet syndrome, brachial plexus compression or other upper extremity nerve conduction problems; 9)
assessment of behavioral or psychiatric disorders requiring medical treatment; 10) chemical dependency
disorders; 11) intractable headache requiring an in-patient pain protocol; 12) intractable multidimensional
chronic pain requiring a comprehensive multidisciplinary in-patient pain program and 13) when appropriate,
screenings should be requested for medical and psychological problems that contraindicate proposed chronic
pain treatment and certain pain medications or that require co-treatment or pre-treatment.

g. Skills necessary in multi-modality interdisciplinary or multidisciplinary pain management for the chronic
orofacial pain disorder patient. This includes but is not limited to the following treatment planning experiences:
1) making an assessment of each problem on the diagnostic problem list; 2) construction of a written
sequential treatment plan after presentation to a multidisciplinary forum as needed, incorporating coordinated
behavioral, medical and dental interdisciplinary care as appropriate, with re-evaluation after segments of
treatment; 3) emphasis of reversible or less invasive therapies in the early phases of treatment, deferring
potential structural change for reassessment and treatment when the patient’s status has stabilized; 4)
informed consent requirements; and 5) establishment of an agreement with the complex pain patient as
appropriate, emphasizing the patient’s responsibilities, involvement, and contingencies.

63
h. Skills necessary in Orofacial Pain Treatment including: 1) advanced treatment of a broad spectrum of
chronic orofacial pain patients in a multidisciplinary orofacial pain clinic setting with interdisciplinary associated
services; 2) treatment of a wide range of patients with local, regional and complex multi-system chronic
orofacial pain; 3) diagnostic and therapeutic injections including myofascial trigger point injections, intra-
articular injections, intra-muscular injections for dystonias, sympathetic nerve blocks for the orofacial region,
trigeminal nerve blocks, and other regional blocks referring to the orofacial region; 4) neurosensory stents for
neuropathic pain and experience with topical pain medications directed at different pain mechanisms; 5) local
pain management of jaw rheumatological disorders, neuromuscular disorders, and chronic
orthopedic/temporomandibular joint disorders with provisional stabilization with or without intra-oral orthotics as
appropriate; 6) diagnostic and therapeutic use of physical medicine procedures including therapeutic exercise,
heat and cold packs, vapo-coolant spray and stretch, ultrasound, phonophoresis, iontophoresis, soft tissue
massage, joint and muscle mobilization, electrical stimulation, postural awareness training, strengthening, and
establishment of at home exercise regimes for orofacial structures and structures contributing to referred pain
into those regions. This should also include the establishment of a close association with physical medicine
services provided for cervical spine, upper quarter and back problems as they are related to orofacial pain; 7)
intraoral appliances for breathing related sleep disorders coordinated with the ability to develop an appropriate
diagnosis and measure outcome.

i. Competency in associated psychological and/or behavioral therapies including: 1) cognitive-behavioral

therapies that include habit reversal for oral habits, sleep problems, muscle tension habits and other behavioral
factors; use of pain and activity diaries for awareness feedback, compliance assurance and monitoring; and
interaction with biofeedback/stress management and hypnosis for pain relief and behavioral changes,
treatment of secondary gain, and chronic pain behavior; 2) tailoring treatment and medication approaches to
recommendations for psychologic and personality profiles; 3) co-management of chronic orofacial pain patients
who are taking antidepressant, anxiolytic, and other psychotropic medications; 4) management of jaw tension
and behavior disorders contributing to chronic orofacial pain.

j. Competency in the pharmacotherapeutic treatment of orofacial pain disorders. This should include: 1)
judicious selection of medications directed at the presumed pain mechanisms as well as titration, adjustment,
monitoring and reevaluation; 2) which should also include: management of side effects, adverse reactions,
undesired potentiations, dependency or tolerance; 3) protocols for serum level monitoring and known risk of
adverse physiological reactions; 4) selection in medically and behaviorally compromised patients, as
appropriate; and 5) preparation and enforcement of controlled substance agreements when indicated.

k. Common chronic pain medications and issues include: 1) muscle relaxants for chronic neuromuscular pain
disorders; 2) sedative agents for chronic pain and sleep management; 3) opioid use in management of chronic
pain; 4) the adjuvant analgesic use of tricyclics and SSRI antidepressants for chronic pain and awareness of
the utility and problems with the use of MAO inhibitors in pain and headache; 5) anticonvulsants, membrane
stabilizers, and sodium channel blockers for neuropathic pain; 6) anxiolytics for anxiety and pain; 7) analgesics
and anti-inflammatories; 8) prophylactic and abortive medications for primary headache disorders (in-patient
and out-patient protocols) including serotonergic and anti-serotonergic medications; 9) management of
analgesic rebound pain; 10) medication side effects that alter sleep architecture; 11) in-patient and outpatient
methods for prescription medication dependency withdrawal; 12) referral and co-management (of pain) in
patients addicted to prescription, non-prescription and recreational drugs; 13) local and systemic anesthetics in
management of neuropathic pain as well as familiarity with the role of preemptive anesthesia in neuropathic
pain; 14) the role of neuroleptics in headache management; 15) topical and systemic use of NMDA inhibitors;
16) GABA and dopaminergic medications used in chronic pain; 17) the role of alpha adrenergic medications in
sympathetically mediated pain; and 18) the therapeutic use of use of Botulinum toxin injections.

64
Table 8. Orofacial Pain skills that are not included in the scope of other recognized specialties as indicated by
the 2019 accreditation standards. Dental Anesthesiology is not included in the table but does include
understanding and use of many of these pharmacological treatments.

65
66
67
In summary, the evidence clearly supports the contention that the scope of knowledge and skills required of
the specialty of Orofacial Pain are separate and distinct from all existing recognized dental specialties and
have
virtually no overlap with the curriculums of Prosthodontics, Oral and Maxillofacial Surgery, Orthodontics, Oral
and Maxillofacial Pathology, Periodontics, Pedodontics, and Public Health.

As noted in previously, over 89% of patients with orofacial pain disorders seen in Specialty practice are beyond
the level of experience and training of any of these existing dental specialties and that 95% of dentists prefer to
refer these patients to an Orofacial Pain dentist. Clearly, the bulk of these patients in this country would be
referred to Orofacial Pain dentists if there was a specialty in this field. However, due to the lack of recognition
of the specialty and the lack of adequate numbers of providers, many patients are referred to various medical
and dental specialties who are not prepared to deal with the complexities of orofacial pain. Recognition of the
Orofacial Pain dentist as a specialist distinct from other specialties will greatly improve patient access to care in
this field.

(3) Provide a listing of the unique and distinct skills for the proposed specialty and contrast them to
the unique and distinct fields and bodies of knowledge of each recognized specialty.

The bodies of knowledge and unique skills that define the practice of Orofacial Pain include:
Have an in depth knowledge of biomedical science areas specific for orofacial pain disorders including:
a. Gross and functional anatomy and neuroanatomy of orofacial, head, and cervical structures,
b. Hereditary, growth, development, and aging of orofacial structures,
c. Neurophysiology of pain transmission,
d. Pharmacology, pharmacodynamics, pharmacokinetics and pharmaco-therapeutics,
e. Central, peripheral and autonomic nervous system mechanisms of pain and pain modulation through
facilitation and inhibition systems
f. Pathophysiology of orofacial pain disorders,
g. Muscle, joint, and bone physiology,
h. Sleep physiology,
i. Behavioral Science as related to orofacial pain disorders,
j. Psychoneuroimmunology, molecular biology, genetics and epigenetics as related to chronic pain,
k. Principles of biostatistics, research design, research methodology, scientific writing, and critical evaluation of
the literature,
l. Epidemiology of orofacial pain disorders and their public health significance.

Have an in-depth knowledge and proficiency in the skills of assessment and diagnosis of orofacial pain
disorders including:
a. Conducting a comprehensive pain history interview including onset event, progression of problem, past
diagnostic testing, past treatment, past self-care, relationship to other pain conditions and medical conditions,
and other aspects of history

b. Collect, organize, analyze and interpret data from medical, dental, behavioral, and psychosocial histories
and clinical evaluation to determine their relationship to the patient’s chronic orofacial pain complaints including
risk factor and protective factor assessment.

c. Perform clinical examinations and tests, and interpret the significance of the data as it may relate to chronic
pain and associated dysfunction; Clinical evaluation may include but is not limited to: 1) musculoskeletal
examination of the head, jaw, neck and shoulders; 2) jaw movement studies; 3) general evaluation of the
cervical spine; 4) assessment of TM joint function; 5) odontologic screening; 6) cranial nerve screening; 7)
testing major reflexes; 8) examination of structural variation including facial-skeletal, and dental-occlusal; 9)
oral and dental hard and soft tissues; 10) posture evaluation; 11) general joint mobility or laxity; 12) general
presentation, gait, and demeanor; 13) signs of tension habits; 14) physical assessment including vital signs.
Chairside clinical tests may include but are not limited to: 1) neurosensory testing; 2) neurosensory, articular

68
and myofascial diagnostic blockade; 3) jaw, muscle and tooth loading and provocation tests; 4) pulp testing; 5)
joint and muscle palpation; 6) spray and stretch responses; 7) mandibular position maneuvers; and 8)
challenges to pain abortive medications; as appropriate.

d. Order or refer for additional tests including but not limited to: 1) plane film or advanced imaging of the
orofacial, mandibular and cervical structures; 2) order or refer for brain imaging; 3) psychometric testing; 4)
referral for psychological or psychiatric evaluation; 5) laboratory medicine tests; 6) diagnostic autonomic
nervous system blocks and systemic anesthetic challenges; 7) differential diagnosis of pain from dental or soft
tissue oral disease; 8) additional consultations and screenings; and ultimately the interpretation of the
significance of the data.

e. Establish a multidimensional differential diagnosis and an ordered (prioritized) problem list, using published
guidelines based on inclusion criteria for the following categories of orofacial pain disorders: 1) neuropathic
orofacial pain disorders, 2) neurovascular orofacial pain disorders; 3) associated primary headache disorders;
4) chronic regional pain syndromes (I, II, III); 5) complex masticatory and cervical neuromuscular and
musculoskeletal disorders; 6) pain from chronic temporomandibular joint disorders; 7) pain secondary to
orofacial cancer and AIDS; 8) functional disorders such as orofacial dyskinesias and dystonias; 9) orofacial
sleep breathing disorders; 10) other disorders causing persistent pain and dysfunction of the orofacial region.

f. Screen for diagnosis, triage, or obtain appropriate consultation for other medical and dental disorders that
could be responsible for chronic orofacial and head and neck pain, including pain from: 1) intracranial disorders
including aneurysm, sentinel headache, exertion headache, cerebral vascular anomaly or constriction,
transient ischemic attacks, neoplasia, edema, intracranial pressure, abscesses and hematomas, and other
secondary headaches; 2) symptomatic trigeminal neuralgia (intra or extracranial pathologic), acoustic
neuroma, and MS; 3) CNS infections including bacterial meningitis; 4) associated unexplained sensory or
motor loss or change; 5) complex migraine; 6) otolaryngological disease involving the ears including sensory
loss, middle, and inner ear (equilibrium and dizziness problems), nose, throat, salivary glands, oropharynx,
larynx, sinuses, mastoid process, stylohyoid, palate, and related structures; 7) ophthalmologic disease
involving the eye and surrounding structures including ruling out papilledema and glaucoma, when appropriate;
8) cervical and upper quarter joints and facets, vertebral artery compression, thoracic outlet syndrome, brachial
plexus compression, or other upper extremity nerve conduction problems; 9) behavioral or psychiatric
disorders requiring medical treatment; 10) chemical dependency disorders; 11) intractable headache requiring
an in-patient pain protocol; 12) intractable multidimensional chronic pain requiring a comprehensive
multidisciplinary in-patient pain program; 13) when appropriate, screenings should be requested for medical
and psychological problems that contraindicate proposed chronic pain treatment, or certain pain medications,
or that require co-treatment, or pre-treatment.

g. Skills in multi-modality interdisciplinary or multidisciplinary pain management for the chronic orofacial pain
disorder patient. This includes but is not limited to the following treatment planning experience: 1) making an
assessment of each problem on the diagnostic problem list; 2) development of a written sequential treatment
plan after presentation to a multidisciplinary forum incorporating coordinated behavioral, medical and dental
interdisciplinary care as appropriate, with re-evaluation after segments of treatment; 3) emphasis on reversible
or less invasive therapies in the early phases of treatment and deferring potential structural change for
reassessment and treatment when the patient’s condition has stabilized; 4) informed consent requirements and
5) establishment of a formal agreement with the complex pain patient as appropriate, emphasizing the patient’s
responsibilities, involvement, and contingencies.

h. Skills in Orofacial Pain Treatment including: 1) a broad spectrum of chronic orofacial pain patients in a
multidisciplinary orofacial pain clinic setting or with interdisciplinary associated services; 2) a wide range of
patients with local, regional and complex multisystem chronic orofacial pain; 3) diagnostic and therapeutic
injections including myofascial trigger point injections, joint injections, intra-muscular injections for dystonias,
sympathetic nerve blocks for the orofacial region, trigeminal nerve blocks, other regional blocks referring to the
orofacial region; 4) neurosensory stents for neuropathic pain and experience with topical pain medications

69
directed at different pain mechanisms; 5) initial pain management of jaw rheumatological disorders,
neuromuscular disorders, and chronic orthopedic temporomandibular joint disorders and provisional
stabilization with or without intra-oral orthotics as appropriate; 6) diagnostic and therapeutic use of physical
medicine procedures including therapeutic exercise, heat and cold packs, vapo-coolant spray and stretch,
ultrasound, phonophoresis, iontophoresis, soft tissue massage, joint and muscle mobilization, electrical
stimulation, postural awareness training, strengthening, and establishment of at home exercise regimes for
orofacial structures and structures referring pain into those regions. Also’ establishment of a close association
with physical medicine services provided for cervical spine, upper quarter and back problems as they are
related to orofacial pain; 7) intraoral appliances for breathing related sleep disorders coordinated with ability to
make a diagnosis and measure outcome.

i. Competency in associated psycho-behavioral therapies including: 1) a. cognitive-behavioral therapies

including habit reversal for oral habits, sleep problems, muscle tension habits and other behavioral factors; b.
use of pain and activity diaries for awareness feedback, compliance assurance and monitoring; and c.
interaction with biofeedback/stress management, and hypnosis for pain relief and behavioral changes,
treatment of secondary gain and chronic pain behavior; 2) tailoring treatment and medication approaches to
recommendations with regard to psychologic and personality profiles; 3) co-management of chronic orofacial
pain patients who are taking antidepressant, anxiolytic, and other psychotropic medications; 4) management of
jaw tension and behavior disorders contributing to chronic orofacial pain;5) competency in the
pharmacotherapeutic treatment of orofacial pain disorders. This should include judicious selection of
medications directed at the presumed pain mechanisms involved, as well as adjustment, monitoring and
reevaluation. In addition, this should include the management of side effects, adverse reactions, undesired
potentiations, dependency or tolerance’ as well as protocols for serum level monitoring and known risk of
adverse physiological reactions and selection in medically and behaviorally compromised patients, as
appropriate.

j. Competency with the use of common chronic pain medications and issues that include: 1) muscle relaxants
for chronic neuromuscular pain disorders; 2) sedative agents for chronic pain and sleep management; 3) opioid
use in management of chronic pain; 4) the adjuvant analgesic use of tricyclics and SSRI antidepressants for
chronic pain and an awareness of the utility and problems with MAO inhibitors in pain and headache; 5)
anticonvulsants, membrane stabilizers, and sodium channel blockers for neuropathic pain; 6) anxiolytics for
anxiety and pain; 7) analgesics and anti-inflammatories; 8) prophylactic and abortive medications for primary
headache disorders (inpatient and out-patient protocols) including serotonergic and anti-serotonergic
medications; 9) management of analgesic rebound pain; 10) medication side effects that alter sleep
architecture; 11) in-patient and outpatient methods for addressing prescription medication dependency and
withdrawal; 12) referral, and co-management (of pain) in patients addicted to prescription, non-prescription and
recreational drugs; 13) local and systemic anesthetics in the management of neuropathic pain including
familiarity with the role of preemptive anesthesia in these conditions; 14) the role of neuroleptics in headache
management; 15) topical and systemic use of NMDA inhibitors; 16) GABA and dopaminergic medications used
in chronic pain; 17) role of alpha adrenergic medications in sympathetically mediated pain; and 18) the
therapeutic use of use of Botulinum toxin injections.

Have an in depth understanding and proficiency with the professional and medico-legal issues in Orofacial
Pain;
a) Legal guidelines governing licensure and dental practice.
b) Scope of practice and boundaries with regard to orofacial pain disorders.
c) Criteria for assessing impairment and disability.
d) Medical record documentation, pain diaries, and outcome measurements for orofacial pain disorders.

c. Overlap in Scope/Advanced Knowledge

(1) Could the specialty be readily incorporated within the scope of a recognized specialty?
Yes_____ No__X__

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Rationale: A comparison of the total program length and items in standards directly related to orofacial pain
disorders in the 2019 accreditation standards for dental specialties as compared to Orofacial Pain standards
reveals that the proportion of educational Standards in the Dental Specialties relevant to orofacial pain
disorders ranges from only a maximum of 11% down to 0%. This provides objective evidence that the scope of
the specialty cannot be accommodated through modification of recognized specialties. By extrapolation, this
signifies that the proportion of curriculum time required to credential students in their primary discipline ranges
from 89% to 100%:

a) Extrapolating this line item analysis to the potential current training hours applicable to TMD/Orofacial Pain
reveals a minimal training except in the Orofacial Pain program:
 e.g. Orthodontic curriculum: At a required 3700 scheduled Orthodontic training hours, and a maximum rate
of <2.9% line items in the standards for Orthodontics = a maximum of 107.3 hours devoted to training in the
field of TMD.
 e.g. Prosthodontic curriculum: At a required 33 month scheduled Prosthodontic training = 4950 hours, at a
maximum rate of <6.5% = a maximum 322 hours with potential involvement in functional and TMD/pain
issues.
 Comparison to training time in the Orofacial Pain curriculum: At a required 3600 scheduled Orofacial Pain
training hours, and a minimum rate of >81.6% line items in the Standards directly related to chronic orofacial
pain sciences and treatment = a minimum of 2937.6 hours devoted to training in the field of chronic orofacial
pain treatment.
 The following documents also attest to the fact that the time required to graduate a post-doctoral student or
resident to minimal competency in chronic orofacial pain management and treatment is 24 months of full
time study. Each of the other dental specialties include at least 24 months for their own didactic and clinical
training leaving insufficient time to incorporate the broad knowledge and clinical skills of Orofacial Pain.

b) The dental specialties therefore do not have the time to accommodate this very large number of hours, and
are not set up to accommodate a totally different orientation in clinic structure, multi-disciplinary management,
and acquire standards competency in diagnosis and management of orofacial pain disorders. Several have
already increased their training period to three years to accommodate their primary curriculum (e.g.
Prosthodontics and Periodontics).

c) The dental specialties do not contain any chronic orofacial pain management or treatment experience and
would need to add a totally new curriculum.
• Current experience is primarily routine diagnosis and treatment of TMJ, jaw myalgia and jaw tension habits
as a complication, requiring triage, and referral, and risk avoidance while performing their primary discipline;
or a TMJ neural surgical approach. None of these are included in scope of the field of Orofacial Pain.
• The current specialty accreditation standards and experience only require application of the primary
modality approaches to orofacial pain disorders (TMJ surgery, Prosthodontics, Orthodontics).
• The experience of established Orofacial Pain programs is that post-doctoral students who already have a
dental specialty certificate still require 24 months training to become competent in the clinical field of
orofacial pain disorders.

Therefore, simple minimal modification of existing specialties would not come close to achieving the
competency to treat complex or orofacial pain disorders to the expected dental and medical standards of care.
In comparison, the Advanced Education Standards for Orofacial Pain demonstrate an extensive pain science
component to the Biomedical curriculum; extensive clinical requirements in orofacial pain disorders that is not
found in any other Dental Specialty, and clearly differentiate Orofacial pain as a separate discipline requiring
separate training, that cannot be duplicated by expansion or combination of other dental disciplines.

(2) Could the specialty be accommodated by a combination of currently recognized specialties.

Yes ____No X . Present the rationale for this response.

Rationale:

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1) Since the Orofacial Pain training and experience in the current 2019 accessed accreditation documents is
limited to either splint therapy for temporomandibular disorders and acute pain and anxiety, this field of
Orofacial Pain cannot be accommodated by a combination of currently recognized specialties. These existing
programs do not produce the required expertise in orofacial pain disorders needed to serve the American
public.
2) Experience in dental schools with University established Orofacial Pain programs, shows them to be:
a) Complementary and not competitive with existing programs and accredited dental specialties for access
to patient care and evidence-based clinical management,
b) Helpful to the co-management of orofacial pain disorders in patients attending those discipline based
clinics.
c) A center for additional diagnostic and education expertise to a dental school,
d) An important vehicle of communication with an affiliated medical center,
e) A link to involve physicians and other non-dentist professionals in the dental school curriculum with
referrals to the orofacial pain clinics,
f) A strategy to attract an entirely separate and additional large patient population pool into the dental
school.
This affirms that a mosaic of the current accredited dental specialties are not providing these services and that
Orofacial Pain cannot be accommodated by a combination of currently recognized specialties.

3) The ADA identifies Orofacial Pain as a necessary field of patient care in many documents and conferences.
The definition of the field has been expanded by the ADA from TMD origins with Griffiths publication in JADA of
1983 (37) into orofacial pain management, and into to orofacial, head and neck pain management.
(Accreditation Document for Advanced Education Programs in Orofacial Pain, 2019)

4) The current accredited dental specialties have meanwhile seen expansions in training requirements and
years in their own primary disciplines, and do not and cannot provide treatment in Orofacial Pain as identified
by the ADA itself. There is therefore a void that can only be met by accreditation of a new specialty of Orofacial
Pain.

5) No current dental specialty program has clinical competency training in orofacial pain disorders and no
current ADA recognized dental specialty Board is able to credential dentists with competency in the field
Orofacial Pain. A simple combination of credentialing from all discipline sources still does not cover 90% of the
required field.

3) Identify any areas of biomedical and/or behavioral science in which advanced knowledge and
advanced skills are required for practice of the proposed specialty that are not included in the scope of
the currently recognized dental specialties.

Biomedical Science: There are many areas biomedical and behavioral science in which advanced knowledge
and advanced skills are required for practice of Orofacial Pain that are not included in the scope of the
currently recognized dental specialties. For example, Orofacial Pain requires much study in the applied
medical sciences, e.g. neurosciences, rheumatology, functional anatomy, laboratory medicine, sleep
physiology; and an important segment of the neurosciences which for convenience is presented in these
documents under “Pain Sciences”. The Pain Sciences are uniquely taught for Orofacial Pain and are not part
of the pre-doctoral or dental specialty curricula in any of the Standards in the existing dental specialties.
Application of these sciences to clinical differential diagnosis of orofacial pain requires a competency level in
understanding rather than just an educational background.

Some biomedical science subjects are “shared” among all dental specialties, but taught with different emphasis
and purpose. This is true in Orofacial Pain and also requires some additional customized instruction in the
following areas: 1) Gross and functional anatomy including the musculoskeletal and articular systems of the
orofacial, head, cervical and upper quarter structures, with assessment of common dysfunction and
pathophysiologic effects. (in-depth level) 2) Functional neuroanatomy of the brain, cervical nerves, and cervical

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system with a particular emphasis on pain and common pathophysiological effects. (in-depth level) (to permit a
differential diagnosis of pain, altered sensory description, and motor lesion disorders) 3) Growth, development,
and aging of the masticatory system. (understanding level) 4) Muscle, joint, bone, oral mucosal and other soft
tissue pathophysiology and common pathology, with emphasis to pain. (understanding level) 5) Basic clinical
laboratory medicine interpretation. (understanding level) (same as Oral and Maxillofacial Surgery program:
needed as a basis for routine clinical application) 6) Sleep physiology and dysfunction. (understanding level)
(only otherwise found in the Prosthodontic Standards as “may be given”) (Needed in Orofacial Pain as a basis
of sleep architecture changes with various psychotropic medications used in pain treatment; study of clinical
depression; understanding serotonin dysregulation and changes during sleep in migraine, other peripherally
and centrally-generated pain).

Biomedical science subjects not shared with other dental specialties, taught with purposeful application as the
basis for orofacial pain disorders in clinical practice, or level of instruction: (at the understanding level of
instruction)
1) Applied rheumatology with emphasis on TM normal and abnormal joint histology, synovial fluid assays,
systemic arthritis affects and serological tests as applied to orofacial pain disorders,
2) Oromotor disorders including dystonias, dyskinesias, and bruxism* (*central mediation of, association with
sleep architecture, relationship to medications in use in chronic pain treatment, responsiveness to short term
medication challenges, association to other sleep disturbance),
3) Reading of current pain science and applied pain literature in dental and medical science journals with
special emphasis on pain mechanisms, orofacial pain, head and neck pain, and headache,
4) Jaw movement kinesiology: jaw movement studies, emg study, (excludes articulator analogues),
5) Epidemiology of orofacial pain disorders and it’s public health significance.

Biomedical sciences with pain sciences subset (required at the in-depth level of instruction) is the basis for
chronic pain clinical practice, and is not taught (unless incidentally by exposure/introduction to) in the other
dental specialties. A strong foundation is required in the neurobiology, neuroanatomy and neurophysiology of
pain through study of:
1) the neurobiology of pain transmission and pain mechanisms
2) nociception, conduction, neurotransmitters and receptor biology in acute and chronic pain conditions and
conditions of neuronal injury.
3) the heterogeneity of the peripheral nervous system and relationship to the second order neuron
transmission in normal function and chronic pain.
4) thalamic and cortical projections, and interaction with the reticular and limbic systems (Biopsychophysiologic
models)
5) pain faciliatory and inhibitory neural pathways and systems.
6) changes associated with chronic pain
7) the neurophysiologic changes in chronic pain; differentiation of chronic pain from acute pain, in terms of
neurotransmitters and receptors; and long term or permanent change because of neuronal plasticity. (See
Appendix for additional chronic pain terminology and concepts),
8) pharmacotherapeutic principles related to sites of neuronal receptor specific action in chronic pain.
9) organization of the trigeminal and cervical nervous systems
10) the nuclear and subnuclear organization of the trigeminal brainstem complex, and relation to orofacial pain.
11) the organization of the CNS dorsal horn and the trigeminal nucleus analogue, in normal function versus
chronic pain and neuropathic change,
12) cervicogenic pain and headache, and interactions between trigeminal and cervical CNS segments.
13) chronic pain classification systems.
14) psychoneuroimmunology and its relation to chronic pain syndromes.
15) primary and secondary headache mechanisms.
16) tooth site pain of odontogenic and non-odontogenic origin.
17) the influence of hormonal cycling on pain threshold and neurovascular pain,
18) the scientific basis of acupuncture, and stimulation analgesia.
19) the contribution and interpretation of orofacial structural variation (occlusal and skeletal) to orofacial pain,

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headache, and dysfunction.

Behavioral Sciences: Clinical behavioral and psychological assessment and co-treatment with behavioral and
psychological therapists is a fundamental and routine operational part of clinical Orofacial Pain programs and
practice. Competency in applying pain psychology findings to treatment decisions is essential in orofacial pain
management, but is largely absent in all other specialty disciplines except for development of skills for
facilitating dental treatment in the anxious or impaired patient, including anxiety and pain management by
conscious and deep sedation techniques.

Formal instruction in didactic behavioral sciences at the in-depth level that is not included in other dental
specialty curriculums include; 2) predisposing, initiating, perpetuating or resultant factors. 3) study of character
disorders and profiles impacting pain behavior, 4) exposure to psychiatric disorders including somatization,
factitious pain, and others 5) understanding, conducting and applying the results of psychometric tests
including standard psychology, and dental (e.g. risk assessment, pain outcomes, interference outcomes)
instruments, and exposure to psycho-physiologic tests.

Formal instruction in Clinical Behavioral Science at the in-depth level that is not included in other dental
specialty curriculums include; 3) Training programs in Orofacial Pain differ greatly from other dental disciplines
in operating in a multidisciplinary clinic framework, with a staff psychologist or psychiatrist on the clinic floor
and in attendance at patient rounds. 4) Competency is required in the identification and co-treatment of chronic
pain behavior, co-management of endogenous and reactive depression, co-management of anxiety traits,
personality disorders, or formal screening for actual psychopathology. 5) Competency is required in the routine
use of psychosocial interviewing, administration of psychometrics (and implementation of psychologist’s
recommendations), or referrals for clinical psychology or psychiatric evaluation of patients with orofacial pain
disorders. 6) use of cognitive-behavioral therapies including habit reversal for oral habits, sleep problems,
muscle tension habits and other behavioral factors, use of pain and activity diaries for awareness feedback,
compliance assurance and monitoring; interaction with biofeedback/stress management, and hypnosis for pain
relief and behavioral changes, treatment of operant pain and treatment of secondary gain, and chronic pain
behavior for patients with orofacial pain disorders 7) tailoring treatment and medication approaches to
psychologic and personality profiles for orofacial pain disorders 8) co-management of orofacial pain patients
who are taking antidepressant, anxiolytic, and other psychotropic medications 9) identification of patient
compliance and abuse profiles. 10) familiarity with medication withdrawal methods, 11) management of jaw
tension and behavior disorders contributing to orofacial pain disorders.

Advanced Knowledge and Skills Summary.

In summary, the clear difference between Orofacial Pain and other dental specialists is that none of the
existing dental specialties have training in diagnosis and management of the orofacial pain patient. Orofacial
Pain is the only discipline with curriculum and clinic time necessary to develop greater experience in the
treatment of patient with orofacial pain disorders. Furthermore, the Orofacial Pain post-graduate curriculum
does not include any of the skills that are in the other specialties such as crown and bridge, TMJ or neural
surgery, endodontics, periodontal surgery, dental anesthesia for pain and anxiety, or orthodontics. In designing
the Orofacial Pain curriculum, the lack of overlap with existing specialties was designed purposely to ensure
there were no conflict with other specialties.

As noted earlier, the Orofacial Pain dentist does and will continue to refer patients to other dentists and dental
specialists for specific treatments such as general dentistry, TMJ surgery, endodontics, prosthodontics,
radiology, and orthodontics. Orofacial pain disorders are one of the only remaining cornerstone in the
evaluation and treatment of dental patients that remains unsupervised by the ADA, and is without the aegis of
an ADA recognized specialty board. As noted earlier this gap is NOT bridged by the 2019 Advanced Education
Standards of the existing dental specialties or by any combination of specialties. The perception that the
treatment of orofacial pain disorders is covered by the existing specialties is shown to be incorrect, when the
knowledge base, content, levels of instruction, and breadth and level of clinical skills required by their
Advanced Education Standards are examined.

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This objective based evidence supports the following conclusions regarding advanced knowledge;
 None of the 2109 Advanced Education Standards of each Dental Specialties require any study of
complex (multi-site, multi-system) orofacial pain, focus on familiarity in knowledge only, and none
develop the skills to treat patients suffering with these many problems.
 The dental specialties limit their requirements to routine temporomandibular disorders at most which is
more local and related problems with associated oral parafunctional habits.
 Requirement Standards are limited with regard to the knowledge and ability to make a differential
diagnosis but with no treatment requirements
 The ability to triage orofacial pain problems before commencing treatment by the primary dental
discipline
 The knowledge competencies are limited to the approaches of that discipline: i.e. prosthodontic/
orthodontic/TM joint surgical/ treatment of patients with TMD problems or are de facto TMD risk
management during the performance of their primary specialty discipline.
 Analysis of the percentage of the curriculum standards, and the time allocated to education in orofacial
pain disorders is minimal.
 The current dental specialty programs operate out of modality based clinics and not multidisciplinary
pain clinics as required (IASP) for pain centers and clinics, and the treatments offered largely mirror the
primary specialty.
 The major curriculum differences, and the time required to train Dentists to competency in orofacial
pain disorders treatment precludes adding this on to an existing specialty.
 A mosaic of services and perspectives exists in only in TMD in the dental specialties, but each sees
only a small part of the orofacial pain diagnosis and treatment spectrum. Those approaches may be
valid in selective subsets of patients who are selected for referral to those modality disciplines such as
Oral and Maxillofacial Surgery, but Orofacial Pain dentists need to be recognized for training and
expertise in management across the field of Orofacial Pain.
 Medical and dental standards of care for the chronic pain patient require a more comprehensive
training and systems approach than is provided by the existing Advanced Education Standards of the
current accredited dental specialties.
 The US dental school deans have taken the lead over the last 10 years to sponsor the current 8
Orofacial Pain post-doctoral two-year specialty training programs, with three more in development.
 The basis for establishment of 2 academy organizations (Academy of Orofacial Pain and American
Academy of Craniofacial Pain), and their journals on orofacial pain disorders that define the field, and
are separate from the interests of the established dental specialties includes;
 The establishment of the Journal of Orofacial Pain and Headache, Journal of Craniomandibular
Practice, Pain, Clinical Journal of Pain, Pain Forum, Headache, Cephalgia, Journal of Musculoskeletal
Pain, and many others independent from any existing dental specialty.
 The establishment of new Board examination process for Orofacial Pain independent from any existing
dental specialty.
 The development of nationally and internationally accepted comprehensive guideline documents for the
diagnosis and treatment of Orofacial Pain from the American Academy of Orofacial Pain (6)
independent from any existing dental specialty.
 The international recognition and spin-off of American Academy of Orofacial Pain (AAOP) leadership
evidenced in the formation of sister academies to the AAOP now in all continents of the world
independent from any existing dental specialty.

It is, thus, the contention of this application that it is the best interest of the public, and the profession of
Dentistry, and other healthcare professionals to acknowledge by the National Commission that the field of
Orofacial Pain needs to be and is a Dental Specialty. A review of the advanced skills of Orofacial Pain as
compared to existing dental specialties will further reinforce this opinion.

(d) Other Information. Provide any other information that demonstrates compliance with this
requirement
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Other dental organizations and countries have established Orofacial Pain as an advanced field of Dentistry.
Numerous national and international dental organizations have already gone through the process of evaluating
the field of Orofacial Pain and have established Orofacial Pain as a dental area distinct from other dental
specialties. For example, the United States Military has recently established Orofacial Pain as a specialty and
has been active and obtaining specialty training for a number of its dentists (See letters in Appendix VII). The
National Institute of Dental and Craniofacial Research (NIDCR) and the American Association of Dental
Schools have treated this field as an advanced field separately from other specialties. NIDCR established a
pain research center dedicated to understanding pain, released several RFPs for orofacial pain research,
organized study sections that have focused exclusively in this area, and has held many conferences including
a Technology Assessment Conference dedicated to expansion of knowledge in the field. The American
Association of Dental Schools have sponsored curriculum conferences on Orofacial Pain focusing on the
development of advanced education program curriculums for Orofacial Pain.

In addition, the national dental organizations in many countries including Costa Rica, Brazil, Australia, Korea,
and the Netherlands have designated this field as a specialty. Each of these efforts has been accomplished
with support from general dentists and current dental specialties. This has led to the general recognition by
most leaders in Dentistry that Orofacial Pain is a distinct advanced field of dentistry not included in any of the
existing dental specialties.

Other evidence of distinction between Orofacial Pain and existing specialties include the vastly different
journals and parameters of care, the lack of membership of existing dental specialists in the AAOP(<5%), lack
of existing specialists among faculty of University orofacial pain clinics and graduate programs(<5%), lack of
existing specialist’s attendance at annual meetings(4% at last meeting), lack of existing specialists among
National Institute of Dental and Craniofacial Research supported research in the field, and lack of existing
specialists authoring articles and textbooks in the field. This knowledge and skills of Orofacial Pain is reflected
in the many international refereed journals that cover the field of Orofacial Pain and are outside of any current
dental specialty as noted earlier. Each of these efforts have been accomplished by members who were trained
in Orofacial Pain and Neuroscience. Thus, there has been general recognition by leaders in dentistry that
Orofacial Pain is a distinct field not incorporated in any of the other specialties.

As indicated, diagnosis and treatment of temporomandibular disorders is not exclusive to the Orofacial Pain
specialty or programs. Since TMD is a common clinic problem, it is important that every dentist and dental
specialist is familiar with the diagnosis and early management of TMD. This is especially true of those dental
specialties that have the potential to make orthopedic changes and shifts in the occlusion and resulting maxilla-
mandibular relationships, also have the potential to increase TM joint stability or to propagate instability. Risk
management and risk avoidance is therefore very important in those disciplines, as well as general dentistry.
Competency in pre-treatment screening of both orofacial pain disorders and TM joint dysfunction is therefore a
very important skill in orthodontics, prosthodontics, endodontics, orthognathic surgery, and general dentistry,
and even prior to prolonged open mouth procedures especially when not reflexively protected such as during
general anesthesia. Competency in recognizing problems arising during or following dental treatment, and
either treating them directly or by referral is an essential skill.

The Advanced Education Standards for those dental specialties only require treatment of TMD/TMJ findings by
application of that primary discipline: i.e. prosthodontic, orthodontic, and TMJ surgical (or trigeminal nerve
surgery). The Orofacial Pain specialty stands alone in requiring advanced training and clinical competency in
treatment of the whole spectrum of orofacial pain disorders. The Orofacial Pain specialty also makes clear
distinction between the co-management of local TMD problems in the course of practicing the primary dental
specialty, from the evaluation, assessment, and actual treatment of chronic pain patients including multi-site,
multi-system pain, that may also include some chronic temporomandibular findings as part of the problem list
not responding to traditional TMD dental treatments. It is also very evident that the dental specialties do not
want to treat these patients, or at least not until the chronic pain problems are better controlled, and most
contain Advanced Education Standards promoting easy referral paths. As the practice survey indicates, 89% of
dental specialists refer these patients and 95% prefer to refer them to an Orofacial Pain dentist (Appendix III)

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 It is also evident that Orofacial Pain programs bring an additional and separate stream of patients into the
dental schools. Proportionally, they derive most of their referrals from medicine as much as dentistry, and are
never a competition with the existing specialty programs or general dental clinic sources for patients. Orofacial
Pain consultation, co-management, or full treatment options are of great benefit to all the dental disciplines
when assistance is needed. This is important to the operation and success of dental schools, and to the
community of Dentistry. Recognition of trained specialists in Orofacial Pain in dental schools (as opposed to
management of acute dental pain problems) is becoming important to affiliated hospital and medical center
programs in knowing whom to call in the co-management of difficult orofacial pain, and head and neck pain
problems.

Orofacial pain programs are important in building greater interaction between Dentistry and Medicine. The
expertise contained within Orofacial Pain programs are complementary to and helpful to the existing accredited
specialties and the general dental school clinics. They do not compete with the existing programs. The general
dental education programs will also benefit greatly from the greater availability of trained dentists in this field.
Orofacial Pain programs and clinics require a multidisciplinary center or clinic that mostly incorporates
expertise outside that of the existing accredited dental specialties. The treatment model for orofacial pain
disorders management usually employs the medical model and not a surgical or traditional dental model
especially in primary care.

Therefore, the specialty of Orofacial Pain, and Orofacial Pain programs are complementary, and not
competitive with existing programs or to general dentistry. They are also extremely helpful to, for example, the
Oral and Maxillofacial Surgery programs just as is the cardiologist to the cardiac surgeon or the orthodontist to
oral and maxillofacial surgery. The oral surgeons rarely want to take on extensive pre- and post-surgical
management of chronic management problems nor should they because this involves medical and psychology
models. The restorative and occlusion related disciplines do not and should not take on the care of chronic
pain because the scientific relationship to dental occlusal problems has been shown to explain only a small
part of the etiology. The current dental disciplines are however important where there are definite structural
deficits, or mandibular instability issues, once the chronic pain problems are under better control.

Overall, the field of Orofacial Pain is a mosaic, with the existing specialties already playing a focused part of
access to care for patients with these conditions. However, the proportion of their curriculum even connected
to this field is limited to 0% to 11% of their Advanced Education Standards, and limited to temporomandibular
joint, jaw muscle pain, and jaw tension habits, except in the performance of triage and making a preliminary
differential diagnosis of pain. The overlap in basic science curriculum etc. with the existing dental specialties is
<15% which is similar to the differences between other specialties. None of the existing specialties can absorb
the extra 24 months minimal training required to train and credential dentists to the current medical and dental
standards of care required to treat patients with chronic pain. The Boards of the dental specialties are not set
up nor require examination of Orofacial Pain to clinical competency as it relates to the primary discipline.

Therefore, there is no current credentialing process for dentists in Orofacial Pain outside those parameters.
Hence the important need for the specialty of Orofacial Pain. Recognition of trained specialists in Orofacial
Pain in dental schools (as opposed to management of acute dental pain problems) is becoming important to
affiliated hospital and medical center programs in knowing whom to call in the co-management of difficult
orofacial pain, and head and neck pain problems. Orofacial pain programs are important in building greater
interaction between Dentistry and Medicine. The expertise contained within Orofacial Pain programs are
complementary to and helpful to the existing accredited specialties and the general dental school clinics. They
do not compete with the existing programs. Orofacial Pain programs and clinics require a multidisciplinary
center or clinic that mostly incorporates expertise outside that of the existing accredited dental specialties,
except in post-acute phase care in a few cases. The treatment model for orofacial pain management usually
employs the medical model and not a surgical or traditional dental model especially in primary care.

Therefore, the Orofacial Pain program is complementary, and not competitive with existing specialties and their

77
programs, and helpful to, for example, the Oral and Maxillofacial Surgery programs just as is the cardiologist to
the cardiac surgeon or the orthodontist to oral and maxillofacial surgery. The surgeons rarely want to take on
extensive pre- and post-surgical management of chronic management problems nor should they because this
involves medical and psychology models. The restorative or occlusal-related disciplines do not take on the
care of orofacial pain because the scientific relationship of orofacial pain to dental occlusal problems explain.

In summary, it is clear that the scope of Orofacial Pain meets each of the requirements #3 by requiring
advanced knowledge and skills that: (a) in their entirety are separate and distinct from the knowledge and skills
required to practice in any recognized dental specialty and (b) cannot be accommodated through minimal
modification of a recognized dental specialty.

References for Requirement 2 and 3

1. National Commission on Recognition of Dental Specialties and Certifying Boards.
https://www.ada.org/en/ncrdscb/dental-specialties. Accessed July 24, 2019.
2. Griffiths, R.H., Report of the president's conference on the examination, diagnosis, and management of
temporomandibular disorders. JADA, 1983. 106(1): p. 75-77.
3. The National Consensus Document on Curriculum Guidelines for the Development of Graduate Programs
in Temporomandibular Disorders and Orofacial Pain based on First Education Conference to Develop the
Curriculum in TM Disorders and Orofacial Pain, co-sponsored by the American Association of Dental
Schools, 1990).
4. Curriculum Guidelines for the Development of Post-doctoral Programs in Temporomandibular Disorders
and Orofacial Pain. J. Dent. Ed. 56:650-657, 1992 (published after review and approval for publication by
the AADS Council of Sections Administrative Board and the Executive Committee).
5. Guidelines for teaching the comprehensive control of pain and anxiety in dentistry. American Dental
Association, Council on Dental Education, 1992.
6. Accreditation Document for The Field of Orofacial Pain. National Commission on Recognition of Dental
Specialties and Certifying Boards. https://www.ada.org/en/ncrdscb/dental-specialties. Accessed July 24,
2019.

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IV. Requirement 4. The specialty applicant must document scientifically, by valid and reliable
statistical evidence/studies, that it: (a) actively contributes to new knowledge in the field; (b) actively
contributes to professional education; (c) actively contributes to research needs of the profession; and
(d) provides oral health services in the field of study for the public; each which the specialty applicant
must demonstrate would not be satisfactorily met except for the contributions of the specialty
applicant.

a. Cite peer reviewed epidemiological data that establishes the incidence and/or prevalence of
conditions diagnosed and/or treated by practitioners in the proposed specialty. Identify the source of
the data and provide an estimate of reliability of the data.
According to the most conservative and reliable data on lifetime prevalence and treatment need studies,
suggest that 25% to 35% of the population have a current orofacial pain problem that is severe enough to
warrant treatment (Table 9) (5-19). The epidemiological data on orofacial pain disorders as compared to dental
disorders provide substantial support that these disorders are as common as caries and periodontal disease
(20-21). Of these we estimate the number of new cases to be at a minimum of about 5-7% of the population.
Several surveys of persistent symptoms of orofacial pain disorders have demonstrated that approximately 7%
or 13 million Americans suffer from an orofacial pain disorder causing pain in the face or jaw. In a survey of
45,711 American households, Lipton (5) demonstrated that 7.4% of the population experienced at least one of
four types of chronic orofacial pain in the past six months. The most common type of persistent orofacial pain
was peri-auricular or jaw pain reported by 5.3% of the population. Face or cheek pain was reported by 1.4%
and burning mouth pain being reported 0.7%.

Chronic pain of all types remain one of the great unsolved health problems of this century (1-3). Pain is the
most common reason that brings patients to health care providers. Chronic pain, particularly in the head is the
leading cause of disability to workers second only to respiratory infections for lost work days, and by far the
leading reason for long term disability. A significant portion of this is spent on inappropriate or ineffective
diagnostic and treatment modalities for orofacial pain disorders. A discussion of the current epidemiology of
orofacial pain disorders includes literature in 3 general areas; orofacial pain, neuropathic pain, and headache.
A comparison of the literature in each area is difficult because of the apparent overlap between the areas.
Headache studies can include both vascular (migraine) and muscular (tension type headache and myofascial
TMD pain). Studies of orofacial pain includes orofacial pain in general, neuropathic pain, and headache. Since
there is overlap, epidemiological data for each category has not been considered as cumulative but rather is
presented to represent the most conservative estimates of need in the field.

Table 9. The lifetime prevalence and need for treatment of orofacial pain disorders compared to caries and
periodontal disease. This is compared to the annual prevalence and need for treatment of the most dental
disorders of caries and periodontal disease, and missing teeth.
Prevalence of Orofacial Pain Disorders (3-8) % of
Population
Temporomandibular disorders 5-7%
Orofacial pain disorders (burning mouth, neuropathic, atypical pain) 2-3%
Headache disorder (tension-type headaches, migraine, neurovascular, mixed, cluster) 10-20%
Orofacial sleep disorders (e.g. sleep apnea, snoring) 3-4%
Neurosensory/ chemosensory disorders (e.g. taste, paresthesias, numbness) 0.1%
Oromotor disorders (e.g. occusal dysethesias, dystonias, dyskinesias, severe bruxism) 5%
Total Estimated Prevalence of Orofacial Pain Disorders 24% to 35%

Estimated Prevalence of Dental Disorders* % of Population

Adolescent Dental caries in the 1988 (at least 1 tooth) 20%
Adolescent Dental caries in the 2000 16%

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 Adult permanent teeth with caries in 1988 6.2%
Adult permanent teeth with caries in 2000 2.6%
Periodontal disease in the 1988 (> 4mm pocket) 22.2%
Periodontal disease in the 2000 (> 4mm pocket) 9.0%
Missing all teeth in 1988 6.1%
Missing all teeth in 2000 3.7%
Total Prevalence in 2000 31.3%
*(NHANES data 1988-2004)

TMD and Orofacial Pain. Von Korff et. al.(11) surveyed 1016 members of a large HMO and found that 12% of
this population reported experiencing facial pain in the past six months. Riley and colleagues studied 1636
elderly population in the age range of 65 to 100 years for orofacial pain and found that 15.6% had reported
either burning mouth(1.1%), jaw joint pain(7.6%), or facial pain(6.9%)(Riley, et al, 2009, Appendix IV). Of these
individuals, over 50% of them reported seeking care in the past year for these problems with 50% seeking care
for burning mouth, 56% for jaw joint pain, and 61% for facial pain.

Recent research has supported that the vast majority of these people in the general population are treated
unsuccessfully, or left untreated and continuing to suffer from pain. For example, a 1999 general population
survey by Robert Starch Worldwide (4) found that of the 805 individuals who reported having a persistent pain
disorder, more than four out of 10 people have yet to find adequate relief, saying their pain is out of control—
despite having the pain for more than 5 years and switching doctors at least once. Considering data on health
care utilization for these chronic orofacial pain patients, the most conservative estimate of the total cases that
will demand or seek treatment per year by an Orofacial Pain dentist is about 2.0 % of the population or 3
million people per year.

There is also substantial evidence to suggest that these patients with orofacial pain disorders are not being
treated adequately by current general practitioners or dental specialists. As noted earlier, few general dentists
and dental specialists choose to provide care to patients with chronic orofacial pain. According to the 2009
practice survey of 403 dentists (Appendix III), the percent of dentists who treat any of these patients is low
including; General Dentists (14%), Oral Surgeons (22%), Orthodontists (13%), Endodontists(5%),
Periodontists(4%), Prosthodontists(5%), and Pediatric dentists(11%) and that nearly all (95%) have less than
5% of their practice in this field.

Furthermore, several studies of chronic orofacial pain patients have found that these patients have a high
number of previous clinicians (a mean of 5.3) and many years with pain (mean of 4.2 years) prior to seeing an
orofacial pain dentist (7-9). This clearly documents that the treatment by general dentists and specialists is
either not provided or inadequate. The results of the previously noted practice survey also found that 89% of
dentists would rather refer chronic orofacial pain patients because they are too complex (78%) and not
trained(81%). In contrast, the practice survey of Orofacial Pain dentists found that about 70% practice fulltime
in the field and those who indicated that they do not practice full time cited the major reason as clinical
preference and financial issues (86%) and not due to an inadequate number of patients referred(14%).

If recognition and treatment of the problem by clinicians is inadequate or inappropriate, the personal impact
can be tragic and the costs great. Persistent pain can cause depression, suicidal ideation, dependent
relationships, loss of work, disability and many lifestyle disturbances. It can lead to patients undergoing many
costly surgeries, diagnostic tests, long-term medications, and an ongoing dependency and drain on the health
care system. A 1986 Harris Poll (12) found that 129 156.9 million work days are lost due to head pain with at
least 50% from orofacial pain disorders. With this prevalence, degree of impact, and lack of interest among
general dentists and dental specialists, the demand for services in by Orofacial Pain dentists is high. Based on
demographic changes and disease projections, it is estimated that a minimum of 3 million patients with chronic
orofacial pain will seek care for their problem this year.

Neuropathic Orofacial Pain Disorders. This category refers to pain occurring in the distribution of one or more
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cranial nerve(s) and/or cervical roots two and three with projection to orofacial areas. Neuropathic and
neurovascular disorders that are part of the scope of orofacial pain practice include post-traumatic continuous
neuropathic pain, trigeminal neuralgia and pre-trigeminal neuralgia, glossopharyngeal neuralgia, occipital
neuralgia, facial nerve neuralgia, nervus intermedius neuralgia, post-herpetic neuralgia of trigeminal, complex
tooth pain from non-dental causes, neurovascular orofacial pain, deafferentation pain syndrome, and
sympathetically mediated orofacial pain. Although many of these disorders have not been studied specifically,
several studies have estimated the prevalence of the most common neuropathic pain includes trigeminal
neuropathic pain ranges from 6.9% to 10% (17).

Primary Headache Disorders and Neurovascular Pain. Headache can be a symptom of many disorders
affecting the orofacial structures and is especially prevalent in patients with orofacial pain disorders. Because
of this, headache also needs to be considered as a problem diagnosed and treated by orofacial pain dentists.
Many studies have found recurrent headache to occur in as many as 70-85% of patients with chronic orofacial
pain disorders (117, 118), compared to approximately 20% of a general population. It has been estimated that
one in three persons suffers from severe headache at some stage in his or her life, a lifetime incidence very
similar to the 34% rate estimated for severe chronic orofacial pain disorders (16). Von Korff et. al.(16) in his
survey of 1016 members of a large HMO found that in the past six months 26% reported headaches and up to
40% of the individuals who reported pain missed one or more work days because of the pain. Currently, 5% to
10% of the North American population has sought medical advice in the past year for severe headache (9).
One comprehensive survey examining chronic pain prevalence among adults in North America (9) found 73 %
experiencing headache in the preceding 12 months. Thus, in the United States, it has been conservatively
estimated that 13.7% of men and 27.8% of women in the adult U.S. population have headaches "every few
days" or that "bother quite a bit" and, thus, have a high predisposition to seek care.

b. Document and assess the need for services by the proposed specialty that are not currently being
met by general practitioners or recognized dental specialists. Include documentation regarding
referral patterns, including documentation that identifies who normally refers patients to practitioners
in the proposed specialty and the frequency of these referrals.

The need and demand for services of an orofacial pain dentist is not being met with current dentists or dental
specialties as documented by the high number of previous clinicians and treatments received by these
patients, the high number of years with pain, and the lack of interest and training by current general dentists
and dental specialists. Data Supporting the Need for Treatment According to the most conservative and
reliable data on prevalence and treatment need, studies suggest that at least 7% or over 13 million Americans
have a current orofacial pain disorder that is severe enough to warrant treatment each year (3-22).

For example, Riley and colleagues studied 1636 elderly population in the age range of 65 to 100 years for
orofacial pain and found that 7.7% had reported seeking care either burning mouth(.5%), jaw joint pain(3.8%),
or facial pain(3.4%) in the past year (119) (Appendix IV). Interestingly in this study, the persistence and
severity of symptoms were the best predictor of frequency of health care utilization. This epidemiological data
on orofacial pain disorders provide substantial support that these disorders are nearly as common as caries
and periodontal disease and treatment need is vast.

Data Supporting the Demand for Treatment: Considering the target population (ages 13 to 70) and that some
people may not seek care due to financial, access to care or other reasons, the most conservative and reliable
estimate of demand for clinical services by patients with chronic orofacial pain disorders is about 2 to 3% of the
population or 3 million people. The reliability of these numbers are supported by several studies that have
examined the percent of people who actually receive care for orofacial pain disorders (8-19). Data suggesting
demand is not being met by general dentists and existing dental specialists. Substantial evidence suggest that
current general practitioners and existing dental specialists are not meeting the demand of services by
consumers with chronic orofacial pain. Recent research has supported that nearly 50% of these people in the
general population are left untreated and continuing to suffer from pain (1-3).

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For example, a 1999 general population survey by Robert Starch Worldwide (4) found that of the 805
individuals who reported having a persistent pain disorder, more than four out of 10 people have yet to find
adequate relief, saying their pain is out of control— despite having the pain for more than 5 years and
switching doctors at least once. Other evidence provides support also and include;

1) Few general dentist or dental specialists provide care for chronic orofacial pain patients. This was clearly
highlighted in Figure 2, 3 and 4. The percent of patients who present with chronic orofacial pain and are treated
by either general dentists or dental specialists is low including; General Dentists (14%), Oral Surgeons (22%),
Orthodontists(3%), Endodontists(5%), Periodontists(4%), Prosthodontists(5%), and Pediatric dentists(11%)
(Appendix III).

In addition, as illustrated in Figure 3, page 42, the vast majority of these dentists (95%) either do or would
prefer to refer to an Orofacial Pain dentist. The results of the previously noted practice survey also found that
95% of dentists would rather refer chronic orofacial pain patients because they were not sufficiently trained
(77%) and that the patients were too complex (63%) as shown on Figure 4.

In contrast, the practice survey of Orofacial Pain dentists found that 70% of them practice a significant part of
their practices in Orofacial Pain and those who indicated that they do not practice full time cited the major
reason as clinical preference and financial issues (86%) and not due to an inadequate number of patients
referred (14%) (Appendix III). It is important to note that it is still very difficult to be reimbursed for care in this
field because at least partially due to the lack of a specialty in Orofacial Pain. Although many AAOP members
would like to practice full time in the field, 30% felt that this lack of reimbursement was the major reason for not
practicing 100% in the field. ADA specialty recognition would greatly help patients obtain insurance
reimbursement for this care.

2) Few patients receive adequate care for their chronic orofacial pain problem by their dentists or physicians.
For example, several studies of chronic orofacial pain patients have found that these patients have a high
number of previous clinicians and treatments prior to seeing an orofacial pain dentist (Figure 5). Many patients
continue to have chronic or persistent pain despite being treated by a general dentist, dental specialist or other
provider. 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 (7). The AAOP practice survey found that the mean number of
previous clinicians was 5.3 prior to seeing an orofacial pain dentists (Appendix III). A patient has to be very
motivated to suffer through the frustration and cost of seeing multiple clinicians and continue to seek care. Our
existing dental and medical care systems are not set up to manage these problems and, thus, the patient
continues to be referred from clinician to clinician hoping someone will know what to do. Patients do not know
who to turn to and clinicians do not know who to refer to when finding a patient with these problems. This will
be improved when a specialty in Orofacial Pain is established by the ADA.

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Figure 5. The figure illustrates that many of the patients have high number of previous clinicians, previous
treatment, and many years with pain prior to being referred to an Orofacial Pain dentist. (AAOP survey, 1999,
Appendix V)

3) Patients with chronic orofacial pain disorders also suffer for many years before finding care with an orofacial
pain dentist. In a survey of Orofacial Pain dentists, the mean years that patients have to suffer with pain prior to
seeing the orofacial pain dentists is 4.2 years (Figure 5). Another recent independent study of 805 individuals
in the community with chronic pain by Roger Starch Worldwide (4) found that more than half (56%) of
respondents reported suffering more than five years, yet only 22% had been referred to a pain specialist.

This is a problem of access to successful care and can only be remedied with supporting an ADA specialty in
this field. Pain that is allowed to persist uncontrolled can by itself contribute to a multitude of other problems for
the patient. If recognition and treatment of the problem by clinicians is inadequate or inappropriate, the
personal impact can be tragic and the costs great (1-4). The pain becomes entrenched in the patient's life with
the development of dependent relationships, emotional disturbances, disability and many behavioral 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. It is
estimated by a 1986 Harris Poll (7) that 156.9 million work days are lost due to head pain and that over 50% of
this head pain is related to orofacial pain disorders (24). In summary, these facts collectively provide
convincing support that there is a huge unmet need for care in the general population and that the demand for
quality successful care for chronic orofacial pain disorders is not being met by general dentists and existing
specialists. The negative personal and lifestyle consequences of inadequately treated chronic orofacial pain
syndromes warrants avoiding care with inexperienced clinicians or experimental treatments to "see if it will
work". It would be unwise to filled the current need for Orofacial Pain clinicians by unqualified individuals since
it may cause the patient more time, effort, and complicate the pain problem if not treated adequately.

c. Identify and provide background information on who contributes to the body of knowledge for the
proposed specialty (this would include individuals who represent the applicant organization and
others including non-dentist scientists, etc).

Many members of the field of orofacial pain and the AAOP have worked at Universities and Clinical practice
with funding agencies including National Institute of Dental and Craniofacial Research to contributes to the
body of knowledge in Orofacial Pain. This research communicates the breadth and depth of prevention
research funded by NIH while also retaining sufficient specificity to be of practical value. The following PRCC
definition of prevention research reflects efforts to align these goals. However, it is important to recognize that
individual Institutes and Centers may adapt the definition to best reflect their missions and the state of
knowledge in their respective scientific fields.

Research by members of the field and NIDCR encompasses research designed to yield results directly
applicable to evaluating and treatment for patients with OFP disorders, identifying and assessing risk, and to
developing interventions for preventing or ameliorating high-risk behaviors and exposures, the occurrence of a
disease, disorder, or injury, or the progression of OFP disorders. Prevention research also includes research

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studies to develop and evaluate disease prevention and health promotion recommendations and public health
programs.

For example, the American Academy of Orofacial Pain funded and lead a team effort to complete systematic
reviews of randomized controlled trials (RCT) to evaluate six types of treatments for temporomandibular
muscle and joint disorders (TMJD) including orthopedic appliances, occlusal therapy, physical medicine
modalities, pharmacologic therapy, cognitive-behavioral and psychological therapy, and temporomandibular
joint (TMJ) surgery. A quality assessment of 210 published RCTs assessing the internal and external validity of
these TMJD RCTs was conducted using CONSORT criteria adapted to the methods of the studies. Appendix
IVc summarizes the clinical trials involved in the reviews. This paper concluded that much of the evidence
base for TMJD treatments may be susceptible to systematic bias and suggested ways to improve clinical trials.
However, a scatter plot of RCT quality versus year of publication shows improvement in RCT quality over time
and it is hoped that future studies will continue to improve methods that minimize bias.

In addition, the AAOP has been involved in the ad hoc TMD committee under the auspices of the National
Academies of Sciences, Engineering, and Medicine’s Health and Medicine Division to address the current
state of knowledge regarding TMD research, education and training, safety and efficacy of clinical treatments
of TMD, and burden and costs associated with TMD. The ad hoc committee is identifying approaches to
advance basic, translational, and clinical research in the field. The committee’s findings, conclusions, and
recommendations will inform development of policies related to evidence-based treatment and clinical
management of TMD patients. Appendix IVd by Past AAOP President Dr. Gary Heir provides a summary of
the some of these issues related to the field of Orofacial Pain.

Members of the field of Orofacial Pain have also contributed to many other categories of research including:
 The need for a better understanding of prevalence and impact of orofacial pain disorders
 Mechanisms of orofacial pain and it's modulation
 orofacial pain assessment, diagnosis, and classification;
 diagnostic strategies for temporomandibular disorders and orofacial pain
 Outcome and clinical trials associated with all strategies for management of orofacial pain
 Underlying mechanisms and diagnosis of orofacial pain disorders
 Identification of modifiable risk and protective factors for diseases/disorders/injuries;
 Studies on assessment of risk, including genetic susceptibility;
 Development of methods for screening and identification of markers for those at risk for onset or
progression of asymptomatic diseases/disorders, or those at risk for adverse, high-risk
behaviors/injuries;
 Development and evaluation of interventions to promote health for groups of individuals without
recognized signs or symptoms of the target condition;
 Translation of proven effective prevention interventions into practice;
 Effectiveness studies that examine factors related to the organization, management, financing, and
adoption of prevention services and practices; and
 Methodological and statistical procedures for assessing risk and protective factors and measuring the
effects of preventive interventions.

d. Identify and analyze new and emerging trends in the field; evaluate findings from surveys, such as
the ADA Survey of Dental Practice data regarding services rendered and time spent providing the
services.

A survey of AAOP members examined referral patients including the source of referrals and their frequency. Of
the surveys returned, 135 reported on referral patterns in their Orofacial Pain practices. Table 20 list the
percent from different referral sources for patients referred to orofacial pain clinicians. Requests for Orofacial
Pain services came from all dental specialties, most medical specialties, and patients as well. This survey
indicated that the frequency of referrals to an Orofacial Pain practice was a mean of 23 patients per month with

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a range from 200 per month (multi-group practice) to 1 per month. The maximum number new patients seen by
specialist is limited by the months of time it takes to treat a patient and the time intensive nature of the
appointments. The best estimate is that a single Orofacial Pain clinicians can see about a maximum of 500
new patient consultations per year.

Table 10. Referral sources for patients of Orofacial Pain dentists (Survey of AAOP members)
Source of Referral Percent
Patients 18.6%
Other patients 15.0
Self-referral 3.6
Dentists 48.6%
General dentists 22.1
Orthodontists 15.7
Oral Surgeons 7.7
Endodontists 1.8
Periodontists 1.6
Prosthodontists 1.2
Pedodontists 0.4
Oral Pathologists 0.1
Physicians 22.7%
Family practice 9.2
ENT 5.5
Neurology 3.8
Physical Medicine 1.2
Rheumatology 0.6
Orthopedists 0.5
Anesthesiologists 0.4
Oncologists 0.3
Psychiatry 0.2
Others 9.1%
Attorneys 3.5
Physical Therapists 2.4
Chiropractors 2.2

e. Indicate the number of individuals who devote the majority (greater than 50%) of time to the practice
of the discipline.

According to a 2009 survey of AAOP members, the number of AAOP dentists currently devoting full time
(>75% limited to the practice of Orofacial Pain) is approximately 70% or 340. (Figure 6). The number of
Orofacial Pain dentists currently devoting over 50% of their time to the practice of Orofacial Pain is
approximately 80% of the membership or 390.

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Figure 6. The percent of dentists currently devoting full-time to the practice of Orofacial Pain.

f. Document how the proposed specialty contributes to the educational needs of the profession at the
pre-doctoral, postdoctoral and continuing education levels.

The members of the field of Orofacial Pain have contributed to the educational needs of the profession at each
of the pre-doctoral, postdoctoral and continuing education levels. The faculty and specialists from Orofacial
Pain have supported advanced education programs in 12 Advanced Education Programs at Universities
through the U.S. IN addition, they have taught at the pre-doctoral, postdoctoral training in existing dental
specialties and continuing education courses. Here is a summary of some of the offerings;

Background for pre-doctoral, postdoctoral training in existing dental specialties and continuing education in
Orofacial Pain. Orofacial pain disorders including headache, temporomandibular muscle and joint disorders
(TMJ), dental sleep disorders, burning mouth, neuropathic, atypical pain, and others are one of the most
common and complex disorders with a collective prevalence that ranges from 30% to 40% of the population.
Since orofacial structures have close associations with functions of eating, communication, sight, and hearing
as well as form the basis for appearance, self-esteem and personal expression, pain in this region can deeply
affect an individual physically and psychosocially often leading to chronic pain, addiction and disability. (6-20)

The purpose of pre-doctoral and continuing education programs in Orofacial Pain is to improve access to care
for those who suffer from orofacial disorders by encouraging all dentists and physicians to broaden their care
of these problems in the United States. Improving access to care for orofacial disorders needs to be a priority
of all healthcare providers, Centers of Medicare (CMS), state boards, health systems, and health plans but is
challenging because care for these conditions lies between medicine and dentistry with a limited number of
health professionals trained to care for these patients. By participating in multidisciplinary clinical team
activities, lectures, on-line training, and professional meetings, it is expected that all dentists will acquire some
skills and knowledge necessary to provide the highest quality of evidence-based care for individuals with TMD
and other common orofacial pain condition to improve access to care for these conditions.

Curriculum Content for these courses. Orofacial Pain is the field of Dentistry that involves pain and
dysfunction caused by diseases or disorders of orofacial and masticatory structures and associated
dysfunction of the peripheral and central nervous system. The objectives of the fellowship include the
following;
 Elicit and document a comprehensive history, emphasising establishing a physical diagnosis for the
condition and identifying risk factors and protective action plans for orofacial conditions.
 Perform and document a thorough musculoskeletal and neurological, dental, and orofacial examination,
including diagnosis of orofacial conditions, record keeping and outcome measures.
 Understand imaging techniques, laboratory and diagnostic studies appropriate for diagnosis of various
orofacial pain disorders.
 Arrive at a differential diagnosis of temporomandibular and orofacial and sleep disorders
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 Assess and address the behavioural and psychosocial diagnoses related to chronic pain
 Assess and measure the cognitive, physical, behavioural, emotional, spiritual, social, and environmental
risk factors within patient’s life that contribute to pain, physical dysfunction and disability using valid and
reliable assessment tools.
 Understanding the efficacy and implementation rehabilitation treatment strategies for TMD and orofacial
pain including intra-oral splints, health psychology, physical therapy, injections, medications, and surgery.
 Understanding the efficacy and implementation of interventional pain treatments for orofacial pain condition
including trigger Point Injections, Botox injections, Trigeminal, and Peri-neural Injections, and others.
 Communicate with and direct interdisciplinary treatment planning with other health providers
 Identify professional, system, patient, family and community barriers to effective pain assessment and
management.
 Implement management that includes patient self-management training and education to learn the
cognitive, physical, behavioural, emotional, spiritual, social, and environmental protective actions that can
relieve pain.
 Demonstrate an awareness of their scope of practice to evaluate and manage patients experiencing pain
using evidenced-based practice strategies for clinical shared decision-making.
 When appropriate, refer patients in a timely manner for additional care to practitioners with expertise such
as medical and surgical, behavioural and psychological, or pharmacological interventions.
 Recognise individuals who are at risk for under or over-treatment of their pain (e.g., individuals who are
unable to self-report pain, neonates, cognitively impaired).
 Apply knowledge of basic science of pain including peripheral and central sensitization to the assessment
and management of people with pain.
 Promote health and well-being through prevention of pain and disability.
 Practice in accordance with an ethical code that recognises human rights, diversity, and the requirement to
"do no harm."
 Reflect critically on effective ways to work with and improve care for people with pain.
 Regularly update personal knowledge on orofacial conditions and its management.
 Training in Business Practice Skills.

This knowledge and content of orofacial pain includes assessment, diagnosis and treatment of the following
conditions:
 Intraoral, intra-cranial, extracranial, and systemic disorders that cause orofacial pain
 Complex masticatory and cervical musculoskeletal pain
 Neurovascular pain, i.e. headache disorders resulting in orofacial pain
 Neuropathic pain
 Psychological concerns
 Dental Sleep disorders
 Orofacial pain secondary to systemic disorders such as cancer or AIDS
 Regional pain syndromes
 Orofacial movement disorders
 Other complex disorders causing persistent pain and dysfunction of the orofacial structures.

Continuing Education Courses in Orofacial Pain. Theoretical and hands on training, including tutorials,
workshops, symposium, case discussions and journal clubs on orofacial conditions are available at the
following Universities;
1) CE Courses and Mini-residencies in Orofacial Pain. There are weekend mini-residencies and on-line
courses in Orofacial Pain at several Universities at;
https://aaop.clubexpress.com/content.aspx?page_id=22&club_id=508439&module_id=128634&sl=104598366
Here is a sample of the some of the education offerings in Orofacial Pain;
a) University of Minnesota Massive Open On-line Course on Preventing Chronic Pain at

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https://www.coursera.org/learn/chronic-pain and Snoring and Sleep Apnea at http://www.dentalce.umn.edu/.
b) University of Kentucky at on Orofacial Pain at https://dentistry.uky.edu/ofpmr2018,
c) UCLA at Sleep Medicine Mini-Residency at [email protected]
http://www.dentistry.ucla.edu/continuing-education/courses/[email protected]
http://www.dentistry.ucla.edu/continuing-education/courses/[email protected]
http://www.dentistry.ucla.edu/continuing-education/courses/sleep and TMJ and Orofacial Pain Mini-Residency
http://www.dentistry.ucla.edu/continuing-education/courses/433-temperomandibular-joint-and-orofacial-pain-
disorders-mini-residency.
d) Louisiana State University Online SU Orofacial Pain Continuum. This 1- hour online course covers the
basics of physiological aspects and categories of orofacial pain including somatic, musculoskeletal,
neuropathic sources of pain and various categories of headache at http://www.lsuorofacialpaince.org/online-
education.html
2) Rutgers School of Dental Medicine Orofacial Pain Beyond TMD. This innovative, online course is a
formal educational experience to learn the latest in orofacial pain diagnosis and management. Emphasis will
be on the diagnosis and management of patients with neuropathic, neurovascular (headache) and
musculoskeletal disorders. See http://sdm.rutgers.edu/CDE/calendar/180924_OFPnet.html
3) USC Online Certificate in Orofacial Pain. This is a hybrid program (face-to-face and online classes) with a
total of 8 courses (12.5 academic units), specifically designed for the practicing dental professional who wants
to improve skills and gain expertise to deliver the best care for patients with complex conditions.
https://online.usc.edu/programs/certificate-orofacial-pain/

g. Project the need for practitioners in the specialty over the next five years, taking into account
disease trends, demographic changes and other pertinent factors.

It is expected that the need for Orofacial Pain dentists is high and will increase over the next five years.
Considering data on health care utilization for these chronic orofacial pain patients, the most conservative
estimate of the total cases that will demand or seek treatment is about 2.0% of the population or 3 million
people per year. The detailed calculation of the need and demand for Orofacial Pain dentists was presented
under Requirement 4-f. (1-19)

Using these figures, Table 11 illustrates the lack of adequate numbers of specialist to provide care for these
patients. Based on demographic changes and disease projections, it is estimated that 3% or a minimum of 10
million patients with orofacial pain conditions will seek care for their problem this year. If 1000 patients per year
can be seen by a full-time Orofacial Pain dentist and we currently have about 250 full-time specialists, an
estimate of the number of additional specialists that are needed in the field is a minimum of 10,000. This is
consistent with the number of specialists in other fields of dentistry such as oral and maxillofacial surgeons and
Endodontists. This also demonstrates how there is a dramatic access to care issue in our country, particularly
when patients see an average of 6.2 previous clinicians for their problem prior to seeing an orofacial pain
specialist.

Table 11. The estimated need for Orofacial Pain dentists nationally over the next 5 years based on health
services rates of treatment need, current numbers of orofacial pain dentists, and patient load. (1-19)
# of current FTE Orofacial Pain Specialists 250
Estimate the number of new cases that are treated by Orofacial Pain 1,000 (20 new patients per
Dentists per year week)
Total Prevalence of TMD, Orofacial Pain, and Headache that need 100 million
treatment per year based on epidemiological data (30% of population)
Prevalence of new cases of TMD, Orofacial Pain, and Headache that need 10 million
treatment per year based on epidemiological data (3% of population)
Total cases that can be managed by the existing total of Orofacial Pain 250,000

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 Specialists
Total cases that are left untreated per year without an orofacial pain 9,750,000
specialist
Number of additional Orofacial Pain Specialists estimated to be needed 10,000
over next 5 years (1000 new patients per year)
Number of Dentists in the U.S. 200,000
Number of Oral and Maxillofacial Surgeons in the U.S. 8,000
Number of Endodontists in the U.S. 4,500

We recognize that patients with orofacial pain disorders seek care with many types of health care professionals
and in many cases successfully managed by physical therapists, physicians, health psychologists and others.
However, as noted, these patients often wander from doctor to doctor in search for successful care because
orofacial pain disorders have such a significant impact. For these reasons, we made several low estimates
and assumptions in understanding the figures in this table;
1) Assumption 1 defines an Orofacial Pain dentist as one who either belongs to the AAOP, has more than 5
years of experience in the field, has passed the ABOP exam, and/ or has more than 50% of clinical practice is
limited to patients with orofacial pain. There are an estimated 250 fulltime current Orofacial Pain dentists who
meet this criteria. There are many more dentists who care for patients with orofacial pain disorders.
2) Assumption 2 defines the total cases treated per year by an Orofacial Pain dentist is that mean number of
new cases that can be evaluated and treated by a full-time Orofacial Pain dentist in a year. This is estimated at
1000 per year based on a survey of both AAOP members in full-time (100%) practices. The figure is the
number of new patients per month cited by the busiest 10th percentile of these clinicians.
3) Assumption 3 defines the total number of cases that need treatment per year by an Orofacial Pain dentist is
about 3% of the population. This is estimated to be a minimum of 10 million people in our country. The
prevalence of any type of orofacial pain is estimated at 30% to 40% of population and includes both those with
existing pain and/or dysfunction and new cases of orofacial pain disorder. However, the number of case of
severe orofacial pain who seek care is estimated to be 10% of that or a minimum 3% of the population or 10
million people. The reliability of the point prevalence is estimated to be with 95% confidence with both United
States and European studies providing prevalence estimates. The point prevalence was chosen over annual
incidence to determine demand for treatment because orofacial pain disorders will fluctuate in severity and
both current and new cases can become severe during in given period, thus, requiring care.
4) Assumption 4 is the total cases that are treated per year by an Orofacial Pain dentist. This is calculated by
the total number of cases that are being treated per year by an Orofacial Pain dentist multiplied by the number
of Orofacial Pain dentists nationally. This is estimated to be 250,000 cases.
5) Assumption 5 is the total cases that are left without an Orofacial Pain dentist to manage their care and is the
difference between the total number of cases that need treatment per year by an Orofacial Pain dentist and the
total number of cases that are being treated by an Orofacial Pain dentist. This is estimated at 9,750,000.
6) Assumption 6 defines the total number of new Orofacial Pain dentists needed per year as the number of
untreated cases per year divided by the 1000 new cases that can be treated per year by each dentist
subtracting the current number of clinicians. The fact that 10,000 new orofacial pain dentists are needed to
meet the minimal need is close to equivalent to the number of Oral and Maxillofacial Surgeons that are
practicing currently and twice as many as endodontists who are practicing. This suggests that Orofacial Pain
has much potential to grow dramatically to meet the access to care needs of our population and a great
opportunity for the profession of Dentistry to grow.

h. Other Information.
There are other considerations when reviewing the adequacy of orofacial pain dentist in the United States.
Here is additional information that demonstrates compliance with this requirement. Among pain conditions,
orofacial pain and associated disorders are one of the most common and potentially complex disorders with a
collective prevalence studies that range from 30% to 40% of the population.(1-20) Orofacial disorders include

89
temporomandibular disorders, orofacial pain disorders, headache disorders, dental sleep disorders,
neurosensory and chemosensory disorders, bruxism, oromotor disorders and many others. Because oral and
facial structures have close associations with functions of eating, communication, sight, and hearing as well as
form the basis for appearance, self-esteem and personal expression, persistent pain or disease in this area
can deeply affect an individual both psychologically and systemically. Furthermore, the higher degree of
sensory innervation in the face and mouth compared to other area of the body can cause more complex and
persistent pain conditions. A national poll found more adults miss work from head and face pain than any other
site of pain. There are additional considerations also.

Ethical Considerations in Access to Care for Orofacial Pain.

Unfortunately, access to quality evidence-based care for patients with these disorders is often difficult because
the limited number of dentists who focus their practices in this area, and the lack of understanding of the
complex nature of these problems by most physicians and dentists. As a result, patients with these conditions
are often confused and frustrated when seeking care from health care professionals. They are at risk of
receiving inconsistent, trial and error, or inappropriate care including extensive dental work, dependency on
opioid medications, multiple surgeries and other treatments that may not be beneficial and in some cases, may
increase risk of adverse events and addiction. Each of these problems have created a problem of low access
to evidence-based care, doctor shopping, the opioid crisis, and high cost of chronic pain.

The Opioid Crisis.

The ADA Statement on the Use of Opioids in the Treatment of Dental Pain (2016) highlights the importance of
Dental profession to recognize their important role in preventing opioid addiction by judicial use of non-opioid
analgesics and preventing chronic pain. One study found that adolescents exposed to opioids have a 33
percent higher risk of abusing prescription painkillers later in life, particularly when they have a pain condition.
Dentists in particular have an increased responsibility to curb this pipeline of addictive drugs because
they prescribe more opioids to teenagers than any other healthcare provider. It’s estimated more than 2 million
Americans abuse prescription drugs. From 2001 to 2011, the number of people seeking treatment for
prescription painkillers increased five times because of pain from pain disorders including orofacial disorders.
Deaths from opioid overdoses are at a level right now reaching proportions. The latest numbers from the
NIH show 1 in 8 high schoolers report using prescription opioid painkillers recreationally. The majority of these
kids get their pills from friends and family, which is hardly surprising considering a 2016 study found nearly 100
million prescribed painkillers go unused after wisdom tooth extractions. Since 1999, sales of opioids have
nearly quadrupled and there have been as many opioid prescriptions as citizens in the U.S.

High Cost of Chronic Pain.

A study published online last month in Pain Practice found that pain conditions including head, neck, and
orofacial pain costs $31,692 per patient per year and this increased by 29% in the 2nd year of the study.(7)
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
including headache, TMD, and orofacial pain during calendar year 2010. Except for pharmacy visits, the most
used resource were outpatient visits, at a mean 18.8 visits per patient. Of these 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 including arthritis, back
pain, headache, and neck pain were associated with the highest overall costs. Another study of the Trillium
health plan in Oregon evaluated the cost of member’s health care costs without a pain condition was $245 per
member per month (PMPM) or $2,940 per year while the cost of members with members with pain conditions
is more than 4 times this at $1,023 PMPM or $12,276 per year.8 Both studies support the need for
comprehensive integrated care programs that include self-management training with treatment to improve
patient outcomes and lower the long-term costs for chronic pain patients. Orofacial care dentists are trained in
transformative care.

The Problem of Limited Reimbursement.

The plight of the patient with orofacial pain disorders in seeking health care is profound due to lack of access

90
and reimbursement of care for these problems. If initial efforts to manage pain fail by inexperienced clinicians
with trial and error treatments, care may escalate to higher cost, higher risk passive interventions such as on-
going opioid analgesics, polypharmacy, implantable devices, injections, extensive dental reconstruction, and
multiple surgeries. Unfortunately, access to care for patients with orofacial disorders is often difficult because
the care for these conditions lies between dentistry and medicine, thus, creating confusion in covering in
helping these patients. Most orofacial pain dentists are out of network from medical health plans and dental
plans do not cover care because of the medical nature of these problems. This lack of recognition limits the
number of dentists who specialize in this area and establish clinical practices to care for these patients.
Furthermore, the lack of awareness of this specialty among both consumers and health professionals also
limits referrals. Yet, the lack of practical training in these disorders within both medical and dental primary care
and specialty training programs motivate most health care providers to choose to refer these patients to a
specialist. A survey of 405 health professionals found that 95% either do or would like to refer these patients
to a specialist because of their complex nature. 7

Lack of Specialty Recognition Drives More Chronic Pain and Addiction.

The lack of specialty recognition has led to low or no reimbursement for treatment of these disorders. This has
led to patient frustration, anger, neglect of the problem, and in many cases, progression of the disorder.
Epidemiological studies have revealed that temporomandibular disorders (TMD) often begin with jaw clicking
and mild pain and can result in serious jaw locking, degenerative arthritis and constant, severe pain in the face,
head and neck. Successful management of these disorders can usually be accomplished with conservative
nonsurgical treatment such as medications, physical therapy, splints, and behavioral therapy. If treatment is
neglected, denied, or inappropriate, the personal consequences can be tragic and the costs great. The pain
may become entrenched in the patient's life with the development of severe pain, disability, difficulty eating and
talking, and many behavioral and psychosocial problems characteristic of a chronic pain syndrome. A
frustrating medical and dental picture results that may involve costly surgeries, diagnostic tests, complex pain
programs, long-term medications, and an on-going dependency on the health care system. It is estimated by a
Harris Poll that 156.9 million work days are lost due to head pain (7). In other studies, over 50% of head and
face pain is related to temporomandibular disorders (6-20). Thus, the lack of successful resolution of these
disorders can have serious consequences in patient suffering and economic impact to insurers and other
businesses. Lack of insurance reimbursement for treatment is a major reason that patients postpone
treatment.

Ethical Issues of Non-Evidence Based Care for Orofacial Pain Disorders.

Due to the lack of health plan coverage, there has also been a proliferation of expensive non-evidence-based
strategies for their care marketed directly to the patient by dentists, physicians, and other clinicians to increase
revenue.(121-123) This includes the following;
4) Use of long-term medical treatments that have questionable long-term efficacy including opioid
analgesics and repeated interventions such as injections, nerve blocks, and manipulation.
5) Use of electronic surface EMG, jaw tracking and other untested diagnostic tests that have no evidence
of reliability and validity for TMD and orofacial pain conditions have been promoted to increase revenue
for the provider.
6) Dental splints used 24 hours per day 7 days per week or partial coverage splints that change the
occlusion permanently and create malocclusions that requiring expensive orthodontics, prosthodontic
dental care, or jaw surgery to correct the malocclusion and allow normal function again.

In contrast, orofacial pain dentists provide transformative rehabilitation care, which integrates patient self-
management training with evidence-based rehabilitation treatments to prevent chronic pain and addiction while
helping the health care system prevent the devastating escalation to chronic pain and addiction. Clinical trials
and systematic reviews have shown that the long-term outcomes of patient-centered rehabilitation approaches
such as splints, exercise, physical therapy, cognitive-behavioral training, mindfulness, and relaxation are
excellent and able to prevent long-term chronic pain, addiction, and disability in nearly every patient.

Denying Health Plan Coverage for Patients with Orofacial Pain Conditions

91
Since legislation was passed in 1987 to clarify coverage of orofacial disorders, many health plans nationally
provide reimbursement for services provided by physicians and dentists on an equal basis in evaluation and
management of orofacial disorders. State regulations state that no policy or certificates of health, medical,
hospitalization, or accident and sickness insurance regulated under state laws is required to specifically
provides coverage for surgical and non-surgical treatment of orofacial disorders and that coverage shall be the
same as that for treatment to any other similar condition in other parts of the body, and shall apply if the
treatment is administered or prescribed by a physician, dentist or other health professional. However, the
confusion regarding who is qualified to provide care for these conditions have added language to their health
care policies that excluded coverage of specific orofacial disorders, out of network providers, or specific
treatments such as splint. This often acts to exclude non-surgical treatment and cover only more expensive
surgical treatment for these problems. Yet, most patients do not require surgery and are successfully treated
with less costly conservative rehabilitation modalities such as self-management strategies, medication, intra-
oral splints, physical therapy and behavioral therapy. In these situations, some patients sought care for
surgery because of insurance coverage and not necessarily appropriateness. Most states have now
responded to these discriminatory policies of insurance companies by issuing regulations that prohibits
discrimination against patients with orofacial disorders. In most CMS regions, Medicare and Medicaid provides
the same coverage for surgical and non-surgical treatment of orofacial disorders that it provides for treatment
of any other joint, muscle or condition in the body or it is considered discriminatory against females since these
conditions have a 4:1 prevalence in women or men (5). Discriminatory practices by health plans to deny
coverage for orofacial pain conditions has been clearly stated by insurance regulators as both unethical or
illegal in most states.

Health Plan Efforts to Improve Quality of Orofacial Care.

In the states that have embraced coverage of these conditions, health plans have had dramatic effect in
helping prevent the staggering cost and suffering chronic pain and addiction, particularly for orofacial disorders
by including orofacial pain dentists in their networks and reimbursing them for their services. National
Government Services (NGS), who administers Medicare and Medicaid, and most health plans have made
administrative decisions to cover treatment of orofacial disorders. These health plans recognize that when a
patient is denied coverage for evidence-based treatment of orofacial disorders, they still are motivated to seek
care and often bounce between many in-network providers who may not understand comprehensive
successful management of these conditions. Some patients with denials have worked diligently to educate
health plans to change policies and bring orofacial pain dentists into the network. These patients can complain
to their health plan or NGS directly and indicated that they are discriminatory. They have first appealed to the
health plan with a simple letter but then can escalate to write to their senator and congressional representative
complaining about the recent change in your health plan. They also file complaints with the state or federal
insurance regulatory agency using the following points to educate health plans that deny including orofacial
pain dentists in their medical networks;
 Orofacial disorders occur in 30% to 40% of the population, affect mostly women, and cause facial pain,
headaches, earaches, and difficulty in chewing and jaw function (5-19).
 Orofacial Pain Dentists are Dental Specialists who successfully treat these pain conditions, have advanced
training in dentistry and medicine, and successfully manage these conditions using evidence-based
treatments.
 State legislation throughout the country has determined that orofacial disorders are medical conditions and
should covered under their medical plans regardless of whether the treatment was provided a physician or
dentist.
 Some health plans are still denying access to care for these disorders to save money by excluding them in
standard policies or recommending that companies not include them in self-insured policies. Discrimination
against these patients only escalates chronic pain, addiction, and healthcare costs.
 Patients must remember that only they can change this policy of health plans trying to deny essential
services.

Collaboration with other Health Care Professionals.

92
Access to health care and changing demographics are driving a new vision of the health care workforce.
Dental curricula can change to develop a new type of dentist, providing opportunities early in their educational
experiences to engage allied colleagues and other health care professionals. Enhancing the public’s access to
oral health care and the connection of oral health to general health form a nexus that links oral health care
providers to colleagues in other health professions. Health care professionals educated to deliver patient-
centered care as members of an interdisciplinary team present a challenge for educational programs. Patient
care by all team members will emphasize evidence-based practice, quality improvement approaches, the
application of technology and emerging information, and outcomes assessment. Dental education programs
are to seek and take advantage of opportunities to educate dental school graduates who will assume new roles
in safeguarding, promoting, and caring for the health care needs of the public.

Promoting Evidence-based Orofacial Pain Care.

Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious integration of
systematic assessments of clinically relevant scientific evidence, relating to the patient's oral and medical
condition and history, with the dentist's clinical expertise and the patient's treatment needs and preferences.1
EBD uses thorough, unbiased systematic reviews and critical appraisal of the best available scientific evidence
in combination with clinical and patient factors to make informed decisions about appropriate health care for
specific clinical circumstances. Curricular content and learning experiences must incorporate the principles of
evidence-based inquiry, and involve faculty who practice EBD and model critical appraisal for students during
the process of patient care. As scholars, faculty contribute to the body of evidence supporting oral health care
strategies by conducting research and guiding students in learning and practicing critical appraisal of research
evidence.

Scientific Discovery and the Integration of Knowledge.

The interrelationship between the basic, behavioral, and clinical sciences is a conceptual cornerstone to
clinical competence. Learning must occur in the context of real health care problems rather than within singular
content-specific disciplines. Learning objectives that cut across traditional disciplines and correlate with the
expected competencies of graduates enhance curriculum design. Beyond the acquisition of scientific
knowledge at a particular point in time, the capacity to think scientifically and to apply the scientific method is
critical if students are to analyze and solve oral health problems, understand research, and practice evidence-
based dentistry.

State Boards of Dentistry Step up to Support Access to care

To help improve this problem of access to quality evidence-based care in their state, some State Dental
Boards have initiated the following steps;
1. Support the recognition of the specialty of Orofacial Pain to encourage awareness that specialty trained
and American Board of Orofacial Pain-certified specialists are available for those residents of the state who
require care. Dental boards are helping ensure that orofacial pain patients have access to quality evidence-
based care and are not subject to unethical care using TMD as a rationale to provide extensive
prosthodontic occlusal reconstruction.
2. Dentists who want to advertise as an Orofacial Pain Specialist can do so if qualified as a specialist by the
State Boards if they complete a 2-year advanced education training (or show the equivalency of this
training), follow ethical guidelines in of care, and maintain board certification in the American Board of
Orofacial Pain (ABOP). The ABOP is the only Orofacial Pain specialty board associated with CODA
approved advanced education programs in Orofacial Pain and approved by the American Board of Dental
Specialties. Recently, the ABOP has had to defend itself against litigation from other unqualified groups
that promote unethical care in claiming to be specialists.
3. Improve the public’s awareness of board-certified orofacial pain specialists in the state to provide care for
these problems through public awareness and marketing programs. This will help the general public,
physicians, dentists, and other health professionals know that successful evidence-based care is available
and help prevent patients from "wandering" from doctor to doctor or undergoing unethical care before
receiving successful care.

93
V. Requirement 5: A specialty must directly benefit some aspect of clinical patient care.

a. Principal Health Services. Identify the principal health services provided to the public by individuals
in this area of practice.

Members of the American Academy of Orofacial Pain have developed and published consensus based
diagnosis and treatment guidelines that have been widely accepted nationally and internationally by most
dental organizations, insurance providers, and government agencies (Appendix III). The services outlined in
these guidelines and provided by all Orofacial Pain practitioners include; 1) a complete head and neck
examination,
2) imaging and laboratory technique and interpretation,
3) differential physical diagnosis of pain disorders,
4) behavioral and psychosocial assessment and diagnosis,
5) interdisciplinary treatment planning,
6) treatment procedures including;
b) craniofacial nerve blocks, joint injections, and Intramuscular injections,
c) physical medicine modalities, therapeutic exercises, and orthotics
d) cognitive-behavioral management strategies,
e) pharmacotherapies and chemical abuse management, and
f) coordinating interdisciplinary and multidisciplinary management strategies.
Because the demand for these services has been so high, state insurance regulators have had to clarify
insurance coverage for treatment of orofacial pain disorders. These laws have used the guidelines to
determine reimbursement of services and have mandated that the care be provided under the medical plans
regardless of whether dentist or physician provided the care. This is distinctly different than any other dental
specialty. The prevalence and loss of productivity and quality of life due to orofacial pain disorders in our
country coupled with the advances by dentists to successfully manage these disorders will continue to increase
demand for care in this field. Thus, recognition of Orofacial Pain by the ADA as a dental specialty will have a
significant impact in serving the public.

A description of the services provided by Orofacial Pain dentists include;

1) Orofacial, head, neck examination Complete musculoskeletal examination, salivary gland and lymph node
examination, biochemical and cytological testing, joint function evaluation, cranial nerve function assessment,
and a dental evaluation including probing, percussion, vitality testing, transillumination, occlusal assessment,
and periodontal probing as indicated. Some of the techniques employed include digital palpation, auscultation,
pinwheel and other sensory differentials, fundoscopic exam, and motor and strength testing.

2) Imaging and laboratory technique and interpretation. Determining the indication and interpretation of
imaging and laboratory data including CT, MRI, tomography, plane film, arthrography, bone scans, EMG,
functional studies, blood studies, urine studies, liver function studies, and other diagnostic tests. A close
alliance exists between the radiologist, pathologists, and orofacial pain dentist.

3) Differential physical diagnosis of pain disorders, The diagnostic range of disorders includes hundreds of
orofacial pain disorders such as masticatory and cervical neuromuscular pain disorders, primary headache
disorders, pain from complex temporomandibular joint disorders, neurovascular pain disorders, neuropathic
pain disorders, chronic regional pain syndrome, orofacial cancer and AIDS pain, orofacial sleep disorders and
other chronic orofacial pain disorders of orofacial structures. In order to reach correct diagnostic conclusions,
the orofacial pain dentist must be able to interpret clinical symptoms, histories, examination findings and
certain diagnostic tests such as blood chemistries, liver functions, therapeutic drug levels particularly with
polypharmacotherapy, histopathology, and imaging. This data is synthesized as part of the differential
diagnostic process in ruling out all possible disorders to arrive at the correct diagnoses.

94
4) Behavioral and Psychosocial Assessment and Diagnoses. The Orofacial Pain dentist must complete a
standard personal history, psychosocial history, behavioral problem review and contributing factor assessment
as part of all evaluations. The contribution of behavioral and psychosocial components to multiple pain
complaints needs to be determined and, if necessary, the interaction and coordination of treatment with a
Health Psychology pain specialists is accomplished. The Orofacial Pain dentist must also have the knowledge
of which psychometric tests are appropriate for each case and be able to understand the interpretations of the
test results provided by the Health Psychologist.
5) Treatment planning. As an Orofacial Pain dentist, the responsibilities of treatment planning include defining
a well-defined course of treatment that may involve multiple treatments and specialties such as Physical
Medicine and Rehabilitation, Health Psychology, and Neurology. The Orofacial Pain dentist serves as team
leader and be responsible for coordinating care, monitoring compliance, adjusting the treatment plan as new
data is collected, and conducting treatment progress meetings with the patient and team members. Objective
outcome data collection during and after treatment is an integral part of this process.

6) Treatment procedures. The Orofacial Pain dentist is responsible for understanding the indications,
contraindications, precautions, and techniques of implementing diagnostic and treatment including; a) Muscle
relaxants for muscular disorders
b) Sedative agents for chronic pain and sleep management
c) Opioids for chronic orofacial pain
d) Tricyclics and SSRIs for chronic pain
e) Anticonvulsants and membrane stabilizers for neuropathic pain
f) Analgesics and anti-inflammatories for chronic orofacial pain
g) Vaso-active analgesics for neurovascular pain and primary headache disorders
h) Chemical dependency issues for chronic orofacial pain disorders
i) Treatment of rebound pain and medication side effects
j) Diagnostic and therapeutic injections including trigger point injections, intramuscular
injections for dystonias, sympathetic nerve blocks for orofacial region,
trigeminal nerve blocks, and joint injections
k) Neurosensory stents for neuropathic pain
l) Physical medicine procedures including therapeutic exercise, cryotherapy, heat and hot packs, ultrasound,
phonophoresis, soft tissue massage, joint and muscle mobilization, electric stimulation, and postural
awareness training
m) Stabilization, anterior positioning and other intra-oral orthotics
n) Intra-oral appliances for breathing related sleep disorders
o) Cognitive-behavioral therapies including habit reversal for oral habits, sleep problems, muscle tension habits
and other behavioral factors, biofeedback/stress management, hypnosis for pain relief and behavioral
changes, and treatment of secondary gain and chronic pain behavior, and compliance assurance and
monitoring

b. Practice Setting
Identify the setting in which these services are customarily provided, e.g., private office, hospital,
laboratory, institutional setting, community health setting, etc.

According to the past surveys of AAOP members, the clinical settings for practitioners are;
 Private Dental Office - 75%
 Hospital - 14%
 Dental School - 28%
 managed care clinic- 4%
 Other/state/ federal institutional setting - 7%.
 Note: many clinicians have multiple settings, thus, adding up to more than 100%.

Many Orofacial Pain dentists also have hospital privileges in addition to their primary practice setting. This
95
survey shows that 41% currently have university or hospital privileges. Orofacial Pain dentists remain readily
available on a consultation basis to both private hospitals, dental and medical professionals in the area.
c. Other Information. None
Requirement 6: Formal advanced education programs of at least two years accredited by the
Commission on Dental Accreditation must exist to provide the special knowledge and skills required
for practice of the proposed specialty.

a. Operational Advanced Education Programs.

List all currently operational advanced education programs in the proposed specialty, indicating:
(1) the name of the sponsoring institution;
(2) the name and educational background of the program director;
(3) the mandatory length of the program for full-time students; (Refer to Standard 4 of CODA’s
Standards for Advanced Specialty Education Programs);
(4) the certificate and/or degree awarded upon completion of the program. Enclose a letter from each
institution's chief executive officer verifying sponsorship of the program. All information provided
should pertain to the most recent academic year for which statistics are available. This timeframe
should be identified. Do not include continuing education courses in this listing.

Table 12 list all of the advanced education programs in Orofacial Pain and a summary of the above required
information. The total first year enrollments in all programs beginning the program in July of 2018 is 53. The
number of graduates in the past five years (2013-8) has been 155. Letters from the Deans of each of the
programs have been included. In addition to the clinically based specialty programs, there are 3 Ph.D.
programs in neuroscience and orofacial pain (the University of New York at Buffalo, the University of
Minnesota, and UCLA) that are concurrent with Orofacial Pain clinical certificate programs. These programs
have support from the National Institute of Dental Research through the Dentist- Scientist program. The
curriculums of these Orofacial Pain advanced education programs as presented in Appendix VII are consistent
with that defined by the Commission of Dental Accreditation's Standards for Advanced Specialty Education
Programs. In addition, the curriculums are consistent with standards recognized by the American Board of
Orofacial Pain, the American Academy of Orofacial Pain, and the American Association of Dental Schools(10-
12).

The operational standards are defined in Standards for Advances Specialty Education Programs in Orofacial
Pain in Appendix IIa as adopted by the AAOP in 1994 and revised several times since then. An accreditation
process to guide the revision and development of new post-doctoral programs in the field has been established
by the AAOP. To date, the “accreditation” site visit process has been university based utilizing the Advanced
Education in Orofacial Pain Self Study Accreditation Document. The UCLA, Kentucky, and Minnesota program
accreditation site visit document as an example is available upon request. A survey was conducted of all
educational programs in Orofacial Pain that are University Based to determine the enrollment, characteristics,
and other relevant of information.

Table 12. Information on advanced Orofacial Pain programs that are a minimum of 2 years
# of
CODA Length Certificate / Program Contact
School residents / Financial Website
Accred. (years) Degree Director Information
year

Mounia
Eastman https://www.urmc.roc
Dr. Junad Demdam
Institute for Yes 3 3 Certificate Tuition hester.edu/dentistry/
Kahn 585-275-
Oral Health education/tmj.aspx
8315

Certificate Tuition
University Dr. Jeffrey Rosemary https://dentistry.uky.e
Yes 2 3 or Master or
of Kentucky Okeson Grayson du/orofacial-pain
of Science Stipend

96
 859-323-
5500

Jared Katz
jkatz11@mg http://www.massgene
Massachuse
Dr. Jeffry h.Harvard.e ral.org/omfs/educatio
tts General Yes 3 2 Certificate Stipend
Shaefer du n/residency.aspx?id=8
Hospital
617-726- 0&display=overview
8222

https://medicine.umic
h.edu/dept/surgery/s
University
Carolyn urgical-
of Dr.
Campbell specialties/oral-
Michigan– Yes 1 2 Certificate Stipend Lawrence
734-232- maxillofacial-surgery-
Michigan Ashman
6048 hospital-
Medicine
dentistry/training/oro
facial-pain-residency

Dr. Shanti https://www.dentistry

Kaimal .umn.edu/degrees-
University Certificate
Dr. Shanti 612-625- programs/advanced-
of Yes 2 2 or Master Stipend
Kaimal 3984 education-
Minnesota of Science
kaima001@ programs/orofacial-
umn.edu pain

Dr. Steve
Naval 2 Hargitai http://www.wrnmmc.
Certificate
Postgradu *Limited capmed.mil/Research
with Dr. Steve
ate Yes to Federal 3 Stipend Education/NPDS/SiteP
Master of Hargitai Istvan.a.har
Dental Service ages/OrofacialPain.as
Science gitai.mil@m
School Dentists px
ail.mil

Stipend Dr.Pei Feng https://www.dentistry

University
dependin Dr. Pei Feng Lim .unc.edu/academicpro
of North Yes 1 2 Certificate
g on Lim PeiFeng_Lim grams/ade/orofacialp
Carolina
funding @unc.edu ain/

4 Master
4 Dr. Gary http://sdm.rutgers.ed
Rutgers
Advanced Master of Heir u/students/prospectiv
School of 3 Dr. Gary
Yes Education Dental Tuition Heirgm@sd e/postdoctoral/other/
Dental 1 Heir
in Science m.rutgers.e orofacial_faculty/g_he
Medicine
Orofacial du ir.html
Pain
Dr. http://dental.buffalo.
Certificate Dr. Yoly YolyGonzale edu/education/advan
SUNY
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Buffalo
of Science Stucker ymg@buffal orofacial-pain-
o.edu program.html

97
 https://dental.tufts.ed
Tufts U.
Certificate Dr. Chao Lu u/academics/graduate
School of
Yes 2 3-Feb or Master Tuition Dr. Chao Lu Chao.Lu@tu -programs/advanced-
Dental
of Science fts.edu education-orofacial-
Medicine
pain
Louis
Gutierrez
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Certificate, Tuition 310-825-
(2 Dr. Robert .ucla.edu/learning/oro
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domestic Merrill facial-pain-
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Dr. Glenn
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Science Clark 213-821-
line
5831

b. Adequacy of Enrollment
1) Indicate the number of dentists currently in practice who have received two or more years of formal
advanced education in the specialty (not including continuing education).

Formal education of two or more years in orofacial pain has been available for more than twenty years at
various dental schools around the country. This has provided the field with at least 95 dentists who have been
formally trained, completed and graduated from their programs, and focus their careers in this field. Table 13
presents the results from the national survey of Orofacial Pain Dentists (Appendix III).

Table 13. Data regarding the number of members in the AAOP survey who have completed
advanced graduate education. (Note: some answered with multiple responses (% of total
members responding n= 117)
Type of Training Program N=117 Percent
Continuing Ed. 23 20%
Fulltime 2-3 yr 95 80%
Formal M.S. 15 13%
Formal Ph.D. 4 3%

2) For each of the past five years list the number of advanced education programs of two years or
more in length in operation in the proposed specialty.

A survey was conducted of all educational programs in Orofacial Pain that are University Based to determine
the enrollment, characteristics, and other relevant of information (Appendix VII). Table 13 present a summary
of some of this information.

Table 13. A summary of information on enrollment in advanced Orofacial Pain programs for 2013-2018. 158
students have graduated from these programs in the past five years.
# of residents /
School CODA Accred. 2013 2014 2015 2016 2017 2018
year

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 Eastman Institute for Oral 3 3 3 3 3 3 3
Yes
Health
University of Kentucky Yes 2 2 2 2 2 2 2
Massachusetts General 3 3 3 3 3 3 3
Yes
Hospital
University of Michigan– 1 1 1 1 1 1 1
Yes
Michigan Medicine
University of Minnesota Yes 2 2 2 2 2 2 2
Naval Postgraduate Dental 2 2 2 2 2 2 2
School (*Limited to Federal Yes
Service Dentists)
University of North Carolina Yes 1 1 1 1 1 1 1
4 Masters 8 8 8 8 9 8
Rutgers School of Dental 4 Advanced
Yes
Medicine Education in
Orofacial Pain
SUNY Buffalo Yes 2 2 2 2 2 2 2
Tufts U. School of Dental 2 2 2 2 2 2 2
Yes
Medicine
UCLA (2 domestic and 3 3 3 3 3 3 3
Yes
1 international)
University of Southern 2 2 2 2 2 2 2
Yes
California (residency)
University of Southern 20 8 15 20 20 20 20
No
California (Hybrid/Online)
Total Students in MS and PhD 53 45 48 53 53 53 53

3) Describe and assess the adequacy of the projected enrollment in these programs to meet the
projected needs in the field over the next five years.

Table 15 illustrates the numbers of additional specialists that are needed in the field nationally and compares
them to the number of specialist that will graduate from a graduate program in the next year and 5 years. Using
the assumptions from Table 11, it estimates that the United States will require close to 10,000 new Orofacial
Pain Dentists to meet the minimal access to care demands. This is about the same numbers of Oral and
Maxillofacial Surgeons in the country in clinical practice. Since only 110 current specialists will be trained in
Advanced Education Programs in next five years, there is a major inadequacy in meeting the access to care
needs. We need another scenario to come close to meeting the need and demand for services.

Given that the vast majority of dentists and physicians currently admit to be poorly trained to manage orofacial
pain patients and prefer to refer these patients to an Orofacial Pain dentist (91%), we need to improve the
training of all dentists and physicians. If the majority of these patients (75%) are treated by existing dentists
and physicians, we could decrease this need to about 2,500 more Orofacial Pain dentists to be trained in the
next five years to meet the minimal needs of the population with orofacial pain. it is clear that the patients will
not have adequate access to an Orofacial Pain dentist.

However, to accomplish this, much more effort is necessary to increase enrollment in advanced education
programs in existing specialties and expand teaching of Orofacial Pain to general dentistry within Schools of
Dentistry in our country. With this estimate, there will still be an enrollment shortfall of at least 2,390 specialists
over the next five years (Table 15). Granting specialty status is just only a beginning to meet the public’s
access to care needs. Schools of Dentistry must also embrace this field by expanding the number of advanced
education programs and training of these specialists in orofacial pain. If an advanced education program is
developed in 50 dental schools with 4 residents per program, we would come close to meeting this need in 10
years by producing 2,000 additional specialists. This is the goal that the profession of Dentistry could

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realistically strive for. However, the limiting factor is to find faculty to teach in dental schools nationally. Another
option is to create fellowships within Orofacial Pain specialty practices to teach clinical skills and knowledge of
Orofacial Pain to interested general dentists. The didactic knowledge can be acquired with the many continuing
education course available across the nation to allow these dentists to meet the qualifications to take the
national speciality board of American Board of Orofacial Pain.

Table 15. Comparison of the numbers of additional Orofacial Pain dentists that are needed in the field
nationally to the number of specialists that will complete a graduate program in the next year and 5 years.
# Orofacial Pain # graduating this # specialist Shortage of
specialist needed year graduating over 5 specialists
years
Nationally 2,500 22 110 -2,390

c. Minimum Curricular Requirements.

Provide a description of the minimum biomedical, behavioral, and clinical science requirements for
advanced education programs in the specialty. These curricular requirements must provide the
advanced knowledge and skills required for the specialty as identified in Requirements 2 and 3 of this
application.

Minimum curricular requirements are provided in The Standards for Advanced Specialty Education Programs
in Orofacial Pain (Appendix IIa). The American Academy of Orofacial Pain began certifying the curricula of
advanced education programs in Orofacial in 1994. The certification process consists of a self-study
assessment evaluation (Appendix IIb) and a site visit by at least two members of the Board as with recognized
specialty programs. The AAOP survey of graduate programs has shown that all of the programs currently meet
this core curriculum. The advanced dental specialty program in Orofacial Pain is designed to provide special
knowledge and skills beyond the D.D.S. or D.M.D. training and is oriented to the accepted standards of
specialty practice as set forth in specific requirements contained in the standards document. The
recommended curriculum guidelines for Orofacial Pain in university graduate programs for dentists, are
intended to provide a broad-based learning experience in a program that requires a minimum of two years to
complete. These programs may be constructed in a post-doctoral or residency format. The core didactic
portion must include both basic science and clinical science topics to provide overall coverage of knowledge in
orofacial pain. Supplementary topics should be added to meet the specific goals of the candidate and fit within
the framework of the overall orofacial pain program.

The clinical portion must include major clinical experiences in primary patient care, pharmacotherapeutics,
physical medicine, chronic pain team management and behavioral medicine, and management of the
medically compromised patients, and minor clinical experience in imaging, management of the TMJ surgery
patient, and inpatient pain management, and oral medicine as it relates to pain. Supplementary clinical
participation experience in hospital-based patient care should be arranged through individual departments or
divisions such as rheumatology, neurology, psychiatry, orthopedics, anesthesiology, physical medicine,
physical rehabilitation, and otolaryngology. Participation in ongoing research is encouraged to exposure the
trainees to the critical thinking and laboratory and experimental skills that are fundamental to exploring new
ideas and the development of new areas of knowledge. A thesis is only required in articulated degree
programs. Minimum core curriculum for Orofacial Pain postgraduate training programs is only in summary
outline form here. For more detail of the curriculum, please refer to the Standards for Advanced Specialty
Education Programs in Orofacial Pain (Appendix II).

The levels of Knowledge are defined as: 1. In-depth - a thorough knowledge of concepts and theories for the
purpose of critical analysis and the synthesis of more complete understanding (the highest level of knowledge).
2. Understanding - a thorough or technical knowledge with the ability to apply; characteristic of specialization.
3. Familiarity - a simplified knowledge for the purpose of orientation and recognition of general principles.

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Levels of Skill are defined as:
1. Proficient - the level of skill attained when a particular activity is accomplished with repeated quality and a
more efficient utilization of time (the highest level of skill).
2. Competent - the level of skill displaying special skill or knowledge derived from training and experience.
3. Exposed - the level of skill attained by observation of, or participation in a particular activity. The minimum
curriculum content areas include the following Minimum core curriculum for Orofacial Pain postgraduate
training programs.

The bodies of knowledge and unique skills that define the practice of Orofacial Pain include those listed in
standard 4 - curriculum and program duration of The Accreditation Standards of The Orofacial Pain The
advanced dental specialty program must be designed to provide special knowledge and skills beyond the
D.D.S. or D.M.D. training and be oriented to the accepted standards of specialty practice as set forth in specific
requirements contained in this document. The level of specialty area instruction in the graduate and
postgraduate programs must be comparable. Documentation of all program activities must be assured by the
program director and available for review. If an institution and/or program enrolls part-time students, the
institution must have guidelines regarding enrollment of part-time students.

Part-time students must start and complete the program within a single institution, except when the program is
discontinued. The director of an accredited program who enrolls students on a part-time basis must assure
that: (1) the educational experiences, including the clinical experiences and responsibilities, are the same as
acquired by full-time students; and (2) there are an equivalent number of months spent in the program.
4-1. Program Duration: Advanced specialty education programs in Orofacial Pain must be a minimum of 24
months of full-time study. Articulation with a graduate program leading to a master’s degree with a thesis is
likely to require an extension period for completion, and as required by the institution for a doctoral degree.
4-2. A minimum of 50% of the total program time must be devoted to providing chronic orofacial pain patient
services, including direct patient care, clinical rotations and reporting services.
4-3 Students must actively participate in the collection of history and clinical data, diagnostic assessment,
treatment planning, treatment, and presentation of treatment outcome. 4-3.1. Each student should have about
200 patients assigned to them over the training period.
4-4. The program should include organized teaching experience in orofacial pain, carefully evaluated in relation
to the goals and objectives of the overall program and the interests of the individual student.
4-5 Research experience of a publishable topic should be included that enhances the students’ ability to
interpret and critically analyze scientific literature. A thesis should only be required if the program is articulated
with an advanced degree program, at the discretion of the degree program.
4-6 The overall goals and objectives for advanced education programs in Orofacial Pain must be defined
developed by each Orofacial Pain program, including: 4-6.1 written goals and objective must be developed for
all instruction included in this curriculum, 4-6.2 content outlines must be developed for all didactic portions of
the program, 4-6.2.1 This must include a strong foundation in basic and applied pain science as a prerequisite
for clinical decision making. 4-6.3 students must become proficient in preparing and presenting diagnostic
data, treatment plans, providing treatment, and presenting the results of treatment for chronic orofacial pain,
and associated head and neck pain patients, including their functional rehabilitation. This should be conducted
according to the standards of care expected in Dentistry and Medicine in chronic pain treatment, 4-6.4
experience in interdisciplinary and multidisciplinary models of care.

BIOMEDICAL SCIENCES
4-7 Formal instruction must be provided at the in-depth * level in each of the following: * in-depth - A
thorough knowledge of concepts and theories for the purpose of critical analysis and the synthesis of more
complete understanding. a. Gross and functional anatomy including the musculoskeletal and articular systems
of the orofacial, head, cervical and upper quarter structures, with assessment of common dysfunction and
pathophysiologic effects. b. Functional neuroanatomy of the brain, cervical nerves, and cervical system with a
particular emphasis on pain and common pathophysiological effects. c. Reading of current pain science and
applied pain literature in dental and medical science journals with special emphasis on pain mechanisms,
orofacial pain, head and neck pain, and headache.

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4-8 Formal instruction at the understanding level must be in each of the following areas: Adequate
knowledge with the ability to apply. a. Growth, development, and aging of the masticatory system. b. Muscle,
joint, bone, oral mucosal and other soft tissue pathophysiology and common pathology, with emphasis to pain.
c. Applied rheumatology with emphasis on TM normal and abnormal joint histology, synovial fluid assays,
systemic arthritis affects and serological tests. d. Basic clinical laboratory medicine interpretation. e. Sleep
physiology and dysfunction: f. Oromotor disorders including dystonias, dyskinesias, and bruxism. g. Jaw
movement kinesiology h. Epidemiology of chronic orofacial pain disorders and it’s public health significance. i.
Pharmacology and pharmacotherapeutics j. Principals of biostatistics, research design and methodology,
scientific writing, and critique of literature.

BEHAVIORAL SCIENCES
4-9 Formal instruction at the in-depth level must be provided in behavioral science,
with exposure to psychiatric assessment, as they relate to chronic orofacial pain and chronic pain behavior
including: a. predisposing, initiating, perpetuating or resultant factors. b. study of character disorders and
profiles impacting pain behavior, c. exposure to psychiatric disorders including somatization, factitious pain,
and others d. conducting and applying the results of psychometric tests including standard psychology, pain,
risk assessments, (e.g. Sleep Tests, Pain assessments, Risk Assessments, Oral Habit Index, SF-36,
Diagnostic Criteria for TMD) instruments, and exposure to psychophysiologic tests.

PAIN SCIENCES
4-10 The program must provide a strong foundation of basic and applied pain sciences to develop knowledge
at the in-depth level in the neuroanatomy and neurophysiology of pain through study of:
4-10.1 Neurobiology of pain transmission and pain mechanisms a. nociception, conduction, neurotransmitters
and receptor biology in acute and chronic pain conditions and conditions of neuronal injury. b. the
heterogeneity of the peripheral nervous system and relationship to the second order neuron transmission in
normal function and chronic pain. c. thalamic and cortical projections, and interaction with the reticular and
limbic systems (Biopsychophysiologic models) d. pain faciliatory and inhibitory pathways and systems.
4-10.2 Changes associated with chronic pain a. the neurophysiologic changes in chronic pain; differentiation of
chronic pain from acute pain, in terms of neurotransmitters and receptors; and long term or permanent change
because of neuronal plasticity. (See Appendix for additional chronic pain terminology and concepts).
4-10.3 Pharmacotherapeutic principles related to sites of neuronal receptor specific action in chronic pain.
4-10.4 Organization of the trigeminal and cervical nervous systems a. the nuclear and subnuclear organization
of the trigeminal brainstem complex, and relation to orofacial pain. b. the organization of the CNS dorsal horn
and the trigeminal nucleus analogue, in normal function versus chronic pain and neuropathic change, c.
cervicogenic pain and headache, and interactions between trigeminal and cervical CNS segments.
4-10.5 Chronic pain classification systems.
4-10.6 Psychoneuroimmunology and its relation to chronic pain syndromes.
4-10.7 Primary and secondary headache mechanisms.
4-10.8 Tooth site pain of odontogenic and non-odontogenic origin.
4-10.9 the influence of hormonal cycling on pain threshold and neurovascular pain.
4-10.10 the scientific basis of acupuncture, and stimulation produced analgesia.
4-10.11 the contribution and interpretation of orofacial structural variation (occlusal and skeletal) to orofacial
pain, headache, and dysfunction.

CLINICAL PROGRAM 4-11 The educational program must provide in-depth instruction and clinical training to
the level of proficiency for the clinical assessment and diagnosis of complex orofacial pain disorders. This
includes:
a. Conducting a comprehensive pain history interview.

b. Collect, organize, analyze and interpret data from medical, dental, behavioral, and psychosocial histories
and clinical evaluation to determine their relationship to the patient’s chronic orofacial pain complaints.

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c. Performing clinical examinations and tests, and interpreting the significance of the data; i) Clinical evaluation
may include but is not limited to: 1) musculoskeletal examination of the head, jaw, neck and shoulders, 2) jaw
movement studies; 3) general evaluation of the cervical spine; and 4) TM joint function; 5) odontologic
screening; 6) cranial nerve screening; 7) testing major reflexes; 8) examination of structural variation including
facial-skeletal, and dental-occlusal; 9) oral and dental hard and soft tissues; 10) posture evaluation; 11)
general joint mobility or laxity; 12) general presentation, gait, and demeanor; 13) signs of tension habits, 14)
physical assessment including vital signs. ii) Chairside clinical tests may include but are not limited to: 1)
neurosensory testing, 2) neurosensory, articular and myofascial diagnostic blockade, 3) jaw, muscle and tooth
loading and provocation tests; 4) pulp testing; 5) joint and muscle palpation; 6) spray and stretch responses; 7)
mandibular position maneuvers; 8) challenges to pain abortive medications; as appropriate.

d) Order or refer for additional tests including but not limited to: 1) plane film or advanced imaging of the
orofacial, mandibular and cervical structures; 2) order or refer for brain imaging; 3) psychometric testing, 4)
referral for psychological or psychiatric evaluation; 5) laboratory medicine tests; 6) diagnostic autonomic
nervous system blocks, and systemic anesthetic challenges; 7) pain from dental soft tissue oral disease; 8)
additional consultations and screenings; and interpreting the significance of the data.

e) Establish a multidimensional differential diagnosis and an ordered (prioritized) problem list, using published
guidelines based on inclusion criteria for the following categories of chronic orofacial pain disorders: 1)
neuropathic orofacial pain disorders, 2) neurovascular pain disorders; 3) associated primary headache
disorders; 4) chronic regional pain syndromes (I, II, III); 5) complex masticatory and cervical neuromuscular
and musculoskeletal disorders; 6) local and systemic rheumatologic diseases and injury affecting the
temporomandibular joints, and associated structural problems; 7) pain from chronic temporomandibular
disorders, 8) pain secondary to orofacial cancer and AIDS; 9) orofacial dyskinesias and dystonias, 10) orofacial
sleep disorders, 11) other disorders causing persistent pain and dysfunction of the orofacial structures.

f) Screen for diagnosis, triage, or obtain appropriate consultation for other medical and dental disorders that
could be responsible for chronic orofacial and head and neck pain, including pain from: 1. intracranial disorders
including aneurysm, sentinel headache, exertion headache, cerebral vascular anomaly or constriction,
transient ischemic attacks, neoplasia, edema, intracranial pressure, abscesses and hematomas, and other
secondary headaches, 2. symptomatic trigeminal neuralgia ( intra or extracranial pathologic), acoustic
neuroma, and MS, 3. CNS infections: including bacterial meningitis, 4. associated unexplained sensory or
motor loss or change, 5. complex migraine, 6. otolaryngological disease involving the ears , including sensory
loss, middle, and inner ear (equilibrium and dizziness problems) , nose, throat, salivary glands, oropharynx,
larynx, sinuses, mastoid process, stylohyoid, palate, and related structures, 7. ophthalmologic disease
involving the eye and surrounding structures, including ruling out papilledema and glaucoma, when
appropriate, 8. cervical and upper quarter joints and facets, vertebral artery compression, thoracic outlet
syndrome, brachial plexus compression, or other upper extremity nerve conduction problems, 9. contribution
from behavioral or psychiatric disorders requiring medical treatment, 10. chemical dependency disorders, 11.
intractable headache requiring an in-patient pain protocol, 12. intractable multidimensional chronic pain
requiring a comprehensive multidisciplinary in-patient pain program, 13. When appropriate, screenings should
be requested for medical and psychological problems that contraindicate proposed chronic pain treatment, or
certain pain medications, or that require co-treatment, or pre-treatment.

4-12 The educational program must provide in-depth instruction and clinical training to the level of proficiency
in skills for multi-modality interdisciplinary or multidisciplinary pain management for the chronic orofacial pain
disorder patient. This includes but is not limited to the following experience: 4-12.1 Treatment planning
including:
a. making an assessment of each problem on the diagnostic problem list,
b. construction of a written sequential treatment plan, after presentation to a multidisciplinary forum as needed,
incorporating coordinated behavioral, medical and dental interdisciplinary care as appropriate, and re-
evaluation after segments of treatment,
c. emphasis of reversible or less invasive therapies in the early phases of treatment, deferring potential

103
structural change for reassessment and treatment to when the patient is more asymptomatic,
d. informed consent requirements, e. and establishment of a patient contract with the complex pain patient as
appropriate, emphasizing the patient’s responsibilities, involvement, and contingencies.

4-12.2 Orofacial Pain Treatment including:

a. students must diagnose and treat to a level of proficiency a broad spectrum (outlined in 4-11e) of chronic
orofacial pain patients in a multidisciplinary orofacial pain clinic setting, or interdisciplinary associated services.

b. the students must have primary responsibility for treatment of a wide range of patients with local, regional
and complex multisystem chronic orofacial pain.

c. the students must achieve proficiency in: 1. diagnostic and therapeutic injections including myofascial
trigger point injections, joint injections, intramuscular injections for dystonias, sympathetic nerve blocks for the
orofacial region, trigeminal nerve blocks, other regional blocks referring to the orofacial region, 2. neurosensory
stents for neuropathic pain, and experience with topical pain medications directed at different pain
mechanisms, 3. initial pain management of jaw rheumatologic and chronic orthopedic problems, and
provisional stabilization with or without intra-oral orthotics as appropriate, 4. diagnostic and therapeutic use of
physical medicine procedures including therapeutic exercise, heat and cold packs, vapocoolant spray and
stretch, ultrasound, phonophoresis, iontophoresis, soft tissue massage, joint and muscle mobilization, electrical
stimulation, postural awareness training, strengthening, and establishment of at home exercise regimes, for
orofacial structures and structures referring pain into those regions. Also establishment of a close association
with physical medicine services provided for cervical spine, upper quarter and back problems as they are
related to orofacial pain, 5. intraoral appliances for breathing related sleep disorders, coordinated with ability to
make a diagnosis and measure outcome, 6. management of post-traumatic injury related to chronic orofacial
myoligamentous, arthrogenous, neurovascular and neuropathic pain; and associated chronic head pain and
behavioral disorders; plus provisional non-surgical management of jaw dysfunction and mandibular position
instabilities.

d. the students must achieve competency in associated psychobehavioral therapies including: 1. cognitive-
behavioral therapies including habit reversal for oral habits, sleep problems, muscle tension habits and other
behavioral factors, use of pain and activity diaries for awareness feedback, compliance assurance and
monitoring; and interaction with biofeedback/stress management, and hypnosis for pain relief and behavioral
changes, treatment of secondary gain, and chronic pain behavior, 2. tailoring treatment and medication
approaches to recommendations from psychologic and personality profiles. 3. co-management of chronic
orofacial pain patients who are taking antidepressant, anxiolytic, and other psychotropic medications 4.
management of jaw tension and behavior disorders contributing to chronic orofacial pain.

e. the students must achieve competency in the pharmaco-therapeutic treatment of chronic orofacial pain
disorders. This should include judicious selection of medications directed at the presumed pain mechanisms
involved, as well as adjustment, monitoring and reevaluation. This should also include management of side
effects, adverse reactions, undesired potentiation, dependency or tolerance; protocols for serum level
monitoring and known risk of adverse physiological reactions; and selection in medically and behaviorally
compromised patients, as appropriate. Common chronic pain medications and issues include: 1. muscle
relaxants, 2. sedative agents for chronic pain and sleep management, 3. opioid use in management of chronic
pain, 4. the adjuvant analgesic use of tricyclics and SSRI antidepressants for chronic pain; and awareness of
the utility and problems with MAO inhibitors in pain and headache, 5. anticonvulsants, membrane stabilizers,
and sodium channel blockers for neuropathic pain, 6. anxiolytics, 7. analgesics and anti-inflammatories, 8.
prophylactic and abortive medications for primary headache disorders (in-patient and out-patient protocols),
including serotonergic and anti-serotonergic medications, 9. management of analgesic rebound pain, 10.
medication side effects that alter sleep architecture, 11. in-patient and outpatient methods for prescription
medication dependency withdrawal, 12. referral, and co-management (of pain) in patients addicted to
prescription, non-prescription and recreational drugs, 13. local and systemic anesthetics in management of
neuropathic pain; and familiarity with the role of preemptive anesthesia in neuropathic pain, 14. role of

104
neuroleptics in headache management, 15. topical and systemic use of NMDA inhibitors, 16. GABA and
dopaminergic medications used in chronic pain, 17. role of alpha adrenergic medications in sympathetically
mediated pain, 18. therapeutic use of use of Botulinum toxin injections.

f. Emergency Services requirements include: 1) emergency coverage for clinic patients of record, 2) on-call
availability to the interdisciplinary team, 3) successful completion of a basic CPR and emergency medicine
course at commencement of training, 4) identification of emergency medical, and psychiatric referral sites.

4-12.3 Students must have an in-depth understanding and competency in the professional and medical legal
issues in chronic Orofacial Pain practice:
a. Patient records and documentation should include: 1) maintenance of a problem oriented style medical
record including a diagnostic problem list and SOAP progress notes format, and medication log; 2)
measurement of patient outcome e.g. using progress sheets, repeat questionnaires, reexamination, and pain
diaries.
b. Students should demonstrate skills in verbal and timely written communication with other health care
professionals and patients. c. Students should understand the requirements of medicolegal, Workers
Compensation, and second opinion reporting; and understand the criteria for assessing impairment and
disability.
d. Students should understand the legal guidelines governing licensure and dental practice, and the scope of
practice with regards to orofacial pain disorders.
e. Students should receive instruction in the regulatory requirements of chronic opioid maintenance.

4-13 Credentialing preparation should include:

a. student feedback on progress, and encouragement to take the written Part I of the ADA recognized
credentialing Orofacial Pain Board on graduation;
b. students should maintain a log of all clinical cases for which they had major responsibility
c. students should extensively document and present a selection of 20 cases as a future teaching resource,
and as a model for submission of their own cases post-graduation to Part II of the Orofacial Pain Board
examination.

DENTAL DEPARTMENT, HOSPITAL AND ADJUNCTIVE EXPERIENCES

4-14 The educational program should provide clinical assistance to other dental and medical disciplines, and
where needed be a helpful part of the treatment team.
a. Orofacial Pain programs should provide pain support services to Oral and Maxillofacial Surgery for the
chronic rehabilitation of TMJ and fifth nerve surgery cases if requested, and consultation pre- and post-
treatment for Orthodontics, Prosthodontics or other disciplines along with co-treatment if requested. Diagnostic
and treatment assistance can be provided for tooth-site pain of nonodontogenic origin and for complex pain
and dysfunction issues if requested. The Orofacial Pain program will refer treated orofacial pain patients to the
appropriate dental and surgical disciplines as needed when stabilized.

4-15 The educational program should provide clinical training to the level of exposure to other medical and
dental services (not to exceed 10 percent of total training period):
a. hold combined rounds with other dental specialties where possible; and attend and participate in selective
medical rounds.
b. observation of closed and open TMJ surgery
c. attend an outpatient anesthesiology pain service, and an in-patient pain program rotation
d. observation or participation in selective rheumatology, neurology, oncology clinics, with other electives at the
discretion of the program chair e. an oral medicine rotation,
f. visitation to hospital pharmacy, radiology departments, and dental laboratory providing support functions.
g. be exposed to several models of pain management treatment, practices, and centers.

TEACHING. 4-16 Students should be encouraged to obtain teaching experience in orofacial pain, in small
group, and lecture formats, presenting to their dental and medical peer groups, pre-doctoral students, and

105
continuing education opportunities. However, this experience must not compromise the didactic or clinical

Sample of Curricula currently used

Provide a representative sample of curricula currently used in several existing programs. The
examples provided should reflect the various approaches for structuring advanced education in the
proposed specialty.

Sample curricula from institutions presently training Orofacial Pain dentists are provided here from the Schools
of Dentistry from University of California, Los Angeles, Rutgers University, and University of Minnesota.

I. UCLA Orofacial Pain Advanced Education Program Residency Program

All course hours are based on a 48 week per year unless otherwise noted, conducted over a 24-month period.
Vacations are on a sliding schedule to maintain clinical coverage. Paid vacation period for UCLA Hospital
Residents is 3 weeks per year, plus administrative holidays provided that one resident remains on call. Faculty
are second on call. Residents are on call to the hospital during the day-time and must respond. A record must
be kept and filed in the OFP program Clinic office of all external and hospital calls taken. On-call residents
must be within 15 minutes travel time to the hospital. You are required to maintain an up-to-date listing of the
courses you are taking for each quarter with the Section secretary in order to receive a course completion or
grades. Course are expected to be taken for credit unless an exception is made for auditing. If you have
already taken a course as a previous UCLA student you should still audit the course. Advanced credit for
courses can only be given with agreement of the course director, or by a pretest if available. Taking Oral
Biology courses in anticipation of enrollment in the Oral Biology MS program cannot be instead of the
residency requirements. The residency program courses are required courses unless stated as Selectives or
Electives.

UCLA OROFACIAL PAIN Curriculum (2019)

1. Clinic Rounds
Schedule: Monday, Wednesday and Friday 7:30-9:00 (120 hours per clinic year)
Course Description: Clinic Rounds are held every Monday and Friday prior to the clinic day. Patients
scheduled for the day are discussed by the resident before the attending faculty. Diagnosis, treatment
protocols and progress of each patient are discussed. The residents keep notes and directions in the patient
chart to help them optimize patient response to treatment.
2. Introduction to TMJ Disorders
Schedule: Summer Quarter as part of the New Resident Orientation. (4 hours divided in 2 session during 1 st
year Summer Quarter)
Course Description: This 2 session 4 hour course reviews TMJ disorders and the examination process. The
new residents learn how to relate the clinical signs and symptoms to the pathophysiology of TMJ disorders and
how to perform a clinical examination of stomatognathic function and muscle system relative to the
temporomandibular joint.
3. Basic Neurology/Neuroanatomy
Schedule: 1st Year Summer Quarter (2 Hours on 4 consecutive Fridays, total 8 hours)
Course Description: The basic neurological examination is taught with emphasis on the cranial nerves. The
cranial nerve exam is related to neuroanatomy of the head and neck. The residents learn how to efficiently
perform the neurological examination including fundoscopy, neurosensory, motor and reflex evaluations.
4. Introduction to Orofacial Pain
Schedule: 1st year Summer Quarter (2 hours per session on 2 consecutive Tuesday mornings)
Course Description: This summer introductory course covers the basic conditions included within the scope of
orofacial Pain. The course reviews musculoskeletal, neuropathic, neurovascular and related neurologic
disorders commonly seen in an orofacial pain clinic. The pathophysiology of these conditions is discussed
and linked with the examination procedure required to form a differential diagnosis and focus on a primary
diagnosis.
5. Introduction to Pain Psychology
Schedule: 1st year Summer Quarter (4 hours in 2 sessions)

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Course Description: The OFP residents are introduced to the impact that chronic pain has on the individual.
Psychological assessment instruments are reviewed and related to patient presentations and response to
treatment.
6. History Taking, Charting and The OFP Examination
Schedule: 1st year Summer Quarter (1 Hour)
Course Description: The OFP Chief Resident introduces the UCLA Chart and teaches the new resident the
charting system including the History, Stomatognathic , Myofascial and Neurologic exam forms, the Progress
Notes, the Pain Diary, the Treatment Contract, the Informed Consent forms, the patient handouts for the
myofascial program and how to complete the forms.
7. Introduction to Myofascial Pain
Schedule: 1st year Fall Quarter (6 hours)
Course Description: The OFP resident is introduced to myofascial pain, including a review of the literature, the
myofascial examination and the treatment protocols, including muscle palpation, trigger point referrals, spray
and stretch and trigger point injections. The theory of the pathophysiology of myofascial pain is introduced. In
addition, clinic experience with assigned patients is monitored by the course director. Each muscle group in
the orofacial, cervical and shoulder girdle is review in detail including insertion, attachments, innervations and
referral patterns.
8. Introduction to Pain Pharmacology
Schedule: 1st year Summer or Fall Quarter (2 hours)
Course Description: The 1st year residents are introduced to the medications that are used to mediate chronic
pain disorders. These medication include the medications for neurovascular disorders, medication for
neuropathic pain disorders, medications for musculoskeletal pain and psychotropic medications that are used
for adjunctive therapy to improve response to pain management.
9. DS300 (TMJ Disorders)
Schedule: 1st Year Summer Quarter, Thursdays 5:30 to 6:30 (7 hours)
Course Description: DS300 Summer course reviews TMJ disorders in detail. Each component of TMJ
disorders is discussed, including Muscle pain disorders, TM joint anatomy, displaced discs with and without
reduction and the arthritides. The examination, pathophysiology and treatment of each TMJ disorder is
discussed, including physical and pharmacologic therapy. This course also is attended by residents in other
UCLA/ VA residency programs.
10. Oral Medicine Clinic Rotation
Schedule: 1st Year Summer and Fall Quarter Wednesday Morning 9-12 (16 hours)
Course Description: Each resident rotates into the Oral Medicine Clinic on Wednesday Mornings for the
Summer and Fall quarters of the 1st year. The resident shadows the oral medicine clinicians, observing the
examination and evaluation of oral lesions, burning mouth syndromes and other pathological conditions seen
in the oral environment. The residents also assist in obtaining biopsies, closing wounds and other oral
medicine procedures.
11. Basic Neuroanatomy of the Orofacial Region
Schedule: 1st Year Summer and Fall Quarters. Tuesday Mornings 10-12. (40 Hours)
Course Description: A detailed review of neuroanatomy. This course uses Blumenfeld’s Neuroanatomy
through Clinical Cases as the text and reviews each of the cranial nerve in terms of the neuroanatomy and
clinical cases illustrating disorders involving the nerves. The neurologic exam is also reviewed for each of the
nerves and the relevant pain and dysfunction problems seen in an orofacial pain practice.
12. Medical Emergencies
Schedule: 1st year Summer Quarter. 6 hours per week for 8 weeks.
Course Description:
13. Sedation
Schedule: 1st Year Summer Quarter. 2 hours per week for 7 weeks.
Course Description: Principles of Sedation
14. Hospital Dentistry
Schedule: 1st Year Summer Quarter. 5 consecutive days, 8 hour/day.
Course Description: The general objectives of the program are to (1) provide residents with the necessary
didactic and clinical experiences that will enable them to provide state-of-the-art comprehensive dental care to

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the broadest possible spectrum of the population; (2) provide advanced training in hospital and operating room
procedures, including admission procedures, history and physical evaluation, laboratory evaluation,
consultations, emergency care, pre- and post-operative care, and inpatient and outpatient surgery; (3) enhance
the graduate’s ability to make sound clinical judgment; (4) provide dental services for segments of the
population which are currently underserved, including medically compromised, mentally and physically
challenged, pediatric, adult, and geriatric individuals; (5) provide training in quality assurance protocols and risk
management techniques; (6) enhance the understanding of and provide experience in practice administration,
including communication and management skills; (7) develop the graduate’s ability to critically review the
literature; and (8) enhance the graduate’s diagnostic and treatment planning skills.
15. Physical Diagnosis
Schedule: 1st Year Summer Quarter. 12 Day 3 hours per day.
Course Description: Physical Assessment
16. Literature Review
Schedule: 2 year 4 Quarters per year, 2 hours per week.
Course Description: The residents and faculty director review journal articles on subjects related to orofacial
pain taken from peer reviewed journals. The subject matter includes Headache Disorders, Neurologic
disorders, Sleep disorders, Orofacial Pain disorders. Residents are assigned to read the articles and prepare
reviews of the articles that are presented in a class format.
17. Radiology
Schedule: 1st year 4 Quarters, 3 hours per week.
Course Description: The residents rotate in Dental Radiology to review radiographs of patients referred to the
Radiology Clinic. They spend time assessing CT’s for both dental and TMJ problems. Additionally, time is
spent evaluating airway problems associated with obstructive sleep disordered breathing.
18. Rotation and Shadowing in UCLA OFP Private Practice
Schedule: 2 years, 6 hours per week.
Course Description: Residents shadow in the orofacial pain faculty practice, participating in the evaluation and
treatment of the private patients. Residents do intakes of the patients, prepare patients for procedures, give
patient instructions for home care. This rotation increases the residents’ experience in evaluation, diagnosing
and treating orofacial pain patients.
19. Rotation and Shadowing in Cedar Sinai Pain Center
Schedule: 6 consecutive weeks in the second year of residency. 1 day per week.
Course Description: Residents shadow in the orofacial pain faculty practice, participating in the evaluation and
treatment of the private patients. Residents do intakes of the patients, prepare patients for procedures, give
patient instructions for home care. This rotation increases the residents’ experience in evaluation, diagnosing
and treating orofacial pain patients.
20. Rotation and Shadowing Neurology in Neurology Headache Fellowship Program.
Schedule: TBA
Course Description: Rotation and Shadowing in the Neurology Headache Clinic
21: Dental Sleep Medicine
Schedule: Starts in Fall Quarter. 5 months, 2 full days per month
Course Description: The course provides in depth lectures in all phases of sleep medicine and provides hands-
on training in all clinical phases of dental sleep medicine including reading and interpreting the PSG study, the
comprehensive medical examination, nasal and oropharyngeal airway assessment, pharyngometry, pulse
oximetry, impression and bite registration, selection and delivery of a variety of dental sleep appliances and
adjustment and optimization of the appliances.
22: Neuroscience of Pain
Schedule: 1st Year: Fall, Winter and Spring Quarters. ! hour per week
Course Description: The neuroscience of pain is reviewed in this course, starting with a description of the
sensory system, a review of the neuroanatomy of the head and neck, peripheral mechanisms of pain
perception, the neurotransmitters and receptors involved in transduction of pain from the periphery, peripheral
sensitization, central sensitization, and Complex Regional Pain syndromes. Papers are assigned to the
residents who will develop powerpoint presentations to discuss the main points of the papers.
23: Occlusion and TMD

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Schedule: 1st Year, Fall Quarter. Monday Evening 4:30-5:30. (2 Hours)
Course Description: In this 2 h our course, the concepts and relationships of occlusion and TMD will be
reviewed. Literature assignments are given to the residents who will review and critique the papers with the
course director.
24: History of Pain
Schedule: 1st Year Fall Quarter (4 Hours)
Course Description: The instructor discusses the history of pain from prehistory to present day. The residents
are taught the concepts of pain in relationship to time and culture with key figures who contributed to the
development and understanding of pain and its treatment through the ages.
25: Pharmacotherapy of Pain
Schedule: 1st Year Fall Quarter (6 hours)
Course Description: This course reviews medications used to treat all aspects of orofacial pain, including the
CYP450 metabolism and excretion of the medications. An in depth review is made of medications used to
treat musculoskeletal disorders, headache disorders and neuropathic pain.
26: Neuropathic Pain Disorders: Diagnosis and Treatment
Schedule: 1st Year Fall Quarter (6 hours)
Course Description: Classification, Diagnosis and Treatment of Head and Neck Neuropathic Pain

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II. Rutgers School of Dental Medicine Program in Orofacial Pain

Orofacial Pain Dentistry is concerned with the prevention, evaluation, diagnosis, and management of persistent
and recurrent orofacial pain disorders. This two year program is designed to provide advanced knowledge and
skills beyond those of the standard curriculum leading to the DDS or DMD degrees.

RSDM requires that the competent orofacial pain dentist demonstrate knowledge, diagnostic skills, and
treatment expertise in areas, such as musculoskeletal, neurovascular, and neuropathic pain syndromes; sleep
disorders related to orofacial pain; orofacial movement disorders; and intraoral, intracranial, extracranial, and
systemic disorders that cause orofacial pain or dysfunction. The orofacial pain dentist is responsible to
understand pain mechanisms and for the diagnosis and treatment of patients in pain that is often chronic,
multifactorial, and complex. It is the responsibility of the orofacial pain dentist to accurately diagnose the
cause(s) of the pain and decide if treatment should be dentally, medically, or psychologically oriented, or if
optimal management requires a combination of all three treatment approaches. Management may consist of a
number of interdisciplinary modalities including, e.g., physical medicine, behavioral medicine, and
pharmacology or, in rare instances, surgical interventions. Among the essential armamentarium is the
knowledge and proper use of pharmacologic agents.

Students pursue a Master of Science in Dentistry or a Master of Dental Science as their degree.
Although 50% of the program is dedicated to patient care, the Master of Science in Dentistry program is also
designed to train students for a career in academic dentistry or for those who wish to focus on research. To
accomplish this objective, each student completes a thirty-credit program comprising eighteen didactic credits
and a twelve-credit thesis/research project.

The Master of Dental Science program is designed to give students a more in-depth understanding of the
biological processes underlying their clinical specialty. The program stresses interpretation of the
literature. The objective of the program is to enable the students to become critical thinkers and evaluators of
best practices in dentistry or for those who may desire a career in research. To accomplish these objectives,
each student must complete thirty credits of the didactic, clinical and research-based program.

Upon completion of the program, the postdoctoral student receives the Master of Dental Science or Master of
Science in Dentistry degree and meets eligibility requirements for the American Academy of Orofacial Pain
Board examination.

Curriculum
The CORE Curriculum is designed to provide a broad foundation in the Biomedical Sciences upon which
training in specialized dental disciplines is based. The PGY1 CORE course is Foundations of Oral Biology,
which consists of the following modules:
 Professional Ethics
 Clinical Photography
 Research Design and Data Analysis
 Microbiology and Immunology
 Gross Anatomy
 Histology and Pathobiology

The PGY2 CORE course is Advanced Biomedical Science in Dentistry, which consists of the following
modules:
 Orofacial Pain
 Oral Medicine & Pathology
 Advanced Dental Therapeutics and Pharmacology
 Embryology and Genetics
 Behavioral and Social Science in Dentistry

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These courses are taught in an interdisciplinary format to residents in RSDM’s Advanced Specialty Education
programs in Endodontics, Pediatric Dentistry, Periodontics, and Prosthodontics, as well as residents in the
Advanced General Dentistry Education program in Orofacial Pain and students in RSDM’s Masters programs.
This didactic instruction occurs in a weekly two-hour seminar.

The curriculum is comprised of didactic assignments, clinical experience, medical and dental rotations, and
teaching responsibilities. Different types of learning experiences include seminars, lectures, workshops, and
self-study activities. Each post graduate student is required to complete a series of courses and rotations
designed to provide the necessary scientific background for management of patients with orofacial pain.
An important part of the program is clinical experience that continues across the entire program commencing in
the first quarter. The clinical component of the program will comprise 50% of the student's time.
The faculty will assess competence in the field of orofacial pain on a regular basis. Knowledge of basic
sciences and material presented in didactic lectures will be assessed by a series of written examinations at the
end of the program.

OFP 701: SEMINARS IN OROFACIAL PAIN (60 HOURS): This seminar series focuses primarily on the
diagnosis and management of temporomandibular disorders, musculoskeletal disorders of the head and neck,
neurovascular disorders, and neuropathic pain disorders.

OFP 702: CLINICAL MANAGEMENT OF OROFACIAL PAIN: This provides the post graduate student with
clinical experience in the diagnosis and management of patients referred to the Orofacial Pain Center. As the
post graduate student progresses, he/she will obtain patient histories, perform examinations, and manage
patients using various modalities. All clinical activities are under the direct supervision of the faculty. Clinical
activity comprises 50% of the Program.

OFP 703: OROFACIAL PAIN LITERATURE REVIEW (JOURNAL CLUB): This seminar consists of an
overview of the current scientific literature relating to the fundamental of pain and pain management as well as
orofacial pain. Each post graduate student will be responsible for a specific reading assignment and will lead
the seminar. An informal seminar setting is used to encourage stimulating discussion from all the participants.
This seminar will be held monthly.

OFP 704: OROFACIAL PAIN GRAND ROUNDS: All new and ongoing patients seen in the clinic are presented
by the post graduate student in an open discussion with the faculty. Emphasis is on diagnosis and
management strategies with all clinical decisions validated and supported by the scientific literature. In
addition, monthly Grand Rounds are held with the New Jersey Neuroscience Institute of Rutgers School of
Medicine where our residents interact with and present case to neurologists, neurosurgeons and their
residents regarding orofacial pain.

OM 801 ORAL MEDICINE GRAND ROUNDS: New and ongoing patients being treated in the Oral Medicine
Clinic for a condition other than an orofacial pain problem are presented and discussed in an open forum. This
conference meets every week.

OM 806: ORAL-MAXILLOFACIAL RADIOLOGY AND ADVANCED IMAGING: In addition to topics discussed in

the Dent 5010 and 5020 courses, the post graduate student will spend time in the Radiology Clinic at the
dental school to become familiar with more sophisticated imaging techniques, their indication/selection and
interpretation.

INDEPENDENT STUDY: Post graduate students have approximately 6 hours per week protected for library
work and independent study.

Interdisciplinary Courses
OFP 706: EXTRAMURAL ROTATIONS: Post graduate students are assigned to various clinical rotations to
gain exposure in various specialized areas including TMJ surgery, Otolaryngology, Physical Medicine and

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Rehabilitation, Neurology, Headache Management and Rheumatology.

Scholarly Activity. Orofacial pain post graduate students are required to prepare case presentations or lectures
on various orofacial pain topics either of their choosing or by assignment from the faculty. Their presentations
are given to the Division of Orofacial Pain faculty and students. Each postgraduate student is expected to
present 3-4-hour presentations per year. This does not include the Masters’ thesis defense.
In addition, as this program culminates in the awarding of a Master’s Degree, each post graduate student must
defend his or her thesis in a public forum by presenting their data in a lecture format. Post graduate students
are also required to complete a paper of publishable quality for submission to a refereed scientific journal on a
topic to be mutually determined by the student and program director.

III. UNIVERSITY OF MINNESOTA SCHOOL OF DENTISTRY OROFACIAL PAIN ADVANCED

EDUCATION PROGRAM COURSE REQUIREMENTS

Course Sequence
During the first summer of graduate study, the academic program in Orofacial Pain focuses on several areas:
acquisition of solid research skills, introduction to anatomy of the head and neck, physical evaluation, and
overview of the theory and principles of orofacial pain. The didactic coursework is as follows:
 Head and Neck Anatomy
 Physical Diagnosis and Evaluation
 Seminars in Orofacial Pain
 Principles of Research in Orofacial Pain (Current Literature)
 Orofacial Pain Clinic

During the following semesters, students take more in-depth courses related to orofacial pain, as well as
continue with additional coursework in related areas. They continue to work in literature review and orofacial
pain seminars in each semester and will take thesis credits.
 Seminars in Orofacial Pain
 Current Literature in TMJ and Orofacial Pain
 Advanced Orofacial Pain Clinic
 Thesis credits

Orofacial Pain courses include:

 TMD Miniresidency (3-day CE course offered to general dentists)
 Clinical Interviewing (Year 1)
 Methods in Research and Writing (Fall, Year 1)
 Teaching and Evaluation in Dentistry (Spring, Year 1)
 Psychological Issues in Orofacial Pain (Fall, Year 1)
 Neurobiology of Pain and Analgesia (every two years)
 Advanced Topics in Orofacial Pain (Spring, every two years)
 Biostatistics (Summer Year 2)
 Principles of Management in Health Services Organizations (Fall Year 2)

All students will be attending the Orofacial Pain Clinic during each semester of both two years. Rotations
through other clinics are arranged during the summer and fall of the second year of study and are part of the
clinic course in Orofacial Pain.

The clinic course is a major course for all students. Students spend 4 full days per week in the clinic. They
mostly observe patients and faculty members during the first summer. During this time they work on clinical
interviewing skill acquisition, head and neck examination skills, gaining solid diagnostic skills. They will also
begin to work with splints (insertion and adjustment), physical medicine techniques, health psychology and
pharmacotherapy.

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In the fall of the first year, students will begin seeing their own patients, supervised by faculty. At this time, they
must begin keeping track of patients seen and procedures performed in order to acquire the number and types
of experiences necessary to meet program standards.

Clinical training within Orofacial Pain Clinic

The knowledge base for all residents includes diagnosis and management of:
 Neuropathic orofacial pain disorders such as trigeminal neuralgia, atypical facial pain and burning
mouth syndrome,
 Primary headache disorders such as tension type and migraine headaches,
 Other neurovascular disorders such as cluster headache, hemicranias continua and medication
overuse headache,
 Chronic regional pain syndromes (I and II),
 Masticatory, cervical, and upper shoulder neuromuscular and musculoskeletal disorders such as
myofascial pain, muscle spasm, and contracture,
 Temporomandibular joint disorders such as arthralgia, disk displacement and arthritis,
 Pain and dysfunction secondary to orofacial trauma, cancer and AIDS and it’s treatment,
 Orofacial dyskinesias and dystonias,
 Sleep disordered breathing such as obstructive sleep apnea, UARS and snoring,
 Other disorders causing persistent pain and dysfunction of the orofacial region

Services provided include:

 Complete clinical history
 Complete head and neck examination
 Imaging and laboratory technique and interpretation
 Differential diagnosis of orofacial pain disorders
 Behavioral and psychosocial assessment and diagnosis
 Interdisciplinary treatment planning
 Diagnostic and treatment procedures including:
a. craniofacial nerve blocks
b. intramuscular trigger point injections in the masticatory, head and neck muscles
c. physical medicine modalities, therapeutic exercises, and orthotics
d. cognitive-behavioral management strategies,
e. pharmacotherapy and chemical abuse management
f. coordination of interdisciplinary and multidisciplinary management strategies

Extramural Rotations
Second-year residents spend part of their clinical training in extramural facilities completing rotations. The
following is a list of rotations for the Orofacial Pain Residents:
 Otolaryngology
 Rheumatology
 Chronic Pain Service, Neurology and Acupuncture
 Sleep Medicine
 Physical Medicine and Rehabilitation
 Neurology
 Oral and Maxillofacial Surgery
 Movement Disorder Clinic

Research
All students are required to engage in research activity. Students who elect to enter the Master of Science
Degree Program are expected to develop the study idea, work through the data collection and/or analyses,
present their findings at a public defense, and submit for publication in an appropriate scientific journal.
They are also required to develop and complete an independent research project under the guidance of a
thesis committee approved by the University of Minnesota Graduate School. Students not participating in a

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Graduate School administered degree program are required to either complete their own research project, or
participate in research being conducted be the Orofacial Pain Faculty. Students are also encouraged to
develop abstracts for presentation at local, state and national meetings.
This portion of the program gives the student:
 A strong foundation in science and analysis
 Competency in critique of the written literature in the field of TMD and orofacial pain
 Competency in research design, methodology and scientific writing

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References to Orofacial Pain Specialty Application (References to treatments are in Appendix IVc)

1. Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education,
and Research. National Academies Press, Washington, DC; June 29, 2011.
2. National Pain Strategy at http://iprcc.nih.gov/docs/DraftHHSNationalPainStrategy.pdf. Accessed on January
10, 2019 and CDC. Opioid overdose: Prescription opioids. Vol 2017. Atlanta, GA: Centers for Disease Control
and Prevention.
3. U.S. Department of Health and Human Services (2019, May). Pain Management Best Practices Inter-
Agency Task Force Report: Updates, Gaps, Inconsistencies, and Recommendations. Retrieved from U. S.
Department of Health and Human Services website: https://www.hhs.gov/ash/advisory-
committees/pain/reports/index.htm
4. Roper Starch Worldwide, Inc., "Chronic Pain In America: Roadblocks To Relief," research conducted for the
American Pain Society, the American Academy of Pain Medicine and Janssen Pharmaceutica, Jan. 1999
5. Lipton, J.A., J.A. Ship, and D. Larach-Robinson, Estimated prevalence and distribution of
reported orofacial pain in the United States. Journal of the American Dental Association, 1993.
124(10): p. 115-21.
6. de Leeuw, R (ed), Orofacial Pain: Guidelines for Assessment, Diagnosis, and Management.
(4th Edition, Quintessence Publishing Company, Chicago, Ill., 2018
7. Fricton, J.R., et al., Myofascial pain syndrome of the head and neck: a review of clinical
characteristics of 164 patients. Oral Surgery, Oral Medicine, Oral Pathology, 1985. 60(6)
8. Schiffman, E.L., et al., The prevalence and treatment needs of subjects with
temporomandibular disorders. Journal of the American Dental Association, 1990. 120(3): p.
295-303.
9. Rugh, J.D. and W.K. Solberg, Oral health status in the United States: temporomandibular
disorders. Journal of Dental Education, 1985. 49(6): p. 398-406.
10. Solberg, W.K., M.W. Woo, and J.B. Houston, Prevalence of mandibular dysfunction in
young adults. Journal of the American Dental Association, 1979. 98(1): p. 25-34.
11. Von Korff, M., et al., Epidemiology of Temporomandibular Disorders: TMD Pain
Compared to Other Common Pain Sites. Pain, 1987. 4(supp): p. S123.
12. Taylor, H. and N.M. Curran, The Nuprin Pain Report. 1985, Louis Harris and Associates:
New York.
13. Agerberg, G. and G.E. Carlsson, Symptoms of functional disturbances of the masticatory
system. A comparison of frequencies in a population sample and in a group of patients. Acta
Odontologica Scandinavica, 1975. 33(4): p. 183-90.
14. Ingervall, B., B. Mohlin, and B. Thilander, Prevalence of symptoms of functional
disturbances of the masticatory system in Swedish men. Journal of Oral Rehabilitation, 1980.
7(3): p. 185-97.
15. Grosfeld, O., M. Jackowska, and B. Czarnecka, Results of epidemiological examinations of
the temporomandibular joint in adolescents and young adults. Journal of Oral Rehabilitation,
1985. 12(2): p. 95-105.
16. Von Korff, M., et al., An epidemiologic comparison of pain complaints. Pain, 1988. 32(2):
p. 173-83.
17. VanDenKerkhof EG, Mann EG, Torrance N, Smith BH, Johnson A, Gilron I. An Epidemiological Study of
Neuropathic Pain Symptoms in Canadian Adults. Pain Res Manag. 2016;2016:9815750.
doi:10.1155/2016/9815750
17. Magnusson, T., I. Egermark-Eriksson, and G.E. Carlsson, Four-year longitudinal study of
mandibular dysfunction in children. Community Dentistry & Oral Epidemiology, 1985. 13(2): p.
117-20.
18. Magnusson, T., Five-year longitudinal study of signs and symptoms of mandibular
dysfunction in adolescents. Cranio, 1986. 4(4): p. 338-44.
19. Magnusson, T., G.E. Carlsson, and I. Egermark-Eriksson, An evaluation of the need and
demand for treatment of craniomandibular disorders in a young Swedish population. Journal of
Craniomandibular Disorders, 1991. 5(1): p. 57-63.

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20. Gordon, M. and E. Newbrun, Comparison of trends in the prevalence of caries and
restorations in young adult populations of several countries. Community Dentistry & Oral
Epidemiology, 1986. 14(2): p. 104-9.
21. WHO, S.G., Epidemiology, etiology and prevention of periodontal diseases, 1978, World
Health Organization: Geneva.
22. Locker, D. and M. Grushka, The impact of dental and facial pain. Journal of Dental
Research, 1987. 66(9): p. 1414-7.
23. Wedel, A. and G.E. Carlsson, Sick-leave in patients with functional disturbances of the
masticatory system. Swedish Dental Journal, 1987. 11(1-2): p. 53-9.
24. Donaldson, D. and R. Kroening, Recognition and treatment of patients with chronic
orofacial pain. Journal of the American Dental Association, 1979. 99(6): p. 961-6.
25. Fricton, J.R., Behavioral and psychosocial factors in chronic craniofacial pain. Anesthesia
Progress, 1985. 32(1): p. 7-12.
26. Rugh, J.D. and W.K. Solberg, Psychological implications in temporomandibular pain and
dysfunction. (Review). Oral Sciences Reviews, 1976. 7: p. 3-30.
27. Greene, C.S., R.E. Olson, and D.M. Laskin, Psychological factors in the etiology,
progression, and treatment of MPD syndrome. Journal of the American Dental Association,
1982. 105(3): p. 443-8.
28. Fordyce, W.E., A.H. Roberts, and R.A.J. Sternbach, The behavioral management of
chronic pain: a response to critics. Pain, 1985. 22(2): p. 113-25.
29. Roberts, A.H. and L. Reinhardt, The behavioral management of chronic pain: long-term
follow-up with comparison groups. Pain, 1980. 8(2): p. 151-62.
30. Fricton, J.R., K.M. Hathaway, and C. Bromaghim, Interdisciplinary management of
patients with TMJ and craniofacial pain: characteristics and outcome. Journal of
Craniomandibular Disorders, 1987. 1(2): p. 115-22.
31. Curriculum guidelines for the development of continuing education programs
in temporomandibular disorders and orofacial pain. Journal of Dental Education, 1992. 56(9)
32. Curriculum guidelines for the development of pre-doctoral and post-doctoral programs in
temporomandibular disorders and orofacial pain. Journal of Dental Education, 1992. 56(9): p.
650-8.
33. Dubner, R., B.J. Sessle, and A.T. Storey, The neural basis of oral and facial function.
1978, New York: Plenum Press.
34. Sessle, B.J., The neurobiology of facial and dental pain: present knowledge, future
directions. (Review). Journal of Dental Research, 1987. 66(5): p. 962-81.
35. Fricton, J.R., Recent advances in temporomandibular disorders and orofacial pain (see
comments). (Review). Journal of the American Dental Association, 1991. 122(11): p. 24-32.
36. Sessle, B.J., P.S. Bryant, and R.A. Dionne, eds. Temporomandibular disorders and related
pain conditions. Progress in pain research and management. Vol. 4. 1995, IASP Press: Seattle.
492.
37. Griffiths, R.H., Report of the president's conference on the examination, diagnosis, and
managment of temporomandibular disorders. JADA, 1983. 106(1): p. 75-77.
38. Helkimo, M., Studies on function and dysfunction of the masticatory system. 3. Analyses of
anamnestic and clinical recordings of dysfunction with the aid of indices. Svensk
Tandlakaretidskrift, 1974. 67(3): p. 165-81.
39. Helkimo, M., Studies on function and dysfunction of the masticatory system. II. Index for
anamnestic and clinical dysfunction and occlusal state. Svensk Tandlakaretidskrift, 1974. 67(2):
p. 101-21.
40. Dworkin, S.F., et al., Research diagnostic criteria, Part II, Axis I: Clinical TMD
Conditions(Review). Journal of Craniomandibular Disorders, 1992. 6(4): p. 327-30.
41. Dworkin, S.F., et al., Research diagnostic criteria, Part II, Axis II: Pain-Related Disability
and Psychological Status(Review). Journal of Craniomandibular Disorders, 1992. 6(4): p. 330-
34.
42. Dworkin, S.F., et al., Research diagnostic criteria, Part III: Examination and History Data

116
Collection(Review). Journal of Craniomandibular Disorders, 1992. 6(4): p. 335-45.
43. Fricton, J.R., Minnesota mandates medical coverage for TMD (editorial). Cranio, 1991.
9(1): p. 1-3.
44. Dubner, R., R.L. Hayes, and D.S. Hoffman, Neural and behavioral correlates of pain in the
trigeminal system. Research Publications - Association for Research in Nervous & Mental
Disease, 1980. 58: p. 63-72.
45. Dubner, R. and G.J. Bennett, Spinal and trigeminal mechanisms of nociception. (Review).
Annual Review of Neuroscience, 1983. 6: p. 381-418.
46. Hokfelt, T., et al., Immunohistochemical analysis of peptide pathways possibly related to
pain and analgesia: enkephalin and substance P. Proceedings of the National Academy of
Sciences of the United States of America, 1977. 74(7): p. 3081-5.
47. Hargreaves, K.M., E.S. Troullos, and R.A. Dionne, Pharmacologic rationale for the
treatment of acute pain. (Review). Dental Clinics of North America, 1987. 31(4): p. 675-94.
48. Cooper, S.A., New peripherally-acting oral analgesic agents. (Review). Annual Review of
Pharmacology & Toxicology, 1983. 23: p. 617-47.
49. Stewart, J.M., et al., Substance P and analgesia. Nature, 1976. 262(5571): p. 784-5.
50. Basbaum, A.I. and H.L. Fields, Endogenous pain control systems: brainstem spinal
pathways and endorphin circuitry. (Review). Annual Review of Neuroscience, 1984. 7: p. 309-
38.
51. Malmberg, A.B. and T.L. Yaksh, Spinal nitric oxide synthesis inhibition blocks NMDAinduced
thermal hyperalgesia and produces antinociception in the formalin test in rats. Pain,
1993. 54(3): p. 291-300.
52. Wilcox, G.L., Spinal Mediators of Nociceptive Neurotransmission and Hyperalgesia. APS
Journal, 1993. 2(4): p. 265-75.
53. Ferrari, M.D., et al., Neuroexcitatory plasma amino acids are elevated in migraine.
Neurology, 1990. 40(10): p. 1582-6.
54. Olesen, J., P. Tfelt-Hansen, and K.M.A. Welch, eds. The Headaches. . 1993, Raven Press:
New York.
55. Zimmerman, M. and T. Herdegen, Control of Gene Transcription by Jun and Fos Protiens
in the Nervous System. APS Journal, 1994. 3(1): p. 33-48.
56. Hoheisel, U., B. Sander, and S. Mense, Blockade of nitric oxide synthase differentially
influences background activity and electrical excitability in rat dorsal horn neurones.
Neuroscience Letters, 1995. 188(2): p. 143-6.
57. Willis, W.D., Mechanical Allodynia. APS Journal, 1993. 2(1): p. 23-33.
58. Dubner, R., Neuropathic Pain: New Understanding Leads to New Treatments. APS
Journal, 1993. 2(1): p. 8-11.
59. Messing, R.B. and L.D. Lytle, Serotonin-containing neurons: their possible role in pain
and analgesia. (Review). Pain, 1977. 4(1): p. 1-21.
60. Goldstein, A., Opioid peptides endorphins in pituitary and brain. Science, 1976.
193(4258): p. 1081-6.
61. Snyder, S.H., Brain peptides as neurotransmitters. Science, 1980. 209(4460): p. 976-83.
62. Kumazawa, T. and E.R. Perl, Excitation of marginal and substantia gelatinosa neurons in
the primate spinal cord: indications of their place in dorsal horn functional organization.
Journal of Comparative Neurology, 1978. 177(3): p. 417-34.
63. Melzack, R. and P.D. Wall, Pain mechanisms: a new theory. (Review). Science, 1965.
150(699): p. 971-9.
64. Fields, H.L. and A.I. Basbaum, Brainstem control of spinal pain-transmission neurons.
(Review). Annual Review of Physiology, 1978. 40: p. 217-48.
65. Melzack, R., Myofascial trigger points: relation to acupuncture and mechanisms of pain.
Archives of Physical Medicine & Rehabilitation, 1981. 62(3): p. 114-7.
66. Kajander, K.C., Evaluation of low-intensity transcutaneous electrical nerve stimulation in
combination with aspirin for reduction of controlled thermal sensation. Anesthesia Progress,
1988. 35(5): p. 195-8.

117
67. Merrill, R.L. and S.B. Graff-Radford, Trigeminal neuralgia: how to rule out the wrong
treatment. Journal of the American Dental Association, 1992. 123(2): p. 63-8.
68. Graff-Radford, S.B. and W.K. Solberg, Atypical odontalgia. CDA Journal, 1986. 14(12): p.
27-32.
69. Marbach, J.J., Is phantom tooth pain a deafferentation (neuropathic) syndrome? Part II:
Psychosocial considerations. Oral Surgery, Oral Medicine, Oral Pathology, 1993. 75(2): p. 225-
32.
70. Naples, R.J., J.E. Van Sickels, and D.L. Jones, Long-term neurosensory deficits associated
with bilateral sagittal split osteotomy versus inverted 'L' osteotomy. Oral Surgery, Oral
Medicine, Oral Pathology, 1994. 77(4): p. 318-21.
71. Ellies, L.G. and P.B. Hawker, The prevalence of altered sensation associated with implant
surgery (see comments). International Journal of Oral & Maxillofacial Implants, 1993. 8(6): p.
674-9.
72. Sessle, B.J., Neural Mechanisms Implicated in the Pathogenesis of Trigeminal Neuralgia
and Other Neuropathic Pain States. APS Journal, 1993. 2(1): p. 17-20.
73. Janig, W. and M. Stanton-Hicks, eds. Reflex sympathetic dystrophy : a reappraisal.
Progress in pain research and management. Vol. 6. 1995, IASP Press: Seattle. 249.
74. Fields, H.L. and J.C. Liebeskind, eds. Pharmacological approaches to the treatment of
chronic pain: new concepts and critical issues. The Bristol-Myers Squibb Symposium on Pain,
ed. B.-M. Squibb. 1994, IASP Press: Seattle. 312.
75. Campbell, J.n., R.A. Meyer, and N.R. Srinivasa, Is Nociceptor Activation by Alph-1
Andrenoreceptors the Culprit in Sympathetically Maintained Pain? APS Journal, 1992. 1(1): p.
3-11.
76. Fordyce, W.E. and J.C. Steger, Chronic pain, in Behavioral medicine, theory and practice,
O.F. Pomerleau and J.P. Brady, Editors. 1979, Williams & Wilkins: Baltimore. p. 125-154.
77. Moody, P.M., et al., Recent life changes and myofascial pain syndrome. Journal of
Prosthetic Dentistry, 1982. 48(3): p. 328-30.
78. Kudrow, L. and B.J. Sutkus, MMPI pattern specificity in primary headache disorders.
Headache, 1979. 19(1): p. 18-24.
79. Rocabado, M., Diagnosis and Treatment of Abnormal Craniocervial and
Craniomandibular mechanics, in Abnormal jaw mechanics : diagnosis and treatment, W.K.
Solberg and G.T. Clark, Editors. 1984, Quintessence: Chicago. p. 141-159.
80. Jaeger, B. and J.L. Reeves, Quantification of changes in myofascial trigger point sensitivity
with the pressure algometer following passive stretch. Pain, 1986. 27(2): p. 203-10.
81. McNeill, C., et al., eds. Craniomandibular disorders : guidelines for evaluation, diagnosis,
and management. . 1990, Quintessence Pub. Co.: Chicago. 141.
82. Check, R.K., et al., Report of the Ad Hoc Committee on Craniomandibular and
Temporomandibular Joint Disorders: Current Concepts of Diagnosis and Treatment, . 1988,
Minnesota Dental Association: Minneapolis.
83. Ng, K. Lorenz, and (editors), New approaches to treatment of chronic pain: a review of
multidisciplinary pain clinics and pain centers. NIDA Research 36 Monograph Series. 1981,
Washington, D.C.: U.S. Government Printing Office.
84. Travell, J. and D.G. Simons, Myofascial Pain and Dysfunction: The Trigger Point Manual.
1983, Baltimore: Williams & Wilkins Co.
85. Simons, D., Muscular Pain Syndromes, in Myofascial Pain and Fibromyalgia, J. Fricton
and E.A. Awad, Editors. 1990, Raven Press: New York. p. 1-43.
86. Melzack, R., The McGill Pain Questionnaire: major properties and scoring methods. Pain,
1975. 1(3): p. 277-99.
87. Gracely, R.H., R. Dubner, and P.A. McGrath, Narcotic analgesia: fentanyl reduces the
intensity but not the unpleasantness of painful tooth pulp sensations. Science, 1979. 203(4386):
p. 1261-3.
88. Kames, L.D., et al., The chronic illness problem inventory: problem-oriented psychosocial
assessment of patients with chronic illness. International Journal of Psychiatry in Medicine,

118
1984. 14(1): p. 65-75.
89. Kerns, R.D., D.C. Turk, and T.E. Rudy, The West Haven-Yale Multidimensional Pain
Inventory (WHYMPI). Pain, 1985. 23(4): p. 345-56.
90. Lundeen, T.F., S.R. Levitt, and M.W. McKinney, Clinical applications of the TMJ scale.
Cranio, 1988. 6(4): p. 339-45.
91. Simons, D.G. and J. Travell, Myofascial trigger points, a possible explanation (letter).
Pain, 1981. 10(1): p. 106-9.
92. Bennett, R., Myofascial Pain Syndromes and the Fibromyalgia Syndrome: A Comparative
Analysis, in Myofascial Pain and Fibromyalgia, J. Fricton and E.A. Awad, Editors. 1990, Raven
Press: New York. p. 43-66.
93. LeResche, L., et al., An epidemiologic evaluation of two diagnostic classification schemes
for temporomandibular disorders. Journal of Prosthetic Dentistry, 1991. 65(1): p. 131-7.
94. Schiffman, E., et al., Diagnostic criteria for intraarticular T.M. disorders. Community
Dentistry & Oral Epidemiology, 1989. 17(5): p. 252-7.
95. Reeves, J.L., B. Jaeger, and S.B. Graff-Radford, Reliability of the pressure algometer as a
measure of myofascial trigger point sensitivity. Pain, 1986. 24(3): p. 313-21.
96. Mohl, N.D., et al., Devices for the diagnosis and treatment of temporomandibular
disorders. Part I: Introduction, scientific evidence, and jaw tracking (published erratum appears
in J Prosthet Dent 1990 May;63(5):13A) (see comments). (Review). Journal of Prosthetic
Dentistry, 1990. 63(2): p. 198-201.
97. Mohl, N.D., et al., Devices for the diagnosis and treatment of temporomandibular
disorders. Part II: Electromyography and sonography (published erratum appears in J Prosthet
Dent 1990 May;63(5):13A). (Review). Journal of Prosthetic Dentistry, 1990. 63(3): p. 332-6.
98. Pullinger, A.G. and D.A. Seligman, TMJ osteoarthrosis: a differentiation of diagnostic
subgroups by symptom history and demographics. Journal of Craniomandibular Disorders, 1987.
1(4): p. 251-6.
99. Jaeger, B. and S.A. Skootsky, Double Blind, Controlled Study of Different Myofascial
Trigger Point Injection Techniques. Pain, 1987. 4(supp): p. S292.
100. Rugh, J.D. and J. Harlan, Nocturnal bruxism and temporomandibular disorders. (Review).
Advances in Neurology, 1988. 49: p. 329-41.
101. Rasmussen, O.C., Description of population and progress of symptoms in a longitudinal
study of temporomandibular arthropathy. Scandinavian Journal of Dental Research, 1981. 89(2):
p. 196-203.
102. Wilkes, C.H., Internal derangements of the temporomandibular joint. Pathological
variations. Archives of Otolaryngology -- Head & Neck Surgery, 1989. 115(4): p. 469-77.
103. Castaneda, R., C. McNeill, and W. Noble, Biochemical Factors in TMJ Osteoarthritis.
Journal of Dental Research, 1988. 67(Special Issue): p. 124.
104. Blaustein, D.I. and R.P. Scapino, Remodeling of the temporomandibular joint disk and
posterior attachment in disk displacement specimens in relation to glycosaminoglycan content.
Plastic & Reconstructive Surgery, 1986. 78(6): p. 756-64.
105. Stegenga, B., et al., Tissue responses to degenerative changes in the temporomandibular
joint: a review. (Review). Journal of Oral & Maxillofacial Surgery, 1991. 49(10): p. 1079-88.
106. Wilkes, C.H., Arthrography of the temporomandibular joint in patients with the TMJ paindysfunction
syndrome. Minnesota Medicine, 1978. 61(11): p. 645-52.
107. Westesson, P.L. and D. Paesani, MR imaging of the TMJ. Decreased signal from the
retrodiskal tissue. Oral Surgery, Oral Medicine, Oral Pathology, 1993. 76(5): p. 631-5.
108. Westesson, P.L., et al., Temporomandibular joint: comparison of MR images with
cryosectional anatomy. Radiology, 1987. 164(1): p. 59-64.
109. Westesson, P.L., et al., CT and MR of the temporomandibular joint: comparison with
autopsy specimens. AJR. American Journal of Roentgenology, 1987. 148(6): p. 1165-71.
110. de Leeuw, R., et al., Temporomandibular joint osteoarthrosis: clinical and radiographic
characteristics 30 years after nonsurgical treatment: a preliminary report. Cranio, 1993. 11(1):
p. 15-24.

119
111. Kircos, L.T., et al., Magnetic resonance imaging of the TMJ disc in asymptomatic
volunteers. Journal of Oral & Maxillofacial Surgery, 1987. 45(10): p. 852-4.
112. Pullinger, A.G., D.A. Seligman, and J.A. Gornbein, A multiple logistic regression analysis
of the risk and relative odds of temporomandibular disorders as a function of common occlusal
features. Journal of Dental Research, 1993. 72(6): p. 968-79.
113. Pullinger, A.G. and D.A. Seligman, The degree to which attrition characterizes
differentiated patient groups of temporomandibular disorders. Journal of Orofacial Pain, 1993.
7(2): p. 196-208.a
114. Graff-Radford, S.B., Oromandibular disorders and headache. A critical appraisal.
(Review). Neurologic Clinics, 1990. 8(4): p. 929-45.
115. Forssell, H., P. Kirveskari, and P. Kangasniemi, Changes in headache after treatment of
mandibular dysfunction. Cephalalgia, 1985. 5(4): p. 229-36.
116. Fricton, J.R. and R. Dubner, eds. Orofacial pain and temporomandibular disorders.
Advances in Pain Research and Therapy, ed. J.J. Bonica. Vol. 21. 1995, Raven Press: New York.
538.
117. Bush, F.M. and S.W. Harkins, Pain-related limitation in activities of daily living in patients
with chronic orofacial pain: psychometric properties of a disability index. Journal of Orofacial
Pain, 1995. 9(1): p. 57-63.
118. Magnusson, T. and G.E. Carlsson, Recurrent headaches in relation to temporomandibular
joint pain-dysfunction. Acta Odontologica Scandinavica, 1978. 36(6): p. 333-8.
119. Riley, JL, Gilbert GH, Orofacial pain symptoms: an interaction between age and sex. Pain 90(3) 2001, Pp
245-256
120. International Association for the Study of Pain Core Curriculum for Professional
Education in Pain Guidelines , IASP Press, 2nd edition, IASP 909 NE 43rd. St., Suite 306;
Seattle, WA 98105-6020, USA, 1996.
121. Reid KI, Greene CS. J Oral Rehabil. 2013 Jul;40(7):546-61. Diagnosis and treatment of
temporomandibular disorders: an ethical analysis of current practices.
122. Greene CS, Obrez A. Treating temporomandibular disorders with permanent mandibular repositioning: is
it medically necessary? Oral Surg Oral Med Oral Pathol Oral Radiol 2015;119:489-498.
123. Brown RS, Greene CS. Ethical Considerations in the Management of Temporomandibular Disorders.
2017, 84(3):28-35.

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APPENDIX Ia. CONSTITUTION AND BYLAWS OF THE AMERICAN ACADEMY OF OROFACIAL PAIN

AAOP Mission Statement

The American Academy of Orofacial Pain, an organization of dentists and allied health care professionals, is
dedicated to alleviating pain and suffering through the promotion of excellence in education, research and
patient care in the field of orofacial pain and associated disorders.

CHAPTER I
MEMBERSHIP
SECTION 1. Classification and Basic Requirements. The membership of the American Academy of Orofacial
Pain shall consist of Active Members, Fellow Members, Student/Initiatory Members, Life/Life Fellow Members,
Retired Members and Honorary Members. The qualifications of each class of membership shall be provided
for herein. The membership criteria may be modified at the request of Membership Committee and then must
be approved by a majority vote of the Council unless an amendment to the bylaws is applicable in which case
the process of amending will be followed.

The following must apply to all members:

(a) All members of the American Academy of Orofacial Pain (Academy), including any and all categories of
membership in the Academy, must agree to abide by the bylaws of the Academy.
(b) All members of the Academy, including any and all categories of membership in the Academy, must
agree to abide by the Code of Conduct of the American Academy of Orofacial Pain and be willing to work
within the Academy’s “Objectives” to promote the best interest and ideals of the Academy throughout said
membership.
(c) All Members of the Academy with the exception of the Retired, Life/Life Fellow & Honorary Membership
categories must be a permanent resident of the United States of America, Canada, Mexico, Bermuda, the
Bahamas or an independent Caribbean nation or
(1) Be a member in good standing of one of the Sister Academies as per the current Sister Academy
Agreement regarding membership, or
(2) Have been a continuous member in good standing of AAOP and joined prior to 1987.

SECTION 2. Active Members. Active Members shall possess the following qualifications. They shall:
(a) Be a licensed dentist (DDS, DMD or equivalent degree) or be a licensed physician (MD or DO or
equivalent degree) or be a non-dental or non-physician allied health care professional or researcher in good
standing within the state or country within which they practice.
(b) Meet the current residency requirements as stipulated in Chapter 1, Section 1.
(c) Applicants shall:
(1) Be approved by Council upon recommendation of the Membership Committee. Upon
approval by Council, the membership at-large will be notified by written or electronic means
of the pending applications, and barring any written objection they will be accepted as
members. If any objections are received, the application will be returned to the membership
committee for further consideration.
(d) Regular payment of dues is a requirement for maintenance of Active membership in the Academy.
(e) Active Members shall be eligible to hold office, serve on the Academy Council or chair a committee.
(f) Active Members shall possess the right to vote in the election of officers at the annual membership
business meeting and for all items required to be presented to the membership of the academy for further
action.

SECTION 3. Fellow of the Academy. Fellows of the Academy shall possess the following qualifications. They
Shall:
(a) Be a Life member prior to 2005 who shall be recognized as a Life Fellow, or
(b) Have been an Active member and a licensed dentist (DDS, DMD or equivalent degree) in good
standing prior to 2005 and maintained their membership since, or

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(c) Be an Active member and a licensed dentist (DDS, DMD or equivalent degree) who has demonstrated
a minimum of five (5) years of an exceptional understanding of the treatment of temporomandibular disorders
and orofacial pain through graduate or post graduate training, research or clinical experience, or graduated
from an advanced university-based orofacial pain program that is equivalent to at least a 2-year full-time
program, and
(1) Completed and submitted the application for Fellowship
(2) Have passed the American Board of Orofacial Pain Examination.
(3) Provide two (2) letters of recommendation from Fellow Members
(d) Fellow of the Academy may be granted by Council to individuals of exceptional merit, who have not
taken the American Board of Orofacial Pain examination, based on their contribution to the field of
temporomandibular disorders and/or orofacial pain. The granting of Fellow status by the Academy Council
under Chapter 1, Section 3, item (d) is solely at the discretion of the Council and may not be applied for.
Additional Membership Rights and Requirements
(e) Regular payment of dues is a requirement for maintenance of Fellow of the Academy membership.
(f) Fellow of the Academy members shall be eligible to hold office, serve on the Academy Council or chair
a committee.
(g) Fellows of the Academy members shall possess the right to vote in the election of officers at the annual
membership business meeting and for all items required to presented to the membership of the academy for
further action.

SECTION 4. Student/Initiatory Members. Student/Initiatory Members shall possess the following

qualifications. They shall:
(a) Be a current full-time dental or post-graduate dental student in good academic standing, and one of the
following
(1) A licensed dentist (DDS, DMD or equivalent degree) in good standing within the state or country within
which they practice and a current participant of an Academy recognized post-doctoral full-time university
residency program, or
(2) A licensed dentist (DDS, DMD or equivalent degree) in good standing within the state or country within
which they practice and a graduate within the past 12 months of an Academy recognized post-doctoral full-time
university residency program, or
(3) A full time, current predoctoral dental student with interest in temporomandibular disorders and/or
orofacial pain, or
(4) Be a licensed dentist (DDS, DMD or equivalent degree) in good standing within the state or country
within which they practice and enrolled in, or successfully completed within the past 12 months, an orofacial
pain post-graduate or residency program not described above and approved by council for student/initiatory
membership.
(5) A full-time orofacial pain post-graduate or residency program must be consistent with current CODA
accreditation standards
(b) Student/Initiatory Members/Applicants shall:
(1) Be approved by Council upon recommendation of the Membership Committee.
(2) Meet the residency requirements as stipulated in Chapter 1, Section 1.
(c) Regular payment of dues is a requirement for maintenance of Student/Initiatory membership in the
Academy.
(d) Student/Initiatory Members may serve on or chair a committee.
(e) Student/Initiatory Members shall possess the right to vote in the election of officers at the annual
membership business meeting and for all items required to presented to the membership of the academy for
further action.
(f) Student/Initiatory Members shall have all the additional benefits of membership except a subscription to
the Academy’s designated journal.
(g) Student/Initiatory Memberships must be transitioned to Active membership within (4) four years from
date of joining.

SECTION 5 Life/Life Fellow Members. Life Members shall possess the following qualifications. They shall:

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(a) Be a licensed dentist (DDS, DMD or equivalent degree) or be a licensed physician (MD or DO or
equivalent degree) or be a non-dental or non-physician allied health professional or researcher in good
standing within the state or country within which they practice or teach
(b) Have been an Active or Fellow Member in good standing for ten (10) consecutive years and therefore
have satisfied all the requirements of Active or Fellow Member and will continue to do so.
(c) Any Fellow of the Academy becoming a Life member will be referred to as a Life Fellow of the
Academy. Life Fellows must meet all of the additional requirements of Fellow Members.
(d) Be retired from active participation in their profession but may be paid to teach two or fewer days per
week.
(e) Have all the privileges of Active or Fellow membership and shall pay dues as determined by council,
with the understanding that any Life member may, for personal reasons, appeal to council in writing for an
exemption from part of, or the entire dues requirement. Receipt of the designated journal is at the discretion of
Council.
(f) Life Membership may be granted at the discretion of the Council upon application by the member.
(g) Life Members who resume active practice or full time academics will automatically be reinstated to their
previous category of membership.

SECTION 6. Retired Member. Retired Members shall possess the following qualifications. They shall:
(a) Have been a Member in good standing for less than ten (10) consecutive years.
(b) Be retired from active participation in their profession but may be paid to teach two or fewer days per
week.
(c) Have all the privileges of their prior Membership category except receipt of the designated journal with
half the applicable Membership dues.
(d) Once a Retired Member achieves ten years of total membership he may be eligible for Life Membership
upon written request to, and approval by the Council.
(e) If a Retired member is unable to meet the full dues requirements for personal reasons, he/she may
appeal to council in writing for an exemption from part of, or the entire dues requirement.

SECTION 7 . Honorary Membership. Honorary Membership may be granted by the Council to individuals who
have made outstanding contributions to their profession even if not directly involved in orofacial pain and/or
temporomandibular disorders.

Honorary Membership is generally granted to individuals who are not Members of the Academy.

Honorary Membership may be proposed by any Academy Member to the Membership Committee which
forwards favorable recommendations to the Council for approval. Honorary Membership shall be granted upon
two-thirds (2/3) majority vote of the Council.

Honorary Members shall have all the rights and privileges of Active Members except the right to vote or be an
Academy officer.

CHAPTER II
ELECTION OF MEMBERS

SECTION 1. Election to Membership. Membership shall be open to all dentists, physicians and allied health
care professionals or researchers who have an interest in the treatment of temporomandibular disorders and
orofacial pain.
(a) Stipulations are:
(1) Adherence to the requirements of membership as detailed in Chapter I
(2) A completed membership application form and submission of dues payment
(3) Copies of the applicant’s current curriculum vitae, professional business card, letterhead, website, and
Yellow Pages and telephone listing may be required if requested by the Membership Committee.

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 (4) Student/Initiatory Member applicants must provide certification from their program chairman that the
candidate is a current participant or a recent graduate of an Academy approved program.

The nomination process may be modified at the request of the Membership Committee and approved by a
majority vote of the Council.

SECTION 2. Forfeiture of Membership.

(a) Violation of the Constitution, Bylaws, Code of Conduct of the Academy, or any part thereof, or any act
of any member which, in the judgment of the Council, is contrary to the welfare and best interest of the
Academy and its members, shall be grounds for forfeiture of membership in the Academy. The Council shall
have full power to act thereon, and its actions shall be final and binding on all members of the Academy.
Forfeiture of membership so determined by Council shall be effective upon the giving of written notice thereof
by the Secretary to the offending member.
(b) Regular timely payment of annual dues is a requirement for maintenance of all dues paying Members
of the Academy. Non-payment of dues may result in forfeiture of membership or affiliation with the Academy
until rectified.

CHAPTER III
OFFICERS AND THE COUNCIL

SECTION 1. Officers.
The Officers of the Academy shall be the President, President-Elect, Treasurer, Secretary and Secretary-Elect.
Fellows of the Academy, Active, Retired and Life/Life Fellow Members shall be eligible to be Academy Officers.

SECTION 2. Election of Officers.

Election of Officers shall be held each year at the annual general membership meeting of the Academy.
(a) The retiring President-Elect shall automatically become President, the retiring Treasurer shall automatically
become President-Elect, and the retiring Secretary shall automatically become Treasurer and the retiring
Secretary-Elect shall become Secretary for the ensuing year.
(b) The Nominating Committee Chair shall request nominations from the Nominating Committee at least one
hundred twenty (120) days prior to the Annual Meeting, and the nominees shall be forwarded to Council at
least ninety (90) days prior to the Annual Meeting. Nominees shall be presented to the Academy General
Membership at least sixty (60) days prior to the annual meeting.
(c) Additional nominations for Secretary-Elect may be made by written petition of fifteen (15) Fellows of the
Academy, Active, Retired, or Life Members and delivered to the Chair of the Nominating Committee at least
sixty (60) days before the election.
(d) Normally nominations at-large can only be for the Office of Secretary-Elect since Officers of the Academy
progress through the sequence from Secretary-Elect to Secretary to Treasurer to President-Elect to President.
(e) Election shall be by official ballot only when there are two or more nominees for a given office.
(f) Voting shall only be in person by Active, Fellow, Retired and Life Members; voting by mail or proxy voting
shall not be permitted.

SECTION 3. The Council Membership.

(a) The Council shall consist of:
i) a Chair, who is the Immediate Past President and presiding officer at the Council Meetings,
ii) a Vice-Chair, who is the Immediate Past Chair,
iii) the incumbent President of the Academy,
iv) the incumbent President-Elect of the Academy,
v) the incumbent Treasurer of the Academy,
vi) the incumbent Secretary of the Academy
vii) the Secretary-Elect,

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 viii) six (6) at-large Fellow, Active, Retired or Life/Life Fellow Members, two (2) of whom shall be
elected by the General Membership upon recommendation by the Nominating Committee each
year at the annual meeting to serve for a term of three (3) years thereafter
(b) A Parliamentarian and the Chair of the Membership Committee shall be ex-officio members of the
Council with no vote in Council decisions.
(c) Any member of the Council, who is absent from a Regular meeting of Council, without reasonable
cause, is accountable to Council, and may be considered by Council for termination as a member of
Council.

SECTION 4. Council Business.

The Council has full power to act on behalf of the Academy in the interim between meetings of the Academy
and shall transact all business of the Academy, except the election of officers. By written petition of three (3)
Active, Fellow, Life, Retired or Life Affiliate Members, any matter may be brought before the Council for action.
The Council shall report its proceedings to the Academy’s General Membership at each annual meeting for
approval.

SECTION 5. Council Meetings.

(a) Regular Meetings. The Council shall have its annual regular meeting, just prior to the academy's annual
scientific conference, unless good cause to do otherwise can be given. The Council shall also have an interim
meeting later in the year, time and location to be determined by the Council in coordination with the executive
director and central office. Regular Meetings of the Council will entail the physical assembly of the Council at a
specified date, time and place.

(b) Special Meetings. May be called by the Chair and shall be called on the written request of three (3)
members of Council, and that having been properly called, proper and adequate notice given. A special
meeting may be held via electronic/conference call means provided all council members have reasonable
access to such means. Any member not having reasonable access to such means may grant a waiver for the
meeting to be held.

(c) Quorum. The presence of 60% of the voting members of the Council at any meeting shall be necessary to
constitute a quorum. In establishing a quorum the Parliamentarian and the Chair of the Membership committee
are not counted.

SECTION 6. Council Minutes.

(a) All official proceedings and decisions of the Council shall be recorded by the Secretary, entered into the
minutes and
(b) a copy of the minutes provided to the members of Council within thirty (30) days of the meeting, unless a
more immediate response is required.
(c) Council members are to submit any corrections to the Secretary within thirty (30) days of receipt of the
minutes, after which the minutes shall be considered as being approved, and
(d) A copy of all Council minutes shall be available to Academy Members.

SECTION 7. Parliamentarian.
A Parliamentarian shall be appointed by the President to facilitate the efficient conduct of business during
Council and General Membership Meetings of the Academy. The Parliamentarian will represent the official
interpretation of the Bylaws, its other governing documents, and the Rules of Order during business meetings.
The Parliamentarian is an ex-officio member of the Council with no vote in Council business decisions.

SECTION 8. Notice of Council Meetings.

The secretary shall give notice to:
(a) Academy members shall be notified of regular meetings to be held by the Council by Postal Mail, electronic
means such as email, or a notice in an Academy publication such as the Newsletter or Journal at least ten (10)
days prior to the date of the Council Meeting.

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(b) Council members may be notified by mail, telephone, facsimile, electronic means such as email, personal
communication or other personal method to members of the Council at least ten (10) days prior to the date of
regular or special meetings of the Council. When immediate Council action is required via a special meeting
this provision will not apply.

SECTION 9. Action by Unanimous Written Consent Without Meeting.

Any action required or permitted to be taken by the Council, under any provision of law, may be taken without
meeting, if all voting members of the Council shall individually or collectively consent in writing or via electronic
communication to such action. Such written consent shall have the same force and effects as the unanimous
vote of the Council members.

SECTION 10. Non-liability of Council Members.

No member of the Council shall be personally liable for the debts, liabilities or obligations of the Academy.

CHAPTER IV
GENERAL MEMBERSHIP MEETINGS

SECTION 1. Annual Meetings. There shall be an annual meeting of the Academy for the election of officers,
the transaction of business, the presentation of essays and papers on professional subjects, the presentation
of clinics, and for such other purposes as may be determined by the Council. The time and place of the
Annual General Membership Meeting and any special meetings shall be determined by the Council, and
members notified thereof.

SECTION 2. Interim Meetings. Interim meetings may be scheduled by the Council if necessary. The time and
place shall be determined by the Council.

SECTION 3. Admission to Meetings. Admittance to all Essay and Clinic Meetings shall be by current
membership registration or as a duly registered guest. Registration Fee to be determined by the Council.

SECTION 4. Quorum and Voting. The Quorum for an official General Membership Meeting necessary to
conduct the business of the Academy shall be ten percent 10 % of the total Academy members eligible to vote.
All members with voting privileges as determined by the Academy bylaws and in good standing with the
Academy shall be entitled to vote on matters brought before the Academy. In case of a tie, the Presiding
Officer shall cast the deciding vote. Please see Chapter XIII for rules governing the amending of these bylaws.

SECTION 5. Emergency Provision. It shall take a majority vote of Council to declare that an emergency
exists. During a declared emergency, the officers and elected members of Council shall remain in office until
the emergency is ended. During the declared emergency, it shall be the duty of the Council to develop
methods of procedure for the continuance of the Academy and its activities. The Council shall determine the
feasibility of holding a meeting and shall prescribe the type of meeting to be held during such emergency.

CHAPTER V
OFFICERS
SECTION 1. President.

(a) The President shall preside at all meetings of the Academy

(b) The President shall appoint all committees.
(c) The President shall have general supervision of the work of all committees and shall be ex-officio
member thereof.
(d) The President shall perform such duties as appertain to his office by custom.

During the President’s tenure as Secretary, the President shall have authority to appoint a Program Chair and
Program Committee to function during the 3 to 4 year period concluding with his/her term as President.

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SECTION 2. President-Elect.

(a) The President-Elect shall assume the duties of the President in the absence of the President.
(b) The President-Elect shall Chair the Budget Committee which develops the ensuing year’s annual
budget.

SECTION 3. Treasurer.

(a) The Treasurer shall take charge of all monies of the Academy, keep an account of the same and pay
bills approved by the Council, present an official audit of the financial affairs of the Academy each year and
report the same to the Academy at the Annual General Membership Meeting. It is understood that the
Treasurer shall include the Secretary’s expense account in this report.
(b) The Treasurer shall be a member of the Budget Committee which shall develop an itemized budget for
the Academy’s ensuing fiscal year for approval by Council.

SECTION 4. Secretary. The Secretary shall record all official proceedings and decisions of the Council, and a
copy of the minutes shall be provided to the members of Council within thirty (30) days of each meeting, unless
a more immediate response is required.

(a) Candidates for the Office of Secretary must have been on a standing committee for at least three (3)
years and served as Chair of a standing committee for at least one term.
(b) The Secretary shall keep a record of the Academy General Membership Meetings and of the Council
Meetings. The Secretary shall notify members of meetings, nominations for membership and similar matters,
and prepare official ballots for election of officers and members of the Council, keep a list of members
delinquent in the payment of dues, keep current copies of the Constitution and Bylaws on hand at all times and
poll the Council on all matters of policy and in an emergency.
(c) The Secretary is entitled to adequate monetary allowance as determined each year by the Council.
(d) The Secretary shall be responsible for maintaining the Policies and Procedures Manual of the
Academy. This shall include establishing and administering a time line for activities and events in coordination
with the President, the Council, and the Chair of all Academy Committees as well as monitoring and
overseeing the activities of the Central Office in the timely performance of these tasks.
(e) The Secretary shall be a member of the Bylaws Committee to facilitate compliance with the Bylaws and
to maintain the Bylaws as a living document through timely updates and necessary changes. The Secretary
shall obtain recommendations for updates and changes from the Chair of each Academy Committee, and the
Secretary shall subsequently present these recommendations to the Bylaws Committee for consideration.
(f) The Secretary shall receive a copy of all correspondence of the Academy. Academy correspondence
shall be directed to the Secretary with copy to the Central Office.

SECTION 5. Secretary Elect.

The Secretary-Elect shall be a full voting member of the Council and Executive Committee. He/she shall
assume the responsibilities of the Secretary in his/her absence.

(a) The prerequisites for the office of Secretary-Elect shall be the same as for Secretary.
(1) Candidates for the Office of Secretary-Elect must have been on a standing committee for at least three (3)
years and served as Chair of a standing committee for at least one term.
(2) The responsibilities of the Secretary-Elect are to assume those of the Secretary as the need arises.

SECTION 6. Term of Office. The term of office for each elected official shall be for approximately one year
and span the period between General Membership Meetings. Officers will be elected by the General
Membership at the annual meeting of the Academy.

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SECTION 7. The Executive Director. The Executive Director shall be selected by the Executive Committee
and shall be reimbursed according to written contract approved by the Council. The duties of the Executive
Director are delineated in detail in the policy and procedures manual and can be changed by vote of council
from time to time reflecting current needs of the Academy.

CHAPTER VI
COMMITTEES

SECTION 1. Establishment of Standing Committees. The power to establish, revise or disband standing
committee shall be vested in the Academy Council and such actions taken by the Council to modify Chapter VI
of these bylaws shall not require a formal “amendment of the bylaws” process to be initiated and adhered to as
outlined in Chapter XII. The Academy Council shall have the authority to amend Chapter VI of the Constitution
and Bylaws with respect to standing committees via the affirmation of 2/3 of those Council members in
attendance, a quorum of the Council having been established.

SECTION 2. Executive Committee.

(a) Composition. The Executive Committee shall be composed of the President, President-Elect,
Treasurer, Secretary, Secretary-Elect, Chair of the Council, and Vice Chair of the Council. The Executive
Director shall be an ex-officio member of the Executive Committee.
(b) Duties if the Committee. The duties of the Executive Committee shall be to contract with an Executive
Director, and to advise and facilitate the activities of the Academy.

SECTION 3. Continuing Education Oversight Committee

Duties and Composition of the Committee. The Continuing Education Oversight Committee (CEOC) will be
responsible for overseeing all continuing education activities of the Academy including the planning, arranging
and conducting the: Annual Scientific Meetings of the Academy, Interim Educational Symposia as they arise,
Online Continuing Education & any other program as determined by the Council.
(a) The Continuing Education Oversight Committee will coordinate with the central office to ensure that the
Academy maintains it status as an approved continuing education provider.
(b) The Continuing Education Oversight Committee will meet at least semi-annually including in person at
the annual scientific meeting. All other meeting may be electronic or coincide with other meetings as
opportunities arise.
(c) The Continuing Education Oversight Committee will review the annual scientific meeting evaluation
summary within five (5) months of the completed meeting.
(d) The Continuing Education Oversight Committee will explore and implement options for modernizing the
Academy’s annual meeting by utilizing current technology to enhance the attendee experience.
(e) Will coordinate with the program chairs and poster chair to develop and present a continuing education
program at each year’s annual scientific meeting.
(f) The Committee’s Composition shall include Two Co-Chairs who shall be the President-Elect of the current
fiscal year and one appointed member for a term of three (3) years. Additional members will include chairs
and members listed under sections (g) and (h).
(g) The yearly Program Committees shall function as independent committees but under the oversight of the
CEC co-chairs and in cooperation with the other program committees as follows:
1. The Program Co-Chairs of the next four (4) annual scientific meetings who shall be appointed by the
individual (Secretary-Elect) who shall be President in the respective year of the meeting.
2. Program Committees shall be responsible for submitting a preliminary planned program and faculty to the
Council for approval twenty four (24) months before the scheduled scientific meeting and shall submit their
proposed planned program and faculty to the Executive Council eighteen (18) Months before the meeting is to
take place for final approval.
3. Reviewing and updating the annual scientific meeting Integrated Action Plan (IAP) on a monthly basis during
the years preceding their meeting and as the IAP dictates in prior years.

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4. Program Co-Chairs shall submit their reports directly to the CEOC Co-Chairs who will intern submit their
report to the AAOP Council.
5. The yearly Program Co-Chairs at their discretion may add members to their program committees who shall
function under their direction as members of that year’s program committee.
(h) Additional members of the Continuing Education Committee shall include:
1. The Poster Chair who will be appointed by the CEOC co-chairs and at least three (3) committee members
to assist in the solicitation review and selection of scientifically appropriate poster displays at the annual
scientific meeting.
3. The Online Education Chair who will be appointed by the CEOC co-chairs and at least three (3) committee
members to assist in the development of an online education program.
4. Additional members may be appointed at the discretion of the CEOC co-chairs provided they are assigned
specific tasks in accordance with the overall committee IAP.
5. The Industry Relations Chair will select one member of the Industry Relations Committee to serve as an ex-
officio member of the CEOC.

SECTION 4. Nominating Committee.

(a) Nominating Committee.
(a) Composition. The Nominating Committee shall be composed of the President, President-Elect,
Treasurer, Chair of the Council, Vice Chair of the Council who shall serve as Chair of the Nominating
Committee, two (2) past president members elected by the General Membership, one each per successive
year and two members at large to be appointed by the president. Each elected past president shall serve a
term of two (2) years.
(b) Duties of the Nominating Committee. The duties of the Nominating Committee are:
(1) To conduct balloting procedures for the nomination and election of candidates for Officers of the
Academy and at-large Council and committee representatives as specified in the Bylaws for the upcoming
fiscal year at the annual business meeting of the General Membership.
(2) To propose to Council a slate of candidates for the immediate subsequent fiscal year following the
upcoming year for the election of the Secretary-Elect, two (2) new members of the Council, one (1) new
member of the Nominating Committee, and a Past President to be Chair of the Sister Academy Liaison
Committee. After approval by Council, the slate is presented by the Nominating Committee Chair to the
General Membership at the annual business meeting.
(3) To solicit and identify new potential leaders from the Academy’s membership and make
recommendations for their placement upon committees.
(4) To conduct annual leadership orientation for Academy directors, committee chairs and committee
members.
(5) The meeting of the Nominating Committee shall be closed to all non-committee members. All
Nominating Committee communications shall be considered confidential.

SECTION 5. International Journal Liaison

(a) Composition. The International Journal Liaison Committee shall be composed of a Chairperson and
two additional members appointed at the discretion of the President.
(b) Duties of the Committee. The Chair and one committee member shall represent the interests of the
American Academy at any deliberations of, or business conducted by, the International Journal Committee.
Representatives of each of the sister Academies are invited to sit on International Journal Liaison Committee
ex-officio.

SECTION 6. Membership Committee.

(a) Composition. The Membership Committee shall consist of a chair or co-chairs appointed by the
president and at least 5 additional members one of which shall be the Secretary-Elect.
(b) Duties of the Committee.
(1) Review all applicants for Membership in the Academy and notify Council and Ethics/Grievances committee
of any discrepancies or possible reasons for denying membership to an applicant.

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(2) Review the applications for Fellow Status in the Academy and make recommendations for approval to
Council.
(3) Review the applications for Life Member Status in the Academy and make recommendations for approval
to Council.
(4) Develop and implement a marketing plan or work directly with any ad-hoc committee or task force in order
to do same
(5) Review and revise as needed the Academy membership application.
(6) Attempt to contact all expired members by June 30th of each year.
(7) Conduct the annual New Member and New Fellow orientation at the annual meeting.

SECTION 7. Committee on Constitution and Bylaws.

(a) Composition. The Chair of the Constitution and Bylaws Committee shall be appointed by the President.
The Committee on Constitution and Bylaws shall consist of at least three (3) members.
(b) Duties of the Committee.
(1) The Committee shall study the Constitution and Bylaws and recommend to the Council any changes
which appear desirable at least thirty (30) days prior to the Annual Council Meeting.
(2) Upon approval by the Council, the Committee Chair shall present the Committee’s recommended
Bylaws changes to the General Membership for approval. For ratification see Chapter XIII section 2.
(3) The Chair shall be responsible to verify that Bylaws changes ratified by the General Membership have
been duly added to the most current Official copy of the Bylaws, as kept by the Secretary at the Academy
Central Office, no later than thirty (30) days after each General Membership Meeting.
(4) The Committee is authorized to correct article and section designation, punctuation, spelling, gender
reference, and cross references as may be necessary to reflect the intent of the Academy without Membership
approval.

SECTION 8. Ethics and Grievance Committee.

(a) Composition. The Chair of the Ethics and Grievance Committee shall be appointed by the President.
The Chair shall select other members to serve on the Committee.
(b) Duties of the Committee.
(1) The Ethics and Grievance Committee shall adopt a Code of Ethics for the Membership subject to
Council approval.
(2) The Committee shall investigate and report to Council any member complaint or violation of the Code
of Conduct.
(3) The Committee shall adopt a due process procedure for investigative and disciplinary action with
continuous review to insure fairness in all investigations.

SECTION 9. Resident/Academic Training Committee.

(a) Composition. The President shall appoint a Chair or Co-Chairs to the Committee. The Chair of the
Guidelines Committee shall be an ex-officio member of the Committee. The Resident/Academic Training
Committee may consist of two (2) standing sub-committees appointed by the President: the Pre-Doctoral
Subcommittee, the Post-Doctoral Subcommittee. There shall be a Review Course coordinator. Other
members may be appointed as needed.
(b) Duties of the Committee.
(1) The Pre-Doctoral Subcommittee shall be responsible for monitoring and recommending pre-doctoral
dental school curricula pertaining to orofacial pain and temporomandibular disorders.
(2) The Post-Doctoral Subcommittee shall be responsible for monitoring and recommending post-doctoral
dental school curricula pertaining to orofacial pain and temporomandibular disorders and shall develop and
operate an accreditation protocol for such programs.
(3) The Review Course Coordinator shall be responsible for developing, arranging and holding continuing
education review courses on orofacial pain and temporomandibular disorders on behalf of the Academy.
(4) Contact all course directors and residents of Post-doctoral Orofacial Pain programs in the United
States.

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(5) Represent to council the specific interests of new members, recent graduates and participants of Post-
doctoral Orofacial Pain programs.

SECTION 10. Research Grant Committee.

(a) Composition. The President shall appoint a Chair and members of the Research Grant Committee.
(b) Duties of the Committee.
(1) The Research Grant Committee shall select grant recipients according to the Committee’s accepted
protocol and determine the amount of each grant for qualified research in the field of orofacial pain and
temporomandibular disorders. Said protocol and guidelines are available upon request from the Executive
Director.
(2) The Committee will be responsible for obtaining agreement by each grant recipient that they will make
a poster presentation at each Academy Annual Meeting during the term of their grant.

SECTION 11. Guidelines Committee.

(a) Composition. The Chair of the Guidelines Committee will be appointed by the President and will serve
for the entire term of publication preparation for each edition of the Academy Guidelines. The Committee
members will also serve throughout the revision period for each edition of the Guidelines unless determined
otherwise by the Chair. After publication of the current edition of the Guidelines, the Chair will continue to
serve as a Committee Member for one year under the new Committee Chair to accommodate transition for the
subsequent edition of the Guidelines.
(b) Duties of the Committee. The Guidelines Committee is responsible for revision of each edition of the
Academy Guidelines publications on Orofacial Pain and Temporomandibular Disorders.

SECTION 12. Sister Academy Liaison Committee.

(a) Composition. The Sister Academy Liaison Committee shall be composed of at least three (3)
members: a Chair, the current Secretary, and at least one (1) other Academy Member/ Affiliate appointed by
the President. The Chair shall be a Past President determined by the Nominating Committee for approval by
Council; the Chair shall serve a four (4) year term to coincide with planning and execution of the next ensuing
International Meeting of the combined affiliated Academies. The Chair shall represent the American Academy
in the International Committee of the combined affiliated academies which fosters mutual aims and purposes of
the combined academies and plans the quadrennial International Meeting. Representatives of each of the
sister Academies are invited to sit on the Sister Academy Liaison Committee ex-officio.
(b) Duties of the Committee. The Sister Academy Liaison Committee shall coordinate all interaction
between the American Academy of Orofacial Pain and the four sister Academies.

SECTION 13. Strategic Plan Steering Committee.

(a) Composition. The Strategic Plan Steering Committee is selected every three years and membership
remains constant during this period. The Chair is the President during the initial year of the three-year period.
Nine other members are chosen by the President/Chair: two (2) Past Presidents, the Secretary-elect, the
Secretary, the treasurer, and the President-elect, one (1) clinician, one (1) academician and one (1) member
at-large. The Executive Director serves ex-officio.
(b) Duties of the Committee. The Strategic Plan Steering Committee shall implement revisions to the
current Academy Strategic Plan and develop a new plan for the ensuing three-year period. This committee will
also monitor the committee IAPs and update the strategic plan accordingly

SECTION 14. Budget Committee.

(a) Composition. The Budget Committee shall consist of the President, President-Elect, Treasurer and
Secretary; the President-Elect shall serve as Chair. The Council Chair, Continuing Education Oversight
Committee Co-Chairs, and the Executive Director serve ex-officio.
(b) Duties of the Committee. The Budget Committee is responsible for developing a detailed budget
proposal for the Academy’s ensuing year. The Committee is to present their proposed itemized budget for
Council approval, 30 days prior to the Annual Meeting.

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SECTION 15. Publications Committee.
(a) Composition. The Publications Committee Chair shall be appointed by the President and shall act as
the Editor of the Academy Newsletter, The AAOP News, and shall oversee other official Academy Publications
as determined by Council. Other members shall be appointed to support the undertakings of the Committee.
(b) Duties of the Committee. The Publications Committee oversees all Academy Publications except the
Journal of Oral and Facial Pain and Headache and the Academy Guidelines. The Publications Committee
shall develop, design, write, solicit and edit the Official Academy Newsletter and other Official Academy
Publications and communications as deemed appropriate by Council.

SECTION 16. Professional Relations Committee

(a) Composition. The Professional Relations Committee Chair shall be appointed by the President. The
committee members will include all official AAOP liaisons to other organizations which are appointed by the
president and/or AAOP Council, the Industry Relations Chair, Sister Academy Liaison Committee
Representative and Access to Care Chair. The Chair shall appoint additional members to the committee.
(b) Duties of the Committee. The Professional Relations Committee develops and oversees relations and
liaisons with other professional organizations. The committee will develop means of cooperation and common
ground with other organizations. The committee will make regular reports to the Academy Council and seek
Council approval before officially endorsing any agreements or liaisons with other organizations.

SECTION 17. Industry Relations Committee

(a) Composition. The Industry Relations Committee Chair shall be appointed by the President. The
committee members will include the Research Grants Committee Chair, Professional Relations Committee
Chair & Budget Committee Chair. The Chair shall appoint additional members to the committee.
(b) Duties of the Committee. The Industry Relations Committee develops and oversees relations and
liaisons with other companies that have in interest and/or market share in the scientific field of health care and
specifically dentistry with a focus on orofacial pain and temporomandibular disorders. The committee will
coordinate the annual exhibits program and any sponsor programs or solicitations originating within the
Academy . The committee will make regular reports to the Council and seek Council approval before officially
endorsing any agreements or liaisons with other organizations.

SECTION 18. Access to Care Committee.

(a) Composition. The Chair of the Access to Care Committee shall be appointed by the President. The
Chair shall select other members to serve on the Committee. In addition, there may be ex-officio members
invited by the Academy from appropriate organizations who can provide useful information and assistance to
the Committee. The Access to Care Committee shall consist of three (3) standing sub-committees, with Chairs
appointed by the President: the Insurance Subcommittee, the Legislative Subcommittee, and the Advocacy
Subcommittee.
(b) Duties of the Committee.
(1) The Insurance Subcommittee shall be responsible for the development of a working relationship with
third parties and issues involving ICD and CPT codes, and the subcommittee shall develop and maintain an
updated ICD/CPT codes brochure pertaining to orofacial pain and temporomandibular disorders for the
Academy.
(2) The Legislation Subcommittee shall be responsible for monitoring and recommending legislation on a
state-by-state and federal level necessary to establish appropriate access to care pertaining to orofacial pain
and temporomandibular disorders.
(3) The Advocacy Subcommittee shall be responsible for interactions with patient advocacy groups
pertaining to orofacial pain and temporomandibular disorders and for incorporating the Academy’s expertise
with other groups’ political endeavors.

SECTION 19. Physical Therapy Committee.

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(a) Composition. The Physical Therapy Committee Chair shall be appointed by the President. Other
members will be selected to facilitate the various Committee activities. The membership of the committee shall
be composed of, but not limited to five (5) of the total Physical Therapist Members of the Academy.
(b) Duties of the Committee. The Committee shall represent and project the interests of the Academy on
issues related to the activities of physical therapists within the Academy.

SECTION 20. Website Committee.

(a) Composition. The Website Committee Chair shall be appointed by the President, shall act as the Editor
of the Academy Website and shall oversee the official Academy Website and its contents as determined by
Council. Other members shall be appointed to support the undertakings of the Committee.
(b) Duties of the Committee. The Website Committee shall develop, design, write, solicit and edit the
Official Academy Website and as deemed appropriate by Council.

SECTION 21. Sleep Medicine Committee

(a) Composition. The committee shall be composed of a least five (5) members, including the Chair
appointed by the president. The Chair may select others to serve on the committee. The
committee shall consist of two (2) subcommittees: 1) the Sleep Education Subcommittee and 2)
the Practice Parameters Subcommittee. Furthermore, because of the nature of this committee’s
work, a Medical Advisory Board may be created and appointed by the President in consultation
with the Chair.
(b) Duties of the Committee.
1) The Sleep Education Subcommittee will function to promote the education of sleep and
sleep related issues germane to the Academy membership, both in an advisory and
cooperative manner with the Academy’s Program Co-Chairs.
2) The Practice Parameters Subcommittee will establish evidence-based guidelines as they
apply to the dentist’s role in sleep medicine.

SECTION 22. Special Meetings. Special Meetings shall proceed according to an agenda as proposed by the
Chair of the committee and proceedings shall be recorded and become part of that committee’s annual report
to Council. Special Meetings are defined as any meeting in addition to the regularly scheduled committee
meeting conventionally held immediately prior to the annual scientific session.

CHAPTER VII
FEES AND DUES

SECTION 1. Initiation Fee for New Active Members. The initiation fee for new Members shall be determined
by the Council.

SECTION 2. Annual Dues for Members of the Academy. Annual dues for all membership categories shall be
determined by the Council after consultation with the Academy Treasurer and Budget Committee. Any Life
Member may, for personal reasons, appeal to the Council in writing for an exemption from part of, or the entire
dues requirement.

SECTION 3. Forfeiture of Membership Because of Non-Payment of Dues. Any Member delinquent in the
payment of dues shall automatically forfeit membership in the Academy on April 1, provided notice of this
delinquency shall have been served upon the Member by postal mail.

SECTION 4. Reinstatement for Non-Payment of Dues. Reinstatement for a Member who has been dropped
for non-payment of dues may be made at the discretion of the Council.

SECTION 5. Dues Suspension. The Council may suspend any member’s dues obligation when special
circumstances prevent the member from normal active participation in their profession.

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CHAPTER VIII
VACANCIES
SECTION 1. Vacancies Among Officers and Members of the Council. In the event of an unexpected vacancy
of one of the elective offices, it shall become the Council’s responsibility to fill the vacancy for the unexpired
term. It will be the responsibility of the Nominating Committee to resolve any vacancy within the progression of
Officers leading to the Office of President.

SECTION 2. Vacancies on Committees. Vacancies on Committees shall be filled by the President.

CHAPTER IX
QUORUM
The Quorum for an official General Membership Meeting of the Academy shall be ten percent (10%) of the
total Academy Members who are eligible to vote.

CHAPTER X
SUSPENSION OF THE BYLAWS

The Bylaws may be suspended by unanimous vote of Members present and eligible to vote.

CHAPTER XI
PROCEDURE AT ANNUAL AND INTERIM MEETINGS

Robert’s Rules of Order, Current Edition, shall govern at all Academy business meetings on points not
otherwise herein provided for.

CHAPTER XII
AMENDMENT TO THE BYLAWS

SECTION 1. Effective Date. These Bylaws shall become effective immediately upon their adoption.
Amendments to these Bylaws shall become effective immediately upon their adoption or such later date as
specified in the Amendment.

SECTION 2. Amendments. Upon recommendation of the Council, the Bylaws of the Academy may be
amended at any General Membership Meeting by the affirmative vote of not less than two-thirds (2/3) of the
Members of the Academy who are eligible to vote and who shall vote at the General Membership Meeting
either in person or via Written Ballot, provided that the Members of the Academy are notified in writing of such
proposed changes at least thirty (30) days prior to the Meeting. Written Proxy Ballot must be received by the
Office of Record no later than ten (10) day prior to the General Membership Meeting.

SECTION 3. Certification and Inspection. The original, or a copy, of these Bylaws as amended or otherwise
altered to date, certified by the Secretary of the Academy, shall be recorded in a book and on a computer disc
and kept in the principal office of the Academy, and an Official Copy shall be available for inspection by
Academy Members at all reasonable times.

CHAPTER XIII
CORPORATE RECORDS

SECTION 1. Minutes of Meetings. The Academy shall keep at its principal office, or at a place the Council
may determine, a book of the minutes of all meetings of the Council and all General Membership Meetings,
with the time and place of holding, whether regular or special, and, if special, how authorized, the notice given,
the names of those present at Council Meetings, the number of Members present at General Membership
Meetings, and the proceedings thereof.

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SECTION 2. Inspection of Records. Any member of the Council shall have the right at any reasonable time to
inspect all Academy books, records, and documents of every kind. The books of account and minutes of
meetings of the Council, the members, and committees shall be open to inspection at any reasonable time on
the written demand of any Academy Member.

SECTION 3. Special Meetings. Special or Extraordinary Meetings of Council or General Membership shall
proceed according to an agenda as proposed by the Presiding Officer and shall be recorded and become part
of the Annual Report to Council.

CHAPTER XIV
LIMITATIONS AND RESTRICTIONS

SECTION 1. Prohibited Transactions. No Member, Director, Officer, employee, or other person connected
with the Academy, or any other private individual, shall receive at any time, any of the net earnings or
pecuniary profit from the operations of the Academy. This provision shall not prevent payment of reasonable
compensation to any person for services rendered to or for the Academy in effecting any of its purposes as
shall be fixed by resolutions of the Council; and no person or persons shall be entitled to share in the
distribution of, and shall not receive any of the corporate assets on dissolution of, or winding up of affairs of the
Academy, whether voluntary or involuntary. The assets of the Academy then remaining in the hands of the
Council after all debts have been satisfied shall be distributed as required by the Articles of Incorporation of the
Academy, and not otherwise.

SECTION 2. The Officers and Council of the Academy shall make no binding, long term alliances with any
other professional academies, organizations or groups, without fulfilling the following:

1. Notify the membership by written or electronic means of the proposed action at least thirty (30) days prior to
the General Membership meeting

2. Request an on-line dialogue concerning the proposal at least thirty (30) days prior to the General
Membership meeting

3. Require a majority vote by the General Membership that requires the presence of a minimum of 25% of
members participating in the voting process, or authorize a vote by written or electronic means requiring a vote
of at least 25% of active members prior to acceptance.

SECTION 3. Other Limitations and Restrictions. Notwithstanding any other provision in these Bylaws, the
Academy shall adhere to all relevant US laws governing non-profit organizations.

END OF BYLAWS
************

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Appendix Ib. AAOP Strategic Plan 2017-2020

MISSION/VISION

The American Academy of Orofacial Pain, an organization of dentists and other health care professionals,
is dedicated to alleviating pain and suffering through the promotion of excellence in education, research,
and patient care in the field of orofacial pain and associated disorders

Current Goals:
I. Provide the highest quality, evidence based educational opportunities and training to professionals
within the fields of orofacial pain, sleep medicine, temporomandibular disorders, and associated
disorders.
II. Increase the effectiveness of the Academy by sustaining member retention and growth, increasing
opportunities for member participation and leadership development, improving the level of member
satisfaction, and maintaining sound financial policies.
III. Improve patient care, access to care, and to broaden insurance benefits for patients suffering from
orofacial pain, TMD, and associated disorders.
IV. Establish and/or maintain relations with other health care professional organizations.

Goal Objectives/ Strategies Committees’ IAP Reference

I. Provide the highest quality, A. Hold an annual evidenced based Academic Education Committee
evidence based educational educational meeting that strives for a Ambassador Committee
opportunities and training to balanced program. Clinical and Budget Committee
professionals within the fields of research topics are covered. Continuing Education
orofacial pain, sleep medicine, Committee
temporomandibular disorders, B. Predoctoral: Advocate to increase Guidelines Committee
and associated disorders. the amount and improve the quality of Physical Therapy Committee
predoctoral education in the areas of Program Committees 2018-
TMD and other orofacial pain 2020
disorders. Research Committee
Residents & New Grad
C. Postdoctoral: Support sustainability Committee
of postdoctoral OFP programs at Sleep Medicine Committee
dental schools. Web Committee

D. Encourage postdoctoral students

and program directors to be part of
AAOP community.

E. Provide financial support for

graduate and predoctoral student
research into orofacial pain and TMD
disorders.

F. Develop online continuing

education.

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Goal Objectives/ Strategies Committees’ IAP Reference
II. Increase the effectiveness of A. Marketing of AAOP to all dentists Academic Education Committee
the Academy by sustaining and other health care professionals Ambassador Committee
member retention and growth, with an interest in OFP, sleep Budget Committee
increasing opportunities for medicine, and/or TMD Constitution & Bylaws
member participation and Committee
leadership development, B. Improved communication between Continuing Education
improving the level of member AAOP leadership and members Committee
satisfaction and maintaining Council
sound financial policies. C. Provide excellence in membership Guidelines Committee
services Industry Relations Committee
Professional Relations
D. Increase annual revenue through Committee
steady growth in membership, annual Leadership Ad-Hoc Committee
meeting attendance and corporate Membership Committee
support Nominating Committee
Past Presidents Committee
E. Develop and promote greater Program Committee
opportunities and participation in Publications Committee
committees by new and existing Residents & New Grads
members Committee
Sleep Medicine Committee
F. Develop new leaders within AAOP Strategic Planning Committee
and provide guidelines and structure Web Site Committee
for overseeing the Academy

G. Establish the governing principles

and documents of the Academy to
insure compliance with legal standards
and documentation history

H. Monitor and control expenses to

within 110% of budget unless special
circumstances deem a necessary
variance

I. Pursue an endowment

137
Goal Objectives/ Strategies Committees’ IAP Reference
III. Improve patient care, access A. Support efforts to secure specialty Access to Care
to care, and to broaden recognition Budget Committee
insurance benefits for patients Constitution & Bylaws
suffering from orofacial pain, B. Increase awareness between Committee
TMD, sleep medicine, and buyers and payers and communicate Council
associated disorders. with insurance providers Publications Committee
Sleep Medicine Committee
C. Actively advocate for patients and Strategic Planning Committee
work within legislative process

D. Pursue body parts equalization

E. Provide education and resources to

help members deal effectively with
third party payers

F. Provide education to patients, e.g.,

through patient brochures

G. Promote the AAOP as the pre-

eminent resource for professional
referrals

Goal Objectives/ Strategies Committees’ IAP Reference

IV. Establish and/or maintain A. Explore possible collaborations with Continuing Education
relations with other health care similar professional organizations Committee Professional
professional organizations Relations Committee
B. Establish Liaisons with other related Sister Academy Liaison
professional organizations

C. Explore the possibilities for holding

complementary or joint educational
meetings with similar organizations

D. Maintain good relationship with

international community

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 Appendix Ic. American Board of Orofacial Pain Constitution and By-Laws
Table Of Contents:
I. Name
II. Status
III. Purpose
IV. Mission Statement
V. Goals and Objectives
VI. Eligibility
VII. Certification
VIII. Board of Directors
IX. The Examination Council

I. NAME
The name of the corporation shall be the American Board of Orofacial Pain. The lettered designation “ABOP” can be used
to mean
the same as the name of the corporation.
II. STATUS
The ABOP is organized and shall operate as a California Nonprofit Mutual Benefit Corporation.
III. PURPOSE
The purpose of the ABOP is to act as an association of licensed professionals in order to conduct certification
examinations in the field
of Orofacial Pain.
IV. MISSION STATEMENT
The mission of the American Board of Orofacial Pain is to assist the public by certifying that individuals who hold
themselves out as “Diplomates of the American Board of Orofacial Pain” have passed a certifying examination and are
subject to periodic
recertification.
V. GOALS AND OBJECTIVES
The goals and objectives of the ABOP are:
1. To inform the public, through a list maintained at its central office and posted on its website, of individuals who are
certified as Diplomates of the American Board of Orofacial Pain,
2. To determine if candidates meet qualifications and requirements of ABOP and recognized specialty certifying
organizations and agencies for challenging certifying examinations in orofacial pain.
3. To create, maintain, and administer certifying examinations to evaluate the knowledge and experience of such
candidates,
4. To issue certificates and award the status of “Diplomate, American Board of Orofacial Pain” to those candidates
who are found to be qualified under the stated requirements of the American Board of Orofacial Pain and
recognized specialty certifying agencies.
5. To communicate to graduates and program directors of U.S. university-based or hospital-based Orofacial Pain
advanced education programs, the scope and topic proportions on current ABOP examinations, changes in
content and topic proportions on future examinations, changes in the types of tests administered, and information
on new tests that may be offered by the ABOP,
6. To provide information to the public, professional organizations, healthcare agencies, and regulatory bodies
regarding certification in Orofacial Pain.

VI. ELIGIBILITY
The Board of Directors may, from time to time, modify existing criteria or impose additional criteria for eligibility.
Written Exam
Dentists who have accrued at least 400 hours of continuing education in topics specifically related to orofacial pain and
have practiced orofacial pain for at least two years are considered board eligible and may sit for the written portion of the
ABOP certifying examination. Dentists enrolled in a full-time U.S. university or hospital-based residency program in
orofacial pain, may be considered board eligible and apply to sit for the written exam upon formal conveyance by the
program director to the ABOP that the dentist has successfully completed at least one year of the program. Dentists who
have previously taken the written examination unsuccessfully may retake the examination.

1
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Oral Exam
Board eligible dentists who have successfully passed the written exam are eligible to take the oral exam. Oral exam
eligible candidates must take the oral exam no sooner than 1 year and no later than 5 years after passing the written
exam. Extensions of the time limit for challenging the oral examination may be considered on a case by case basis,
based on academic, research, military or other extenuating circumstances.

CERTIFICATION
Board eligible dentists must pass both the written and oral examinations to receive the designation of Diplomate-elect.
The entire examination process is supervised by and passing scores are statistically determined by an independent
testing service. Upon receipt by the Executive Secretary of a signed agreement to abide by the ABOP Code of Conduct,
future revisions of the Code of Conduct, and Guidelines for Disciplinary Action, the Board of Directors shall award to the
Diplomate-elect the status of Diplomate of the American Board of Orofacial Pain. The Diplomate shall receive a certificate
that bears the Diplomate’s name, degree(s) conferred by a university, the ABOP seal, certification number and date of the
certification. The Diplomate is then entitled to all rights designated by the ABOP. Those individuals who successfully
challenge the exams but have not yet completed training programs will receive Diplomate status after completion of a
formal training program.
Individuals who have been Diplomates in good standing for at least a minimum of 10 years may, upon permanent
disability or retirement, apply to the Board of Directors for “Diplomate Emeritus” status of the American Board of Orofacial
Pain.” This designation is available only to those individuals who have maintained an orofacial pain practice, not been in
arrears on renewal fees, and have appropriately documented all continuing education requirements during the immediate
past ten years prior to the application for this change in status. A Diplomate Emeritus may not practice in the field of
orofacial pain, but may continue to contribute through teaching, research and publications. A Diplomate Emeritus will
maintain all of the privileges of an active member. A minimal fee for administrative support will be assessed as
determined appropriate by the Board of Directors.

VIII. THE BOARD OF DIRECTORS

General Powers of the Board of Directors
1. The ABOP shall be governed by its Board of Directors which shall have full authority to manage its affairs,
including but not limited to the power to establish policies, rules, regulations, examination candidacy
requirements, requirements for certification, recertification and other examinations within the scope of orofacial
pain.
2. Decisions of the Board of Directors shall require a majority vote of the Board of Directors with the exception of the
following, which will require a ¾ (seventy five percent majority) vote: election of the Examination Council
Chairperson, filling an unfilled position of President-elect or President, making changes to these Bylaws,
impeaching a Diplomate, revising the examination blueprint, and rejecting a recommendation of the Examination
Council. Should there be a need to fill the position of Immediate Past President the position must be filled by the
next most recent past president.
3. The Board of Directors authorizes the President and Secretary to award a Diplomate certificate to a Diplomate-
elect to identify himself or herself as a “Diplomate of the American Board of Orofacial Pain” and permits use of
such designation on letterhead, business cards, biographical information and prescriptions. The Board of
Directors must approve the designation of “Diplomate of the American Board of Orofacial Pain” on other
communications prior to its use. Diplomates must abide by local laws and regulations regarding use of the
designation of Diplomate, in the aforementioned, or other media.
4. The Board of Directors may retain an accounting firm, a legal firm specializing in certification law, an independent
testing service, an executive secretary, a parliamentarian, and other professionals as may be needed from time to
time. The individuals and companies filling these positions, as well as the amount of compensation they are to
receive, must be confirmed by the Board of Directors.
5. The Board of Directors shall write, update, administer, and govern a formal Code of Conduct and Guidelines for
Disciplinary Action subject to restrictions imposed by law. Each Diplomate-elect shall be provided with a copy of
the ABOP Code of Conduct and Guidelines for Disciplinary Action. Signed acceptance of the Code of Conduct
and Guidelines for Disciplinary Action by the Diplomate-elect must be received by the Executive Secretary of the
ABOP in order to receive full and official Diplomate status.
6. The Board of Directors shall determine certifying examination fees and renewal fees.
7. The Board of Directors may maintain an insurance policy for the purpose of protecting officials of the Board of
Directors from civil liability.

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 Composition, Tenure and Qualifications of the Board of Directors.
1. The officers of the ABOP shall consist of the President, the Immediate-past President, the President-elect, the
Secretary and the Treasurer.
2. There shall be an automatic rotation of offices from President-elect, to President and to Immediate Past
President. In the event that the President-elect, or another officer, cannot ascend to the next position, or chooses
not to ascend, the Nominating Committee shall recommend a replacement to be confirmed by a ¾ (seventy five
percent) majority of the Board of Directors.
3. The term of all offices of the ABOP will begin on June 1 and terminate on May 31. The term of office of the
President, President Elect, and Immediate Past President shall be two years. The term of office of the
Examination Council Chairperson and Vice Chairperson will be a minimum of two years and a maximum of 4
years. The term for the examination council chairperson and vice chairperson may be renewed at the discretion of
the Board of Directors. The term of office of at-large Directors shall be four years with two at-large Directors
rotating off of the Board of Directors every two years. At-large Directors may serve more than one term provided
those terms do not run consecutively. Officials of the Board of Directors may not hold more than one office
simultaneously.
4. The number of voting Directors shall be at least nine (and not more than 15). These Directors are the Immediate
Past President, President, President-elect, and six at-large Directors. All voting Directors must be Diplomates of
the ABOP.
5. Non-voting officials shall be the Examination Council Chair and Vice-Chair who must be Diplomates of the ABOP
and, at the discretion of the Board of Directors, one representative from selected organizations that the ABOP
determines are dedicated to the field of orofacial pain and whose input would enhance the ABOP mission. These
representatives may or may not be Diplomates. Representatives from other professional organizations serve a
two-year term. The Board of Directors may appoint an Ad Hoc committee chair for a specified task. Ad Hoc
committee chairs are non-voting members of the Board of Directors.
6. The Executive Director of the ABOP is not a formal member of the Board of Directors but attends the meetings, is
responsible for the day-to-day business of the ABOP, and is available to officers for assistance in performing their
responsibilities.

The Nominating Committee

The Nominating Committee shall be composed of the Immediate Past President, the President, and the President
Elect. The Immediate Past President shall serve as chairperson. The committee is charged with nominating the
Exam Council Chairperson, six at-large directors (two of whom will also be nominated as the Secretary and
Treasurer of the Board of Directors), vacancies on the Board of Directors, and additional seats to the Board of
Directors or Examination Council. A nominee will be confirmed by a 2/3 (two thirds) vote of the Nominating
Committee. Should nominees of the Nominating Committee fail to be confirmed by a majority of the Board of
Directors, additional nominations can be made by members of the Board of Directors.

General Powers and Responsibilities of Officers of the

Board of Directors

1. President.

The President shall be the principal executive officer of the ABOP and shall in general supervise the
affairs of the ABOP that include

but are not limited to:

1. Representing the public and professional interests of the ABOP,
2. Writing and editing journal announcements for certification examinations,
3. Choosing journals and other formats in which examinations are to be publicized with the approval of the Board of
Directors,
4. Setting the date and location of certifying examinations with approval of the Board of Directors
5. Presiding over the resolution of disputes between a potential candidate, or candidate, and the ABOP with
approval of the Board of Directors,
6. Calling at least one annual Board of Directors’ meeting to conduct the affairs of the ABOP,
7. Setting the agenda for the Board of Directors’ meetings,

141
8. Setting the budget of the ABOP in consultation with the Treasurer and authorizing loans and payments of debts
with the approval of the Board of Directors,
9. Conferring regularly with the Examination Council Chairperson,
10. Being an ex-officio member of all committees appointed by the Board of Directors and the Examination Council,
11. Appointing committees, and committee chairpersons, all of whom must be Diplomates of the ABOP, to perform
tasks on behalf of the ABOP,
12. Selecting a time and method of updating the ABOP Blueprint with consultation of the Examination Council
Chairperson, and the Independent testing service followed by the majority approval of the Board of Directors,
13. Interviewing candidates to fill the positions of Independent testing service and Executive Secretary, as needed,
and present at least two choices to the Board of Directors for their consideration and approval.
14. Providing documentation necessary to show compliance with the American Dental Association rules and
regulations,
15. Preside over the impeachment process in the event that the Immediate Past President is the subject of
allegations or violations of the ABOP Code of Conduct.
16. Participating as a member of the nominating committee.

2. President-elect

In the absence of the President, or in the event of the President’s inability to act, the President-elect shall
perform the duties of the President. When so acting, the President-elect shall have all the powers of and
be subject to all of the restrictions of the President. The President-elect shall perform additional duties
assigned by the Board of Directors from time to time. The President-elect is a member of the nominating
committee.

3. Immediate Past President

The Immediate Past President’s responsibilities include but are not limited to:
1. Providing counsel to the President,
2. Presiding over meetings of the Nominating Committee,
3. Participating as a member of the nominating committee.
4. Contacting nominees to ensure that the nominee is willing to serve, if confirmed,
5. Presiding over allegations of violations of the ABOP Code of Conduct by a Diplomate,
6. Presiding over impeachment of an official of the Board of Directors, an official of the Examination Council, or a
Diplomate for actions prejudicial to the best interests of the ABOP,
7. Reviewing and recommending to the Board of Directors updates to the Code of Conduct,
8. Performing additional duties assigned by the Board of Directors from time to time.

4. Secretary (also an at-large director)

The Secretary’s responsibilities include but are not limited to:

1. Maintaining a historical record of the ABOP, including names and positions of all ABOP officials and their dates of
tenure, and providing a yearly update of these records to the Executive Secretary of the ABOP,
2. Recording the proceedings of the Board of Directors meetings, maintaining records of the Examination Council
meetings and committee meetings,
3. Maintaining records of the ABOP Blueprint and the means by which the Blueprint was determined,
4. Maintaining lists of candidates who have passed, failed, requested hand scoring of examinations, and those who
are Board eligible,
5. Consulting with the President regularly,
6. Reporting yearly to the Board of Directors.
7. Perform additional duties assigned by the Board of Directors from time to time.

5. Treasurer (also an at-large director)

If required by the Board of Directors the Treasurer shall give a bond for the faithful discharge of his/her
duties a sum and with surety,

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 or sureties, as the Board of Directors may determine

The Treasurer shall have responsibility for:

1. Performing all duties incident to the office and other duties as from time to time may be assigned by the President
or the Board of Directors,
2. Overseeing the management of bank accounts and investment accounts in consultation with the President the
Board of Directors regarding changes in investment strategies,
3. Signing disbursement checks presented by the Executive Secretary, or alternately, signing and faxing an approval
to the Executive Secretary to sign and disburse funds for specific amounts to specific parties. In the event that the
Treasurer is unable to perform this function, the President-elect and President shall be authorized to institute the
disbursement of funds,
4. Reviewing and signing tax documents prepared by the ABOP’s accounting firm,
5. Conferring quarterly with the President,
6. Reporting yearly to the Board of Directors.
7. Perform additional duties assigned by the Board of Directors from time to time.

IX. THE EXAMINATION COUNCIL

General Powers of the Examination Council

1. The purpose of the Examination Council is to construct and recommend to the Board of Directors
psychometrically valid examinations that test minimal competence of the scope and breadth of knowledge of an
orofacial pain practitioner while faithfully adhering to the specifics of the entire ABOP examination blueprint,
oversee examination administration, determine passing scores for each question on examinations, and generally
facilitate the credentialing process,
2. Decisions relating to examination shall be approved by a majority of the Examination Council officials, provided
the construction of the examination does not violate the ABOP examination blueprint and is made in accordance
with the advice of the Independent Testing Service,

1. The Examination Council may write examination questions, solicit questions from experts in the field of orofacial
pain, or, with approval of the Board of Directors, purchase questions from other certification organizations. If
questions are purchased, they must be purchased from certifying boards in the field of pain whose test
construction standards and confidentiality standards are similar to those of the ABOP,
2. The Examination Council rates questions and sets the passing score for each examination according to
guidelines set forth by the Independent Testing Service,
3. The Examination Council shall maintain a standing committee of no less than six Diplomates to administer oral
examinations. The minimal term of officials in this committee is five years beginning June 1 and ending May 31.
Three officials of the Examination Council standing committee may rotate off the committee every five years and
can be replaced by three new officials.
4. The Examination Council publishes an annual Bulletin of Information that describes the types of examinations
being given, the content and approximate proportion of subject content of the examinations, and the date, place,
and time of examinations. The Bulletin of Information shall also describe qualifications to become a candidate for
the certifying examination, the ABOP Code of Conduct, Guidelines for Disciplinary Action, and other information
deemed necessary by the Board of Directors. The Bulletin of Information must be published approximately six (6)
months in advance of the examination date.

Composition, Tenure and Qualifications of the

Examination Council

The officials of the Written Examination Council include a Chairperson, a Vice-Chairperson and not less than 7 or more
than 13 additional Examination Council officials. The geographic representation of the Examination Council should be
consistent with the geographic distribution ratios of the Diplomates of the ABOP,
1. The Written Examination Council officials shall be nominated by the Examination Council Chairperson and
confirmed by the Board of Directors. Once the Examination Council officials have been confirmed by the Board of
Directors, the Written Examination Council Chairperson shall select one of the officials to serve as the Written
Examination Council Vice-Chairperson.
2. The Oral Examination Council Chairperson and Vice-Chairperson must have served on the Examination Council
for at least one examination cycle before assuming these roles,

143
 3. The Oral Examination Council officials shall be nominated by the Examination Council Chairperson and confirmed
by the Board of Directors. Once the Examination Council officials have been confirmed by the Board of Directors,
the Oral Examination Council Chairperson shall select one of the officials to serve as the Examination Council
Vice-Chairperson,

The term of all Examination Council officials will be a minimum of two years and a maximum of 4 years. This term
may be altered at the discretion of the Board of Directors, upon recommendation of the Exam Chair.

The Examination Council Chairperson is the principal officer of the Examination Council and shall preside over all
meetings of the Examination Council,
4. Examination Council officials are expected to contribute to examination construction as determined necessary by
the Examination Council Chairperson and must attend in person at least one of at most 2 annual examination
council meetings.
5. To protect the integrity of the examinations, all officials of the Examination Councils must be Diplomates of the
ABOP and must sign a confidentiality form provided by the Examination Council Chairperson.

General Powers and Responsibilities of Officers of the Examination Councils

1. Examination Council Chairperson
The Examination Council Chairpersons, for the written and oral examinations, shall be the principal officer of the
Examination Council and shall in general supervise the
affairs of the Examination Council that include but are not limited to:
1. Supervising the construction and administration of examinations given by the ABOP.
2. Appointing an official of the Examination Council to serve as Examination Council Vice-Chairpersons.
3. Nominating officials of the Examination Council and securing signed confidentiality forms from each selected
official,
4. Appointing committee(s) and committee chairperson(s) for a specific purpose and for a specific period of time, all
of whom must be Diplomates of the ABOP, to assist the Examination Council Chairperson in carrying out the
responsibilities of the Examination Council,
5. Serving as an ex-officio member of all Examination Council committees,
6. Updating the ABOP Examination Bulletin of Information annually, which must then be approved by the President
of the ABOP. When policies of the ABOP are changed in the Bulletin of Information, approval must be obtained by
a majority vote of the Board of Directors,
1. Publishing the Bulletin of Information in advance of each examination,
2. Setting the agenda for the Examination Council meetings, choosing the date, time and location of the meetings,
and notifying the Independent Testing Service of the meetings to assure that a representative, if necessary,
attends the meetings,
3. Assisting with documentation required by the Independent Testing Service to assure compliance with nationally
accepted standards,
4. Assisting with documentation required by official agencies certifying specialty.
5. Supervising the review, editing, addition and deletion of questions from the ABOP pool of questions with approval
of the Examination Council officials,
6. Reviewing the examination, as presented by the Independent Testing Service to assure the quality and quantity of
questions assigned to each category, discarding questions deemed inappropriate, selecting replacement
questions from the pool of questions and submitting the final examination to the Examination Council for their
editing and approval,
7. Editing and approving for recommendation to the Board of Directors the final draft of examinations providing
changes are consistent with national testing standards and the ABOP blueprint,
8. Recommending to the Board of Directors the cut-off passing score, should there be a statistical variation,
9. Reviewing questioned or disputed items with the Independent Testing Service after the administration of each
examination and making a final determination, with consultation from the President of the ABOP, as to which
items, if any, will be deleted from scoring,
10. Periodically reviewing the Blueprint and recommending to the President of the ABOP whether an update is
needed,
11. Reviewing and advising the President of the ABOP of financial needs of the Examination Council.

2. Examination Council Vice-Chairpersons

In the absence of the Examination Council Chairperson, or in the event of the Chairperson’s inability to
144
 act, the Vice-Chairperson shall perform the duties of the Chairperson. When so acting the Vice-
Chairperson shall have all the powers of and be subject to all of the restrictions on the Chairperson. The
Vice-Chairperson duties include but are not limited to:
1. Reviewing candidate’s applications to take the certifying examination to assure that the candidate has met the
requirements of the ABOP and the ADA to sit for the ABOP Certifying examination. If, in the event the Vice-
Chairperson is uncertain whether a candidate meets the ABOP criteria to sit for the examination, the Vice-
Chairperson will defer the decision to the Examination Chairperson and the Board of Directors,
2. Notifying the Executive Secretary of the candidate’s qualifications to sit for the examination in order to facilitate
completion of documentation required for appearing for the examination,
3. Answering inquiries relating to the eligibility of an applicant for a certifying examination,
4. Functioning as the test supervisor of examinations,
5. Recruiting assistant proctors to help in the administration of the examinations,
6. Assist the Examination Council Chairperson in ways that facilitate the Chairperson to carry out his/her
responsibility,
7. Maintaining minutes of meetings of the Examination Council, and its committees, and reporting the minutes to the
President and Secretary of the ABOP.

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Appendix II. a) Standards for Advanced Education Programs in Orofacial Pain

Commission on Dental Accreditation Standards for Advanced Dental Education Programs in Orofacial
Pain

Commission on Dental Accreditation

211 East Chicago Avenue
Chicago, Illinois 60611-2678

Document Revision Item Action

History Date
August 5, 2016 Accreditation Standards for Advanced General Dentistry Approved
Education Programs in Orofacial Pain
August 5, 2016 Revised Mission Statement Adopted
January 1, 2017 Revised Mission Statement Implemented
July 1, 2017 Accreditation Standards for Advanced General Dentistry Implemented
Education Programs in Orofacial Pain
August 4, 2017 Revised Accreditation Status Definitions Approved,
Implemented
August 4, 2017 Revised Standards 1-5, 1-9, 1-10, 2-2, 2-3, 2-4, Adopted
2-12, 2-18, 2-20, 3-3, 3-6, 4-6, 4-7, 4-9 and 5-1
and new Standard 3-9
July 1, 2018 Revised Standards 1-5, 1-9, 1-10, 2-2, 2-3, 2-4, Implemented
2-12, 2-18, 2-20, 3-3, 3-6, 4-6, 4-7, 4-9 and 5-1
and new Standard 3-9
August 3, 2018 Revised Terminology Related to Advanced Education Adopted
Programs
January 1, 2019 Revised Terminology Related to Advanced Education Implemented
Programs

Mission Statement of the Commission on Dental Accreditation

The Commission on Dental Accreditation serves the public and profession by developing and implementing
accreditation standards that promote and monitor the continuous quality and improvement of dental education
programs.
Commission on Dental Accreditation

Adopted: August 5, 2016

Accreditation Status Definitions
Programs That Are Fully Operational

Approval (without reporting requirements): An accreditation classification granted to an educational program

indicating that the program achieves or exceeds the basic requirements for accreditation.
Approval (with reporting requirements): An accreditation classification granted to an educational program
indicating that specific deficiencies or weaknesses exist in one or more areas of the program. Evidence of
compliance with the cited standards or policies must be demonstrated within a timeframe not to exceed
eighteen (18) months if the program is between one and two years in length or two years if the program is at
least two years in length. If the deficiencies are not corrected within the specified time period, accreditation will
be withdrawn, unless the Commission extends the period for achieving compliance for good cause.
Identification of new deficiencies during the reporting time period will not result in a modification of the specified
deadline for compliance with prior deficiencies.

Circumstances under which an extension for good cause would be granted include, but are not limited to:

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• sudden changes in institutional commitment;
• natural disaster which affects affiliated agreements between institutions; faculty support; or facilities;
• changes in institutional accreditation;
• interruption of an educational program due to unforeseen circumstances that take faculty, administrators or
students away from the program.

Revised: 8/17; 2/16; 5/12; 1/99; Reaffirmed: 8/13; 8/10, 7/05; Adopted: 1/98
Programs That Are Not Fully Operational
A program which has not enrolled and graduated at least one class of students/residents and does not have
students/residents enrolled in each year of the program is defined by the Commission as not fully operational.
The accreditation classification granted by the Commission on Dental Accreditation to programs which are not
fully operational is “initial accreditation.” When initial accreditation status is granted to a developing education
program, it is in effect through the projected enrollment date. However, if enrollment of the first class is delayed
for two consecutive years following the projected enrollment date, the program’s accreditation will be
discontinued, and the institution must reapply for initial accreditation and update pertinent information on
program development. Following this, the Commission will reconsider granting initial accreditation status.

Initial Accreditation is the accreditation classification granted to any dental, advanced dental or allied dental
education program which is not yet fully operational. This accreditation classification provides evidence to
educational institutions, licensing bodies, government or other granting agencies that, at the time of initial
evaluation(s), the developing education program has the potential for meeting the standards set forth in the
requirements for an accredited educational program for the specific occupational area. The classification “initial
accreditation” is granted based upon one or more site evaluation visit(s).
Introduction

This document constitutes the standards by which the Commission on Dental Accreditation and its site visitors
evaluate Advanced Dental Education Programs in Orofacial Pain for accreditation purposes. It also serves as a
program development guide for institutions that wish to establish new programs or improve existing programs.

The standards identify those aspects of program structure and operation that the Commission regards as
essential to program quality and achievement of program goals. They specify the minimum acceptable
requirements for programs and provide guidance regarding alternative and preferred methods of meeting
standards.
Although the standards are comprehensive and applicable to all institutions that offer advanced dental
education programs, the Commission recognizes that methods of achieving standards may vary according to
the size, type, and resources of sponsoring institutions. Innovation and experimentation with alternative ways
of providing required training are encouraged, assuming standards are met and compliance can be
demonstrated. The Commission has an obligation to the public, the profession, and the prospective resident to
assure that programs accredited as Advanced Dental Education Programs in Orofacial Pain provide an
identifiable and characteristic core of required training and experience.

Goals
Advanced Dental Education Programs in Orofacial Pain are educational programs designed to provide training
beyond the level of predoctoral education in oral health care, using applied basic and behavioral sciences.
Education in these programs is based on the concept that oral health is an integral and interactive part of total
health. The programs are designed to expand the scope and depth of the graduates’ knowledge and skills to
enable them to provide care for individuals with orofacial pain.
The goals of these programs should include preparation of the graduate to:
1. Provide education in orofacial pain at a level beyond predoctoral education relating to the basic mechanisms
and the anatomic, physiologic, neurologic, vascular, behavioral, and psychosocial aspects of orofacial pain.
2. Plan and provide interdisciplinary/multidisciplinary health care for a wide variety of patients with orofacial
pain.
3. Interact with other healthcare professionals in order to facilitate the patient’s total healthcare.

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4. Manage the delivery of oral health care by applying concepts of patient and practice management and
quality improvement that are responsive to a dynamic health care environment.
5. Function effectively and efficiently in multiple health care environments and within
interdisciplinary/multidisciplinary health care teams.
6. Apply scientific principles to learning and oral health care. This includes using critical thinking, evidence or
outcomes-based clinical decision-making and technology-based information retrieval systems.
7. Enhance the dissemination of information about diagnosis and treatment/management of orofacial pain to all
practitioners of the health profession.
8. Encourage the development of multidisciplinary teams composed of basic scientists and clinicians from
appropriate disciplines to study orofacial pain conditions, to evaluate current therapeutic modalities, and to
develop new and improve upon existing procedures for diagnosis and treatment/management of such
conditions/diseases/syndromes.
9. Enhance the interaction and communication among those investigating pain at their institution and beyond.
10. Utilize the values of professional ethics, lifelong learning, patient centered care, adaptability, and
acceptance of cultural diversity in professional practice.

Definition of Terms
Key terms used in this document (i.e., Must, should, could and may. were selected carefully and indicate the
relative weight that the commission attaches to each statement. The definition of these words as used in the
standards follows:
Competencies: Written statements describing the levels of knowledge, skills, and values expected of residents
completing the program.
Competent: The level of knowledge, skills, and values required by residents to perform independently an
aspect of dental practice after completing the program.
Educationally qualified: Board eligible in orofacial pain or successful completion of an orofacial pain program of
at least two years in length.
Examples of evidence to demonstrate compliance include: Desirable condition, practice or documentation
indicating the freedom or liberty to follow a suggested alternative.
Intent: Intent statements are presented to provide clarification to the advanced dental education programs in
orofacial pain in the application of and in connection with compliance with the Accreditation Standards for
Advanced Dental Programs in Orofacial Pain. The statements of intent set forth some of the reasons and
purposes for the particular Standards. As such, these statements are not exclusive or exhaustive. Other
purposes may apply.
Interdisciplinary: Including dentistry and other health care professions.
Manage: Coordinate the delivery of care using a patient-focused approach within the scope of their training.
Patient-focused care should include concepts related to the patient’s social, cultural, behavioral, economic,
medical and physical status.
May or could: Indicates freedom or liberty to follow a suggested alternative.
Multidisciplinary: Including all disciplines within the profession of dentistry.
Must: Indicates an imperative or duty; an essential or indispensable item; mandatory.
Patients with special needs: Those patients whose medical, physical, psychological, or social situations make it
necessary to modify normal dental routines in order to provide dental treatment for that individual. These
individuals include, but are not limited to, people with developmental disabilities, complex medical problems,
and significant physical limitations.
Should: Indicates a suggested way to meet the standard; highly desirable, but not mandatory.
SOAP: Subjective Objective Assessment Plan
Sponsor: The institution that has the overall administrative control and responsibility for the conduct of the
program.
Resident: The individual enrolled in a Commission on Dental Accreditation-accredited advanced dental
education program.

STANDARD 1 – INSTITUTIONAL AND PROGRAM EFFECTIVENESS

1-1 Each sponsoring or co-sponsoring United States-based educational institution, hospital or health care

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organization must be accredited by an agency recognized by the United States Department of Education or
accredited by an accreditation organization recognized by the Centers for Medicare and Medicaid Services
(CMS).
United States military programs not sponsored or co-sponsored by military medical treatment facilities, United
States-based educational institutions, hospitals or health care organizations accredited by an agency
recognized by the United States Department of Education or accredited by an accreditation organization
recognized by the Centers for Medicare and Medicaid Services (CMS) must demonstrate successful
achievement of Service-specific organizational inspection criteria.
Examples of evidence to demonstrate compliance may include:
Accreditation certificate or current official listing of accredited institutions
Evidence of successful achievement of Service-specific organizational inspection criteria
1-2 The sponsoring institution must ensure that support from entities outside of the institution does not
compromise the teaching, clinical and research components of the program.
Examples of evidence to demonstrate compliance may include:
Written agreement(s)
Contract(s/Agreement(s) between the institution/program and sponsor(s) related to facilities, funding, and
faculty financial support
1-3 The authority and final responsibility for curriculum development and approval, resident selection, faculty
selection and administrative matters must rest within the sponsoring institution.
1-4 The financial resources must be sufficient to support the program’s stated purpose/mission, goals and
objectives.
Examples of evidence to demonstrate compliance may include:
Program budgetary records
Budget information for previous, current and ensuing fiscal year
1-5 Arrangements with all sites not owned by the sponsoring institution where educational activity occurs must
be formalized by means of current written agreements that clearly define the roles and responsibilities of the
parties involved.
Intent: Sites where educational activity occurs include any dental practice setting (e.g. private offices, mobile
dentistry, mobile dental provider, etc.). The items that are covered in agreements do not have to be contained
in a single document. They may be included in multiple agreements, both formal and informal (e.g., addenda
and letters of mutual understanding).

Examples of evidence to demonstrate compliance may include:

Written agreements
1-6 There must be opportunities for program faculty to participate in institution-wide committee activities.
Examples of evidence to demonstrate compliance may include:
Bylaws or documents describing committee structure
Copy of institutional committee structure and/or roster of membership by dental faculty
1-7 Orofacial pain residents must have the same privileges and responsibilities provided residents in other
professional education programs.
Examples of evidence to demonstrate compliance may include:
Bylaws or documents describing resident privileges
1-8 The medical staff bylaws, rules, and regulations of the sponsoring, co-sponsoring, or affiliated hospital
must ensure that dental staff members are eligible for medical staff membership and privileges.
Intent: Dental staff members have the same rights and privileges as other medical staff of the sponsoring, co-
sponsoring or affiliated hospital, within the scope of practice.
Examples of evidence to demonstrate compliance may include:
All related hospital bylaws
Copy of institutional committee structure and/or roster of membership by dental faculty
1-9 The program must have written overall program goals and objectives that emphasize:
a. orofacial pain,
b. resident education,
c. patient care, and

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d. research.
Intent: The “program” refers to the Advanced Dental Education Program in Orofacial Pain that is responsible
for training residents within the context of providing patient care. The overall goals and objectives for resident
education are intended to describe general outcomes of the residency training program rather than specific
learning objectives for areas of residency training as described in Standard 2-2. Specific learning objectives for
residents are intended to be described as goals and objectives or competencies for resident training and
included in the response to Standard 2-2. An example of overall goals can be found in the Goals section on
page 8 of this document.

Examples of evidence to demonstrate compliance may include:

Written overall program goals and objectives

1-10 The program must have a formal and ongoing outcomes assessment process that regularly evaluates the
degree to which the program’s overall goals and objectives are being met and make program improvements
based on an analysis of that data.
Intent: The intent of the outcomes assessment process is to collect data about the degree to which the overall
goals and objectives described in response to Standard 1-9 are being met.
The outcomes process developed should include each of the following steps:
1. development of clear, measurable goals and objectives consistent with the program's purpose/mission;
2. implementation of procedures for evaluating the extent to which the goals and objectives are met;
3. collection of data in an ongoing and systematic manner;
4. analysis of the data collected and sharing of the results with appropriate audiences;
5. identification and implementation of corrective actions to strengthen the program; and
6. review of the assessment plan, revision as appropriate, and continuation of the cyclical process.

Examples of evidence to demonstrate compliance may include:

Written overall program goals and objectives
Outcomes assessment plan and measures
Outcomes results
Annual review of outcomes results
Meeting minutes where outcomes are discussed
Decisions based on outcomes results
Successful completion of a certifying examination in Orofacial Pain
Ethics and Professionalism
1-11 The program must ensure that residents are able to demonstrate the application of the principles of
ethical reasoning, ethical decision making and professional responsibility as they pertain to the academic
environment, research, patient care, and practice management.
Intent: Residents should know how to draw on a range of resources such as professional codes, regulatory
law, and ethical theories to guide judgment and action for issues that are complex, novel, ethically arguable,
divisive, or of public concern.

STANDARD 2 – EDUCATIONAL PROGRAM

2-1 The orofacial pain program must be designed to provide advanced knowledge and skills beyond the D.D.S.
or D.M.D. training.
Curriculum Content
2-2 The program must either describe the goals and objectives for each area of resident training or list the
competencies that describe the intended outcomes of resident education.
Intent: The program is expected to develop specific educational goals that describe what the resident will be
able to do upon completion of the program. These educational goals should describe the resident’s abilities
rather than educational experiences the residents may participate in. These specific educational goals may be
formatted as either goals and objectives or competencies for each area of resident training. These educational
goals are to be circulated to program faculty and staff and made available to applicants of the program.
Examples of evidence to demonstrate compliance may include:

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Written goals and objectives for resident training or competencies
2-3 Written goals and objectives must be developed for all instruction included in this curriculum.
Example of Evidence to demonstrate compliance may include:
Written goals and objectives
Content outlines
2-4 The program must have a written curriculum plan that includes structured clinical experiences and didactic
sessions designed to achieve the program’s written goals and objectives or competencies for resident training.
Intent: The program is expected to organize the didactic and clinical educational experiences into a formal
curriculum plan. For each specific goal or objective or competency statement described in response to
Standard 2-2, the program is expected to develop educational experiences designed to enable the resident to
acquire the skills, knowledge, and values necessary in that area. The program is expected to organize these
didactic and clinical educational experiences into a formal curriculum plan.
Examples of evidence to demonstrate compliance may include:
Written curriculum plan with educational experiences tied to specific written goals and objectives or
competencies
Didactic and clinical schedules
Biomedical Sciences
2-5 Formal instruction must be provided in each of the following:
a. Gross and functional anatomy and physiology including the musculoskeletal and articular system of the
orofacial, head, and cervical structures;
b. Growth, development, and aging of the masticatory system;
c. Head and neck pathology and pathophysiology with an emphasis on pain;
d. Applied rheumatology with emphasis on the temporomandibular joint (TMJ) and related structures;
e. Sleep physiology and dysfunction;
f. Oromotor disorders including dystonias, dyskinesias, and bruxism;
g. Epidemiology of orofacial pain disorders;
h. Pharmacology and pharmacotherapeutics; and
i. Principals of biostatistics, research design and methodology, scientific writing, and critique of literature.
2-6 The program must provide a strong foundation of basic and applied pain sciences to develop knowledge in
functional neuroanatomy and neurophysiology of pain including:
a. The neurobiology of pain transmission and pain mechanisms in the central and peripheral nervous systems;
b. Mechanisms associated with pain referral to and from the orofacial region;
c. Pharmacotherapeutic principles related to sites of neuronal receptor specific action pain;
d. Pain classification systems;
e. Psychoneuroimmunology and its relation to chronic pain syndromes;
f. Primary and secondary headache mechanisms;
g. Pain of odontogenic origin and pain that mimics odontogenic pain; and
h. The contribution and interpretation of orofacial structural variation (occlusal and skeletal) to orofacial pain,
headache, and dysfunction.

Behavioral Sciences
2-7 Formal instruction must be provided in behavioral science as it relates to orofacial pain disorders and pain
behavior including:
a. cognitive-behavioral therapies including habit reversal for oral habits, stress management, sleep problems,
muscle tension habits and other behavioral factors;
b. the recognition of pain behavior and secondary gain behavior;
c. psychologic disorders including depression, anxiety, somatization and others as they relate to orofacial pain,
sleep disorders, and sleep medicine; and
d. conducting and applying the results of psychometric tests.
Clinical Sciences
2-8 A majority of the total program time must be devoted to providing orofacial pain patient services, including
direct patient care and clinical rotations.
2-9 The program must provide instruction and clinical training for the clinical assessment and diagnosis of

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complex orofacial pain disorders to ensure that upon completion of the program the resident is able to:
a. Conduct a comprehensive pain history interview;
b. Collect, organize, analyze, and interpret data from medical, dental, behavioral, and psychosocial histories
and clinical evaluation to determine their relationship to the patient’s orofacial pain and/or sleep disorder
complaints;
c. Perform clinical examinations and tests and interpret the significance of the data;
Intent: Clinical evaluation may include: musculoskeletal examination of the head, jaw, neck and shoulders;
range of motion; general evaluation of the cervical spine; TM joint function; jaw imaging; oral, head and neck
screening, including facial-skeletal and dental-occlusal structural variations; cranial nerve screening; posture
evaluation; physical assessment including vital signs; and diagnostic blocks.
d. Function effectively within interdisciplinary health care teams, including the recognition for the need of
additional tests or consultation and referral; and
Intent: Additional testing may include additional imaging; referral for psychological or psychiatric evaluation;
laboratory studies; diagnostic autonomic nervous system blocks, and systemic anesthetic challenges.
e. Establish a differential diagnosis and a prioritized problem list.

2-10 The program must provide instruction and clinical training in multidisciplinary pain management for the
orofacial pain patient to ensure that upon completion of the program the resident is able to:
a. Develop an appropriate treatment plan addressing each diagnostic component on the problem list with
consideration of cost/risk benefits;
b. Incorporate risk assessment of psychosocial and medical factors into the development of the individualized
plan of care;
c. Obtain informed consent;
d. Establish a verbal or written agreement, as appropriate, with the patient emphasizing the patient’s treatment
responsibilities;
e. Have primary responsibility for the management of a broad spectrum of orofacial pain patients in a
multidisciplinary orofacial pain clinic setting, or interdisciplinary associated services. Responsibilities should
include:
1. intraoral appliance therapy;
2. physical medicine modalities;
3. sleep-related breathing disorder intraoral appliances;
4. non-surgical management of orofacial trauma;
5. behavioral therapies beneficial to orofacial pain; and
6. pharmacotherapeutic treatment of orofacial pain including systemic and topical medications and
diagnostic/therapeutic injections.
Intent: This should include judicious selection of medications directed at the presumed pain mechanisms
involved, as well as adjustment, monitoring, and reevaluation.
Common medications may include: muscle relaxants; sedative agents for chronic pain and sleep management;
opioid use in management of chronic pain; the adjuvant analgesic use of tricyclics and other antidepressants
used for chronic pain; anticonvulsants, membrane stabilizers, and sodium channel blockers for neuropathic
pain; local and systemic anesthetics in management of neuropathic pain; anxiolytics; analgesics and anti-
inflammatories; prophylactic and abortive medications for primary headache disorders; and therapeutic use of
botulinum toxin injections.
Common issues may include: management of medication overuse headache; medication side effects that alter
sleep architecture; prescription medication dependency withdrawal; referral and co-management of pain in
patients addicted to prescription, non prescription and recreational drugs; familiarity with the role of preemptive
anesthesia in neuropathic pain.

2-11 Residents must participate in clinical experiences in other healthcare services (not to exceed 30% of the
total training period).
Intent: Experiences may include observation or participation in the following: oral and maxillofacial surgery to
include procedures for intracapsular TMJ disorders; outpatient anesthesia pain service; in-patient pain rotation;
rheumatology, neurology, oncology, otolaryngology, rehabilitation medicine; headache, radiology, oral

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medicine, and sleep disorder clinics.
2-12 Each assigned rotation or experience must have:
a. written objectives that are developed in cooperation with the department chairperson, service chief, or facility
director to which the residents are assigned;
b. resident supervision by designated individuals who are familiar with the objectives of the rotation or
experience; and
c. evaluations performed by the designated supervisor.
Intent: This standard applies to all assigned rotations or experiences, whether they take place in the
sponsoring institution or a major or minor activity site. Supplemental activities are exempt.
Examples of evidence to demonstrate compliance may include:
Description and schedule of rotations
Written objectives of rotations
Resident evaluations
2-13 Residents must gain experience in teaching orofacial pain.

Intent: Residents should be provided opportunities to obtain teaching experiences in orofacial pain (i.e. small
group and lecture formats, presenting to dental and medical peer groups, predoctoral student teaching
experiences, and/or continuing education programs.
2-14 Residents must actively participate in the collection of history and clinical data, diagnostic assessment,
treatment planning, treatment, and presentation of treatment outcome.
2-15 The program must provide instruction in the principles of practice management.
Intent: Suggested topics include: quality management; principles of peer review; business management and
practice development; principles of professional ethics, jurisprudence and risk management; alternative health
care delivery systems; informational technology; and managed care; medicolegal issues, workers
compensation, second opinion reporting; criteria for assessing impairment and disability; legal guidelines
governing licensure and dental practice, scope of practice with regards to orofacial pain disorders, and
instruction in the regulatory requirements of chronic opioid maintenance.
Examples of evidence to demonstrate compliance may include:
Course outlines
2-16 Formal patient care conferences must be held at least ten (10) times per year.
Intent: Conferences should include diagnosis, treatment planning, progress, and outcomes. These conferences
should be attended by residents and faculty representative of the disciplines involved. These conferences are
not to replace the daily faculty/resident interactions regarding patient care.
Examples of evidence to demonstrate compliance may include:
Conference schedules
2-17 Residents must be given assignments that require critical review of relevant scientific literature.
Intent: Residents are expected to have the ability to critically review relevant literature as a foundation for
lifelong learning and adapting to changes in oral health care. This should include the development of critical
evaluation skills and the ability to apply evidence-based principles to clinical decision-making.
Relevant scientific literature should include current pain science and applied pain literature in dental and
medical science journals with special emphasis on pain mechanisms, orofacial pain, head and neck pain, and
headache.
Examples of evidence to demonstrate compliance may include:
Evidence of experiences requiring literature review
Program Length
2-18 The duration of the program must be at least two consecutive academic years with a minimum of 24
months, full-time or its equivalent.
Examples of evidence to demonstrate compliance may include:
Program schedules
Written curriculum plan
2-19 Where a program for part-time residents exists, it must be started and completed within a single institution
and designed so that the total curriculum can be completed in no more than twice the duration of the program
length.

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Intent: Part-time residents may be enrolled, provided the educational experiences are the same as those
acquired by full-time residents and the total time spent is the same.
Examples of evidence to demonstrate compliance may include:
Description of the part-time program
Documentation of how the part-time residents will achieve similar experiences and skills as full-time residents
Program schedules
Evaluation
2-20 The program’s resident evaluation system must assure that, through the director and faculty, each
program:
a) periodically, but at least two times annually, evaluates and documents the resident’s progress toward
achieving the program’s written goals and objectives of resident training or competencies using appropriate
written criteria and procedures;
b) provides residents with an assessment of their performance after each evaluation. Where deficiencies are
noted, corrective actions must be taken; and
c) maintains a personal record of evaluation for each resident that is accessible to the resident and available
for review during site visits.

Intent: While the program may employ evaluation methods that measure a resident’s skills or behavior at a
given time, it is expected that the program will, in addition, evaluate the degree to which the resident is making
progress toward achieving the specific goals and objectives or competencies for resident training described in
response to Standard 2-2.
Examples of evidence to demonstrate compliance may include:
Written evaluation criteria and process
Resident evaluations with identifying information removed
Personal record of evaluation for each resident
Evidence that corrective actions have been taken

STANDARD 3 – FACULTY AND STAFF

3-1 The program must be administered by a director who is board certified or educationally qualified in
orofacial pain and has a full-time appointment in the sponsoring institution with a primary commitment to the
orofacial pain program.
3-2 The program director must have sufficient authority and time to fulfill administrative and teaching
responsibilities in order to achieve the educational goals of the program.
Intent: The program director’s responsibilities include:
a. program administration;
b. development and implementation of the curriculum plan;
c. ongoing evaluation of program content, faculty teaching, and resident performance;
d. evaluation of resident training and supervision in affiliated institutions and off-service rotations;
e. maintenance of records related to the educational program; and
f. resident selection; and
g. preparing graduates to seek certification by the American Board of Orofacial Pain.
In those programs where applicants are assigned centrally, responsibility for selection of residents may be
delegated to a designee.
Examples of evidence to demonstrate compliance may include:
Program director’s job description
Job description of individuals who have been assigned some of the program director’s job responsibilities
Formal plan for assignment of program director’s job responsibilities as described above
Program records
3-3 All sites where educational activity occurs must be staffed by faculty who are qualified by education and/or
clinical experience in the curriculum areas for which they are responsible and have collective competence in all
areas of orofacial pain included in the program.
Intent: Faculty should have current knowledge at an appropriate level for the curriculum areas for which they
are responsible. The faculty, collectively, should have competence in all areas of orofacial pain covered in the

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program.
The program is expected to develop criteria and qualifications that would enable a faculty member to be
responsible for a particular area of orofacial pain if that faculty member is not trained in orofacial pain. The
program is expected to evaluate non-discipline specific faculty members who will be responsible for a particular
area and document that they meet the program’s criteria and qualifications.
Whenever possible, programs should avail themselves of discipline-specific faculty as trained consultants for
the development of a mission and curriculum, and for teaching.
Examples of evidence to demonstrate compliance may include:
Full and part-time faculty rosters
Program and faculty schedules
Completed BioSketch of faculty members
Criteria used to certify a non-discipline specific faculty member as responsible for teaching an area of orofacial
pain
Records of program documentation that non-discipline specific faculty members as responsible for teaching an
area of orofacial pain
3-4 A formally defined evaluation process must exist that ensures measurements of the performance of faculty
members annually.
Intent: The written annual performance evaluations should be shared with the faculty members. The program
should provide a mechanism for residents to confidentially evaluate instructors, courses, program director, and
the sponsoring institution.
Examples of evidence to demonstrate compliance may include:
Faculty files
Performance appraisals
3-5 A faculty member must be present in the clinic for consultation, supervision, and active teaching when
residents are treating patients in scheduled clinic sessions.
Intent: This standard does not preclude occasional situations where a faculty member cannot be available.
Faculty members should contribute to an ongoing resident and program/curriculum evaluation process. The
teaching staff should be actively involved in the development and implementation of the curriculum.
Examples of evidence to demonstrate compliance may include:
Faculty clinic schedules
3-6 At each site where educational activity occurs, adequate support staff, including allied dental personnel
and clerical staff, must be consistently available to allow for efficient administration of the program.

Intent: The program should determine the number and participation of allied support and clerical staff to meet
the educational and experiential goals and objectives.
Examples of evidence to demonstrate compliance may include:
Staff schedules
3-7 There must be evidence of scholarly activity among the orofacial pain faculty

Intent: Such evidence may include: participation in clinical and/or basic research; mentoring of orofacial pain
resident research; publication in peer-reviewed scientific media; development of innovative teaching materials
and courses; and presentation at scientific meetings and/or continuing education courses at the local, regional,
or national level.
3-8 The program must show evidence of an ongoing faculty development process.
Intent: Ongoing faculty development is a requirement to improve teaching and learning, to foster curricular
change, to enhance retention and job satisfaction of faculty, and to maintain the vitality of academic dentistry
as the wellspring of a learned profession.
Examples of evidence to demonstrate compliance may include:
Participation in development activities related to teaching, learning, and assessment
Attendance at regional and national meetings that address contemporary issues in education and patient care
Mentored experiences for new faculty
Scholarly productivity
Presentations at regional and national meetings

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Examples of curriculum innovation
Maintenance of existing and development of new and/or emerging clinical skills
Documented understanding of relevant aspects of teaching methodology
Curriculum design and development
Curriculum evaluation
Resident assessment
Cultural Competency
Ability to work with residents of varying ages and backgrounds
Use of technology in didactic and clinical components of the curriculum
Evidence of participation in continuing education activities
3-9 The program must provide ongoing faculty calibration at all sites where educational activity occurs.
Intent: Faculty calibration should be defined by the program.
Examples of evidence to demonstrate compliance may include:
Methods used to calibrate faculty as defined by the program
Attendance of faculty meetings where calibration is discussed
Mentored experiences for new faculty
Participation in program assessment
Standardization of assessment of resident
Maintenance of existing and development of new and/or emerging clinical skills
Documented understanding of relevant aspects of teaching methodology
Curriculum design, development and evaluation
Evidence of the ability to work with residents of varying ages and backgrounds
Evidence that rotation goals and objectives have been shared

STANDARD 4 – EDUCATIONAL SUPPORT SERVICES

4-1 The sponsoring institution must provide adequate and appropriately maintained facilities and learning
resources to support the goals and objectives of the program.
Intent: The facilities should permit the attainment of program goals and objectives. Clinical facilities suitable for
privacy for patients should be specifically identified for the orofacial pain program. Library resources that
include dental resources should be available. Resource facilities should include access to computer,
photographic, and audiovisual resources for educational, administrative, and research support. Equipment for
handling medical emergencies and current medications for treating medical emergencies should be readily
accessible. “Readily accessible” does not necessarily mean directly in the dental clinic. Protocols for handling
medical emergencies should be developed and communicated to all staff in patient care areas.
Examples of evidence to demonstrate compliance may include:
Description of facilities
4-2 There must be provision for a conference area separated from the clinic for rounds discussion and case
presentations, sufficient to accommodate the multidisciplinary team.

4-3 Dental and medical laboratory, dental and medical imaging, and resources for psychometric interpretation
must be accessible for use by the orofacial pain program.

4-4 Lecture, seminar, study space, and administrative office space must be available to conduct the
educational program.
Selection of Residents

4-5 Applicants must have one of the following qualifications to be eligible to enter the advanced dental
education program in orofacial pain:
a. Graduates from a predoctoral dental education program accredited by the Commission on Dental
Accreditation;
b. Graduates from a predoctoral dental education program in Canada accredited by the Commission on Dental
Accreditation of Canada; and
c. Graduates from an international dental school with equivalent educational background and standing as

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determined by the institution and program.

4-6 Specific written criteria, policies and procedures must be followed when admitting residents.
Intent: Written non-discriminatory policies are to be followed in selecting residents. These policies should make
clear the methods and criteria used in recruiting and selecting residents and how applicants are informed of
their status throughout the selection process.
Examples of evidence to demonstrate compliance may include:
Written admission criteria, policies and procedures

4-7 Admission of residents with advanced standing must be based on the same standards of achievement
required by residents regularly enrolled in the program. Residents with advanced standing must receive an
appropriate curriculum that results in the same standards of competence required by residents regularly
enrolled in the program.
Intent: Advanced standing refers to applicants that may be considered for admission to a training program
whose curriculum has been modified after taking into account the applicant’s past experience. Examples
include transfer from a similar program at another institution, completion of training at a non-CODA accredited
program, or documented practice experience in the given discipline. Acceptance of advanced standing
residents will not result in an increase of the program’s approved number of enrollees. Applicants for advanced
standing are expected to fulfill all of the admission requirements mandated for residents in the conventional
program and be held to the same academic standards. Advanced standing residents, to be certified for
completion, are expected to demonstrate the same standards of competence as those in the conventional
program.
Examples of evidence to demonstrate compliance may include:
Written policies and procedures on advanced standing
Results of appropriate qualifying examinations
Course equivalency or other measures to demonstrate equal scope and level of knowledge

4-8 The program’s description of the educational experience to be provided must be available to program
applicants and include:
a. a description of the educational experience to be provided;
b. a list of program goals and objectives; and
c. a description of the nature of assignments to other departments or institutions.

Intent: This includes applicants who may not personally visit the program and applicants who are deciding
which programs to apply to. Materials available to applicants who visit the program in person will not satisfy
this requirement. A means of making this information available to individuals who do not visit the program is to
be developed.
Examples of evidence to demonstrate compliance may include:
Brochure or application documents
Program’s website
Description of system for making information available to applicants who do not visit the program
Due Process

4-9 There must be specific written due process policies and procedures for adjudication of academic and
disciplinary complaints that parallel those established by the sponsoring institution.
Intent: Adjudication procedures should include institutional policy that provides due process for all individuals
who may be potentially involved when actions are contemplated or initiated that could result in dismissal of a
resident. Residents should be provided with written information that affirms their obligations and responsibilities
to the institution, the program and the faculty. The program information provided to the residents should
include, but not necessarily be limited to, information about tuition, stipend or other compensation, vacation
and sick leave, practice privileges and other activity outside the educational program, professional liability
coverage, due process policy, and current accreditation status of the program.
Examples of evidence to demonstrate compliance may include:

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Written policy statements and/or resident contract

STANDARD 5 – PATIENT CARE SERVICES

5-1 The program must ensure the availability of patient experiences that afford all residents the opportunity to
achieve the program’s written goals and objectives or competencies for resident training.
Intent: Patient experiences should include evaluation and management of head and neck musculoskeletal
disorders, neurovascular pain, neuropathic pain, sleep-related disorders, and oromandibular movement
disorders.
Examples of evidence to demonstrate compliance may include:
Written goals and objectives or competencies for resident training
Records of resident clinical activity, including specific details on the variety and type and quantity of cases
treated and procedures performed

5-2 Patient records must be organized in a manner that facilitates ready access to essential data and be
sufficiently legible and organized so that all users can readily interpret the contents.
Intent: Essential data is defined by the program and based on the information included in the record review
process as well as that which meets the multidisciplinary educational needs of the program. The patient record
should include a diagnostic problem list, use of pain assessment and treatment contracts, progress sheets,
medication log, and outcome data, plus conform to SOAP notes format.
The program is expected to develop a description of the contents and organization of patient records and a
system for reviewing records.
Examples of evidence to demonstrate compliance may include:
Patient records
Record review plan
Documentation of record reviews

5-3 The program must conduct and involve residents in a structured system of continuous quality improvement
for patient care.
Intent: Programs are expected to involve residents in enough quality improvement activities to understand the
process and contribute to patient care improvement.
Examples of evidence to demonstrate compliance may include:
Description of quality improvement process including the role of residents in that process
Quality improvement plan and reports

5-4 All residents, faculty, and support staff involved in the direct provision of patient care must be continuously
recognized/certified in basic life support procedures, including cardiopulmonary resuscitation.
Intent: ACLS and PALS are not a substitute for BLS certification.
Examples of evidence to demonstrate compliance may include:
Certification/recognition records demonstrating basic life support training or summary log of
certification/recognition maintained by the program
Exemption documentation for anyone who is medically or physically unable to perform such services

5-5 The program must document its compliance with the institution’s policy and applicable regulations of local,
state and federal agencies, including, but not limited to, radiation hygiene and protection, ionizing radiation,
hazardous materials, and blood-borne and infectious diseases. Polices must be provided to all residents,
faculty and appropriate support staff and continuously monitored for compliance. Additionally, policies on
blood-borne and infectious diseases must be made available to applicants for admission and patients.
Intent: The policies on blood-borne and infectious diseases should be made available to applicants for
admission and patients should a request to review the policy be made.
Examples of evidence to demonstrate compliance may include:
Infection and biohazard control policies
Radiation policy

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5-6 The program’s policies must ensure that the confidentiality of information pertaining to the health status of
each individual patient is strictly maintained.
Examples of evidence to demonstrate compliance may include:
Confidentiality policies

STANDARD 6 - RESEARCH
6-1 Residents must engage in research or other scholarly activity and present their results in a
scientific/educational forum.

Intent: The research experience and its results should be compiled into a document or publication

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 Appendix II b) Self Study Accreditation Guidelines for Orofacial Pain by the ADA Commission on
Dental Accreditation

Document Revision History

Date Item Action

January 1, 2010 Self-Study Guide for the Accreditation of an Advanced Effective
General Dentistry Education Program in Orofacial Pain

August 6, 2010 Policy Additions and Revisions (Distance Education, Off- Adopted
Campus Sites), Revised Criteria for Granting
Accreditation.

January 1, 2011 Policy Additions and Revisions (Distance Education, Off- Implemented
Campus Sites), Revised Criteria for Granting
Accreditation.

February 4, 2011 Ethics and Professionalism Standard (1-11) Adopted

July 1, 2011 Ethics and Professionalism Standard (1-1) Implemented

August 5, 2011 Addition of intent statement to Standard 5-4 Adopted and
Implemented

August 5, 2011 Selection of Residents Standard (4-5) Adopted

February 3, 2012 Revised Standard 1-1 Adopted
July 1, 2012 Selection of Residents Standard (4-5) Implemented
July 1, 2012 Revised Standard 1-1 Implemented
August 1, 2012 Revised Compliance with Commission Policies and Implemented
Program Effectiveness sections

February 1, 2013 Addition of Exhibit 13 (BioSketch) Implemented

February 1, 2013 Revised Policy on Accreditation of Off-Campus Sites Adopted and
Implemented
February 1, 2013 Addition of Faculty Development Standard (3-8) Adopted
February 1, 2013 Revised Compliance with Commission Policies section Implemented
(Complaints)

July 1, 2013 Addition of Faculty Development Standard (3-8) Implemented

Document Revision History (cont)

August 9, 2013 Revised Policy on Accreditation of Off-Campus Sites Adopted and

Implemented

August 9, 2013 Revised Instructions for Completing Self-Study Adopted and

Implemented
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August 9, 2013 Revision of intent statement for Standard 5-4 Adopted and
Implemented

January 30, 2014 Revised Examples of Evidence for Standard 1-1 Implemented
January 30, 2014 Revised Protocol for Conducting a Site Visit Implemented
February 6, 2015 Revised Standard 1-1 Adopted, Implemented
February 6, 2015 Revised Standard 4-7 Adopted, Implemented
February 6, 2015 Addition of intent statement to Standard 4-7 Adopted, Implemented
August 7, 2015 Revision of term “resident” to “resident.” Approved, Implemented
August 7, 2015 Updated language related to Privacy and Data Implemented
Security Requirements for Institutions
August 7, 2015 Addition of Program Changes to Compliance with Implemented
Commission Policies section

Commission on Dental Accreditation

211 East Chicago Avenue
Chicago, Illinois 60611-2678

(312) 440-4653
www.ada.org/coda

Copyright©2015
Commission on Dental Accreditation
All rights reserved. Reproduction is strictly prohibited without prior written permission

Table of Contents

Introduction to the Self-Study Page 4

Policies and Procedures Related to the Evaluation of Advanced General

Dentistry Education Programs in Orofacial Pain Page 6

Organizing the Self-Study Page 9

Instructions for Completing the Self-Study Report Page 11

Administration Verification Page 14

Compliance with Commission Policies and Program Effectiveness Page 15

Summary of Factual Information Page 17

Standard 1 – Institutional and Program Effectiveness Page 18

Standard 2 – Educational Program Page 26
Standard 3 – Faculty and Staff Page 40
Standard 4 – Educational Support Services Page 45
Standard 5 – Patient Care Services Page 51
Standard 6 – Research Page 55
Summary of Self-Study Report Page 56

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Appendices Page 57

Index of Suggested Exhibits Page 66

Protocol for Conducting Site Visit Page 79

INTRODUCTION TO THE SELF-STUDY GUIDE

The Self-Study Guide is designed to help an institution succinctly present information about its Advanced
General Dentistry Education Programs in Orofacial Pain in preparation for an evaluation visit by the
Commission on Dental Accreditation. It is suggested that the institution initiate the self-study process
approximately 12 months prior to completion of the Self-Study Report. The primary focus of the self-study
process should be to assess the effectiveness of the educational program in meeting (1) the program’s stated
goals and objectives and (2) the Commission’s Accreditation Standards for Advanced General Dentistry
Education Programs in Orofacial Pain.

The Self-Study Report should be a concise, yet thorough, summary of the findings of the self-study process.
The Commission hopes that the self-study will be a catalyst for program improvement that continues long after
the accreditation process has been completed. In its opinion, this is a more likely outcome if there is thorough
planning, as well as involvement of residents and administrators in the self-study process. Most programs will
concentrate upon questions germane to the Commission’s Accreditation Standards. Nevertheless, the benefits
of self-study are directly related to the extent to which programs evaluate their efforts, not simply in light of
minimal standards for accreditation, but also in reference to the program’s stated goals and objectives as well
as standards for educational excellence. Conclusions of the self-study may include qualitative evaluation of
any aspect of the program whether it is covered in the Self-Study Guide or not. Programs must respond to all
questions included in the Self-Study Guide. The responses should be succinct, but must in every case provide
or cite evidence demonstrating achievement of objectives in compliance with each of the Accreditation
Standards.

For the Commission and visiting committee, the self-study process should:

1. Ensure that the program has seriously and analytically reviewed its objectives, strengths and
weaknesses.

2. Provide the site visitors the basic information about the program and the program’s best judgment of its
own adequacy and performance, thus providing a frame of reference to make the visit effective and helpful to
the program and the Commission.

3. Ensure that the accrediting process is perceived not simply as an external review but as an essential
component of program improvement.

4. Ensure that the Commission, in reaching its accreditation decisions, can benefit from the insights of
both the program and the visiting committee.

The Self-Study process and report are not the following:

A self-study is not just a compilation of quantitative data. Such data may be a prerequisite for developing an
effective self-study, but such data in themselves are not evaluative and must not be confused with a self-study.

A self-study is not or should not be answers to a questionnaire or a check-off sheet. While a questionnaire
may be probing, it is essentially an external form and does not relieve the responder of the critical review
essential to self-study. A check-off list based on the Commission’s Accreditation Standards can be helpful in
developing the self-study but does not reveal the conditions or rationale leading to the answers - again both the

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organizing activity and the critical analysis are missing.

A self-study is not or should not be a simple narrative description of the program. While such a description is
necessary, the self-study should go beyond such description to an analysis of strengths and weaknesses in
light of the program’s objectives, as well as develop a plan for achieving those objectives that have not been
fully realized. It should be emphasized that, while the self-study is essential to the accrediting process, the
major value of an effective self-study should be to the program itself. The report is a document which
summarizes the methods and findings of the self-study process. Thus, a self-study report written exclusively
by a consultant or an assigned administrator or faculty member is not a self-study.

POLICIES AND PROCEDURES RELATED TO THE EVALUATION OF ADVANCED GENERAL DENTISTRY

EDUCATION PROGRAMS IN OROFACIAL PAIN

The Commission has established a seven-year site visit cycle for accreditation review. Every effort is made to
review all existing dental and dental-related programs in an institution at the same time. However, adherence
to this policy of institutional review may be influenced by a number of factors, e.g., graduation date established
for new programs, recommendations in previous Commission reports, and/or current accreditation status.

The purpose of the site evaluation is to obtain in-depth information concerning all administrative and
educational aspects of the program. The site visit verifies and supplements the information contained in the
comprehensive self-study document completed by the institution prior to the site evaluation.

As stated in “Instructions for Completing the Self-Study Report,” one copy of the completed Self-Study Report
should be sent directly to each member of the visiting committee at least sixty (60) days prior to the date of the
visit. Names and addresses of the members of the team will be provided to the institution approximately two to
three months ahead of the visit. In addition, one copy of all self-study materials is to be submitted to the
Commission office sixty (60) days in advance of the visit. NOTE: If a Commission staff member is serving on
the visiting committee, the Commission should receive one copy of the self-study report for this individual and
a second copy for the program’s files.

Third Party Comment Policy: The program is responsible for soliciting third party comments from residents
and patients that pertain to the Standards or policies and procedures used in the Commission’s accreditation
process. An announcement for soliciting third party comments is to be published at least ninety (90) days prior
to the site visit. The notice should indicate that third party comments are due in the Commission’s office no
later than sixty (60) days prior to the site visit. Please review the entire policy on “Third Party Comments” in
the Commission’s EOPP: Evaluation and Operational Policies and Procedures.

Complaints Policy: The program is responsible for developing and implementing a procedure demonstrating
that residents are notified, at least annually, of the opportunity and the procedures to file complaints with the
Commission. Additionally, the program must maintain a record of complaints received since the Commission’s
last comprehensive review of the program. Commission on Dental Accreditation site visitors will expect to have
documentation demonstrating compliance with the policy on “Complaints” made available on-site. Please refer
to the Commission’s publication, Evaluation and Operational Policies and Procedures for the entire policy on
“Complaints.”

Distance Education: Programs that offer distance education must have processes in place through which the
program establishes that the resident who registers in a distance education course or program is the same
resident who participates in and completes the course or program and receives the academic credit. In
addition, programs must notify residents of any projected additional resident charges associated with the
verification of resident identity at the time of registration or enrollment. Please read the entire policy on
“Distance Education” in the Commission’s EOPP: Evaluation and Operational Policies and Procedures manual.

Consultant Requests or Additional Information: Visiting committee members are expected to carefully review

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the completed self-study reports and note any questions or concerns they may have about the information
provided. These questions are forwarded to Commission staff (or staff representatives), compiled and
submitted to the program director prior to the visit. The requested information is provided to the team
members either prior to the visit or upon their arrival to the program.

Site Visit Committee Composition: The Commission on Dental Accreditation’s accreditation program is
accomplished through mechanisms of annual surveys, site evaluations and Commission reviews. The visiting
committees are assigned to review dental and dental-related programs by the Commission Chairman. The
visiting committees are composed, as appropriate, of Commission staff representatives who are responsible
for coordinating the visit and preparing the site visit report; Commission representatives/dentists who chair the
committees; and Commission-appointed site visitors in orofacial pain.

For advanced education site visits, the Commission urges the program to invite a representative from the
dental examining board of the state in which the program is located to participate with the committee as the
State Board representative. This representation; however, must be at the request of the institution/program
being evaluated. State Board representatives participate fully in site visit committee activities as non-voting
members of the committee. State Board representatives are required to sign the Commission’s “Agreement of
Confidentiality.”

After the Site Visit: The written site visit report embodies a review of the quality of the program. It serves as
the basis for accreditation decisions. It also guides officials and administrators of educational institutions in
determining the degree of their compliance with the accreditation standards. The report clearly delineates any
observed deficiencies in compliance with standards on which the Commission will take action.

The Commission is sensitive to the problems confronting institutions of higher learning. In the report, the
Commission evaluates educational programs based on accreditation standards and provides constructive
recommendations which relate to the Accreditation Standards and suggestions which relate to program
enhancement.

Preliminary drafts of site visit reports are prepared by the site visitors, consolidated by staff into a single
document and approved by the visiting committee. The approved draft report is then transmitted to the
institutional administrator for factual review and comment prior to its review by the Commission. The institution
has a maximum of thirty (30) days in which to respond. Both the visiting committee’s approved draft report and
the institution’s response to it are considered by the Commission in taking the accreditation action.

The site visit report reflects the program as it exists at the time of the site visit. Any improvements or changes
made subsequent to a site visit may be described and documented in the program’s response to the
preliminary draft report, which becomes part of the Commission’s formal record of the program’s evaluation.
Such improvements or changes represent progress made by the institution and are considered by the
Commission in determining accreditation status, although the site visit report is not revised to reflect these
changes. Following assignment of accreditation status, the final site visit report is prepared and transmitted to
the institution. The Commission expects the chief administrators of educational institutions to make copies of
the Commission site visit reports available to program directors, faculty members and others directly
concerned with program quality so that they may work toward meeting the recommendations contained in the
report.

Commission members and visiting committee members are not authorized, under any circumstances, to
disclose any information obtained during site visits or Commission meetings. The extent to which publicity is
given to site visit reports is determined by the chief administrator of the educational institution. Decisions to
publicize reports, in part or in full, are at the discretion of the educational institution officials, rather than the
Commission. However, if the institution elects to release sections of the report to the public, the Commission
reserves the right to make the entire site visit report public.

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Commission Review of Site Visit Reports: The Commission and its review committees meet twice each year to
consider site visit reports, progress reports, applications for accreditation and policies related to accreditation.
These meetings are usually in January and July. Reports from site visits conducted less than ninety (90) days
prior to a Commission meeting are usually deferred and considered at the next Commission meeting.

Notification of Accreditation Action: An institution will receive the formal site visit report, including the
accreditation status, within 30 days following the official meeting of the Commission. The Commission’s
definitions of accreditation classifications are published in its Accreditation Standards documents.

Additional Information: Additional information regarding the procedures followed during the site visit is
contained in the Commission’s publication, Evaluation Policies and Procedures. The Commission uses the
Accreditation Standards for Advanced General Dentistry Education Programs in Orofacial Pain as the basis for
its evaluation of Advanced General Dentistry Education Programs in Orofacial Pain; therefore, it is essential
that institutions be thoroughly familiar with this document.

ORGANIZING FOR THE SELF-STUDY

The self-study should be comprehensive and should involve appropriate faculty and staff throughout the
institution.

When feasible, it is suggested that a committee, with appropriate faculty representation, be selected to assist
the program director with the self-study process. This committee should be responsible for developing and
implementing the process of self-study and coordinating the sections into a coherent self-study report. It may
be desirable to establish early in the process some form or pattern to be used in preparing the sections in the
report in order to provide consistency.

The committee should have assistance with preparing and editing the final self-study report. Appropriate
faculty and other institutional representatives (e.g., learning resources staff, financial/budget officers,
counselors, admissions officers, instructional design staff) should be involved in the process to ensure that the
Self-Study Report reflects the input of all individuals who have responsibility for the program.

Suggested Timetable for Self-Study

Months Prior to Visit

12 Appoint committee and resource persons; Assign sections of self-study to appropriate faculty-
resource persons; Develop action plan and report format

10 Sections of report are analyzed and developed by assigned individuals

7 Faculty and program director review tentative reports

6 Committee prepares rough draft of self-study document

5 Draft document is reviewed institution-wide

4 Self-study document finalized and duplicated

3 Solicit comments in accordance with the “Policy on Third Party Comments” found in the Commission’s
Evaluation and Operational Policies and Procedures manual.

2 Final self-study document forwarded to Commission and members of the visiting committee
sixty (60) days prior to date of the scheduled visit.

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Staff Assistance/Consultation: The Commission on Dental Accreditation provides staff consultation to all
educational programs within its accreditation purview. Programs may obtain staff counsel and guidance at any
time.

Policies and Procedures for Site Visits: These policies and procedures are included at the end of this Self-
Study Guide.

Self-Study Format: As noted in the instructions with this Self-Study Guide, this is a suggested approach to
completing a self-study report. All institutions should be aware that the Commission respects their right to
organize their data differently and will allow programs to develop their own formats for the exhibits requested in
the “Examples of Evidence” to demonstrate compliance may include” sections of the Guide. However, if the
program’s proposed format differs from that suggested in the Self-Study Guide, the program should contact
Commission staff for review and approval prior to initiating the self-study process. This procedure will provide
assurance to the program that its proposed format will include the elements considered essential by the
Commission and its visiting committees.

INSTRUCTIONS FOR COMPLETING THE SELF-STUDY

The following general instructions apply to the development of the Advanced General Dentistry Education
Programs in Orofacial Pain program’s self-study report:

1. It is expected that information collected during the self-study will be presented in the order that the
sections and questions occur in the Guide. The sections of the report should culminate in a qualitative analysis
of the program’s strengths and weaknesses. Keep in mind that the program’s written responses must provide
the Commission and its visiting committee with enough information to understand the operation of the
programs.

2. The suggested format for preparing the report is to state the question and then provide the narrative
response. A copy of the Self-Study Guide is available on a word processing program (IBM compatible-
Microsoft Word) from the Commission office.

3. All questions posed in the Guide should be addressed. In the event that a program has chosen to meet
a particular standard in a manner other than that suggested by the questions, please so indicate and explain
how the program complies with the Standards. There is no need to repeat at length information that can be
found elsewhere in the documentation. Simply refer the reader to that section of the report or appended
documentation which contains the pertinent information.

4. The completed self-study document should include appropriately indexed sections; pages should be
numbered. (The page numbers in the completed document are not expected to correspond to the page
numbers in this Guide).

5. The completed document should include:

a. Title Page: The title page should include the name of program and sponsoring institution; street
address, city and state, telephone number and area code; and date of accreditation visit.

b. Verification Page: The Commission requests that the institution’s chief executive officer, chief
administrator of the academic unit that sponsors the Advanced General Dentistry Education Programs in
Orofacial Pain, program director and other appropriate administrators of the institution verify that the contents
of the completed self-study document are factually correct. The verification page should include the names,
titles, and signatures of individuals who have reviewed the self-study report.

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 c. Table of Contents: The table of contents should include the verification page, the summary of
factual information, previous site visit recommendations, compliance with Commission policies,
sections on each of the Standards, the conclusions and summary of the Self-Study Report and
any necessary appendices; page numbers for each section should be identified.

d. Self-Study Report: The Commission encourages programs to develop a self-study report that
reflects a balance between outcomes and process and that produces an appropriately brief and cost-effective
Self-Study Report. The supportive documentation substantiating the narrative should not exceed what is
required to demonstrate compliance with the Standards. Exhibits should be numbered sequentially. The
Exhibit numbers in the completed document are not expected to correspond with the example exhibits
provided in the Self-Study Guide.

e. Conclusion and Summary: At the completion of the report, a standard by standard qualitative
analysis of the program’s strengths and weaknesses is required. Actions planned to correct any identified
weaknesses should be described. It is suggested that the summary be completed by the program director with
assistance from other faculty and appropriate administrators.

6. Keeping costs in mind, the Commission requests the minimum number of copies of the Self-Study
Report necessary. One copy of the completed Self-Study Report, bound in soft pliable plastic binders, and the
program’s suggested schedule of conferences should be sent directly to each member of the visiting
committee and the Commission office at least 60 days prior to the date of the visit. (Hard cover binders are
expensive in terms of cost, postage and filing space and should not be used).

In addition to the number of paper copies requested above, please be advised that the Commission requires
that all accreditation documents, reports and related materials submitted to the Commission for a program’s
permanent file be done so electronically. The attached Electronic Submission Guidelines will assist you in
preparing your report. The program is responsible for assuring that the electronic copy submitted is an exact
replica of the paper copy. Failure to comply with these guidelines will constitute an incomplete report. If the
program is unable to provide a comprehensive electronic document, the Commission will accept a paper copy
and assess a fee for electronic conversion to the program for converting the document to an electronic version.

A summary of the self-study documentation that must be provided to the visiting committee prior to the
visit and additional information which must be available on-site is listed in “Policies and Procedures Related to
the Evaluation of Advanced General Dentistry Education Programs in Orofacial Pain” section of the Self-Study
Guide.

7. Note: The program’s documentation for CODA (self-study, application, or reports to CODA, for
example) must NOT contain any sensitive personally identifiable information (“Sensitive Information” or “PII”)
as outlined in “Privacy and Data Security Requirements for Institutions” (see below). Similarly, such
documentation must not contain any identifiable patient information (“PHI”); therefore, no “patient identifiers”
may be included (see below). This applies whether or not the program is required to comply with HIPAA.

Before sending documents such as self-studies or faculty CVs to CODA, institutions must fully and
appropriately redact all PII and all PII all patient identifiers such that the PII and patient identifiers cannot be
read or otherwise reconstructed. Covering information with ink is not an appropriate means of redaction.

If the program/institution submits documentation that does not comply with the directives on PHI and PII (noted
above), CODA will assess a penalty fee of $1000 to the institution; a resubmission that continues to contain
PHI or PII will be assessed an additional $1000 fee.

8. Programs/institutions must meet established deadlines for submission of requested information.

Program information (i.e. self-studies) is considered an integral part of the accreditation process. If an
institution fails to comply with the Commission’s request, it will be assumed that the institution no longer wishes

167
to participate in the accreditation program. In this event, the Commission will immediately notify the chief
executive officer of the institution of its intent to withdraw the accreditation of the program at its next scheduled
meeting.

ADMINISTRATOR VERIFICATION OF SELF-STUDY REPORT FOR THE ADVANCED GENERAL

DENTISTRY EDUCATION PROGRAMS IN OROFACIAL PAIN

I have reviewed this document and verify that the information it is accurate and complete, and that it
complies with the Commission on Dental Accreditation’s Privacy and Data Security Requirements for
Institutions.

SPONSORING OR CO-SPONSORING INSTITUTION

CO-SPONSORING INSTITUTION (If applicable)
Name: Name:
Street Address Street Address
(do not list P.O.Boxes) (do not list P.O.Boxes)
City, State, Zip: City, State, Zip:
Chief Executive Officer Chief Executive Officer
(Univ. Pres., Chancellor, Hospital President) (Univ. Pres., Chancellor, Hospital President.)
Name: Name:
Title: Title:
Phone: Phone:
E-Mail: E-Mail:
Signature: Signature:
Date: Date:
Chief Administrative Officer Chief Administrative Officer
(Dental Dean/Chief of Dental Service) (Dental Dean/Chief of Dental Service)
Name: Name:
Title: Title:
Phone: Phone:
Fax: Fax:
E-Mail: E-Mail:
Signature: Signature:
Date: Date:
Program Director or Co-Program Director Program Director or Co-Program Director
Name: Name:
Title: Title:
Phone: Phone:
Fax: Fax:
E-Mail: E-Mail:
Signature: Signature:
Date: Date:

PREVIOUS SITE VISIT RECOMMENDATIONS

Using the program’s previous site visit report, please demonstrate that the recommendations included in the
report have been remedied.

The suggested format for demonstrating compliance is to state the recommendation and then provide a
narrative response and/or reference documentation within the remainder of this self-study document.

* Please note if the last site visit was conducted prior to the implementation of the most current Accreditation
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Standards for Advanced General Dentistry Education Programs in Orofacial Pain (see document revision
history), some recommendations may no longer apply. Should further guidance be required, please contact
Commission on Dental Accreditation staff.

COMPLIANCE WITH COMMISSION POLICIES

Please provide documentation demonstrating the program’s compliance with the Commission’s
Reporting Program Changes in Accredited Programs, Third Party Comments, Complaints, and
Distance Education policies.

Program Changes

Changes have a direct and significant impact on the program’s potential ability to comply with the accreditation
standards. These changes tend to occur in the areas of finances, program administration, enrollment,
curriculum and clinical/laboratory facilities, but may also occur in other areas. Failure to report in advance any
increase in enrollment or other change, using the Guidelines for Reporting Program Changes, may result in
review by the Commission, a special site visit, and may jeopardize the program’s accreditation status.

The program must report changes to the Commission in writing at least thirty (30) days prior to a regularly
scheduled, semi-annual Review Committee meeting. The Commission recognizes that unexpected, changes
may occur. If an unexpected change occurs, it must be reported no more than 30 days following the
occurrence. Unexpected changes may be the result of sudden changes in institutional commitment, affiliated
agreements between institutions, faculty support, or facility compromise resulting from natural disaster. Failure
to proactively plan for change will not be considered unexpected change. Depending upon the timing and
nature of the change, appropriate investigative procedures including a site visit may be warranted.

For enrollment increases in postdoctoral general dentistry education programs the program must submit a
request to the Commission one (1) month prior a regularly scheduled semiannual Review
Committee/Commission meeting.

For the addition of off-campus sites, the program must report in writing to the Commission at least thirty (30)
days prior to a regularly scheduled semi-annual Review Committee meeting.

See the Guidelines for Reporting Enrollment Increases In Postdoctoral General Dentistry Education Programs
and the Guidelines for Reporting Off-Campus Sites for specific information on these types of changes. Please
review the entire policy on “Reporting Program Changes in Accredited Programs” in the Commission’s EOPP:
Evaluation and Operational Policies and Procedures manual.

1. Identify all changes which have occurred within the program since the program’s previous site visit, in
accordance with the Commission’s policy on Reporting Program Changes in Accredited Programs

Third Party Comments

The program is responsible for soliciting third party comments from residents and patients that pertain to the
Standards or policies and procedures used in the Commission’s accreditation process. An announcement for
soliciting third party comments is to be published at least ninety (90) days prior to the site visit. The notice
should indicate that third party comments are due in the Commission’s office no later than sixty (60) days prior
to the site visit. Please review the entire policy on “Third Party Comments” in the Commission’s EOPP:
Evaluation and Operational Policies and Procedures manual.

1. Please provide documentation and/or indicate what evidence will be available during the site visit to
demonstrate compliance with the Commission’s policy on “Third Party Comments.”

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Complaints

The program is responsible for developing and implementing a procedure demonstrating that residents are
notified, at least annually, of the opportunity and the procedures to file complaints with the Commission.
Additionally, the program must maintain a record of resident complaints received since the Commission’s last
comprehensive review of the program. Please review the entire policy on “Complaints” in the Commission’s
EOPP: Evaluation and Operational Policies and Procedures manual.

1. Please provide documentation and/or indicate what evidence will be available during the site visit to
demonstrate compliance with the Commission’s policy on “Complaints.”

Distance Education

Programs that offer distance education must have processes in place through which the program establishes
that the resident who registers in a distance education course or program is the same resident who participates
in and completes the course or program and receives the academic credit. In addition, programs must notify
residents of any projected additional resident charges associated with the verification of resident identity at the
time of registration or enrollment. Please read the entire policy on “Distance Education” in the Commission’s
EOPP: Evaluation and Operational Policies and Procedures manual.

1. Please provide documentation and/or indicate what evidence will be available during the site visit to
demonstrate compliance with the Commission’s policy on “Distance Education.”

PROGRAM EFFECTIVENESS
Program Performance with Respect to Resident Achievement:
1. Provide a detailed analysis explaining how the program uses resident achievement measures, such as
national assessment scores, results of licensure or certification examinations and/or employment rates to
assess the program’s overall performance. In your analysis, provide examples of program changes made
based on resident achievement data collected and analyzed.

SUMMARY OF FACTUAL INFORMATION

Enrollment at Completion of this Self-Study:

Year Full-Time Part-Time

1
2
3

Award Granted upon Completion: ___________________

Off-Campus Training Sites (For Didactic and Clinical Activity):

List the names and addresses of all off-campus training sites, purposes of the training, and amount of time any
resident is assigned to the training site.
Name & Address Purpose (include if enrichment Amount of time any
and/or optional) resident spends at site

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Dental Service Data:
Is there a dental service at the sponsoring institution? ____YES _____NO

If YES, please answer the following questions. If NO, provide projected caseload, if applicable.

Number of total patient visits per year: _____

Source of patients: _______________________________________

Number of orofacial pain patients per year: _____

Source of patients:

If applicable, number of dental inpatients/same day surgery per year: _____

Hospital Data:
If applicable, identify the hospital (name, city and state) at which residents receive their primary hospital
experiences.
____________________________________________________________

Indicate the number of beds at this hospital: ____

Briefly describe the mission and scope of services at this hospital, including the variety of medical and dental
cases treated; also describe the role of dentists in this hospital.

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STANDARD 1 – INSTITUTIONAL AND PROGRAM EFFECTIVENESS

1-1 Each sponsoring or co-sponsoring United States-based educational institution, hospital or health care
organization must be accredited by an agency recognized by the United States Department of Education or
accredited by an accreditation organization recognized by the Centers for Medicare and Medicaid Services
(CMS).

United States military programs not sponsored or co-sponsored by military medical treatment facilities,
United States-based educational institutions, hospitals or health care organizations accredited by an agency
recognized by the United States Department of Education or accredited by an accreditation organization
recognized by the Centers for Medicare and Medicaid Services (CMS) must demonstrate successful
achievement of Service-specific organizational inspection criteria.

Self-Study Analysis:
1. Please provide the following information:

Sponsor Information
Institutional Accrediting Agency Name
Current Status
Year of Next Review
Describe any scheduled reviews or
expected changes in status that will
occur prior to the site visit

Co-Sponsor, if applicable Information

Institutional Accrediting Agency Name
Current Status
Year of Next Review
Describe any scheduled reviews or
expected changes in status that will
occur prior to the site visit

2. If the sponsoring institution(s) are not accredited, please explain.

Examples of evidence to demonstrate compliance may include:

Accreditation certificate or current official listing of accredited institutions
Evidence of successful achievement of Service-specific organizational inspection criteria

Note: As of September 2013, accreditation organizations recognized by the Centers for Medicare and
Medicaid Services (CMS) include:
Accreditation Association for Ambulatory Health Care (AAAHC)
Accreditation Commission for Health Care, Inc. (ACHC)
American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)
American Osteopathic Association Healthcare Facilities Accreditation Program (AOA/HFAP)
Center for Improvement in Healthcare Quality (CIHQ)
Community Health Accreditation Program (CHAP)
Det Norske Veritas Healthcare (DNV Healthcare)
The Joint Commission (JC)
Self-Study: Provide above item(s) in the appendix

1-2 The sponsoring institution must ensure that support from entities outside of the institution does not
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compromise the teaching, clinical and research components of the program.

Self-Study Analysis:
1. Briefly describe the organizational flow and identify the individuals responsible for the teaching, clinical
and research components of the program.

Examples of evidence to demonstrate compliance may include:

Written agreement(s)
On-Site: Have signed agreements available for review committee.
Contract(s/Agreement(s) between the institution/program and sponsor(s) related to facilities, funding, and
faculty financial support
On-Site: Have signed contracts available for review committee

1-3 The authority and final responsibility for curriculum development and approval, resident selection,
faculty selection and administrative matters must rest within the sponsoring institution.

Self-Study Analysis:
1. Briefly describe the organizational flow and identify the individuals responsible for curriculum
development and approval, resident selection, faculty selection, and administrative matters.

1-4 The financial resources must be sufficient to support the program’s stated purpose/mission, goals and
objectives.

Self-Study Analysis:
1. Describe/Explain the process utilized to develop the program’s budget. Include the timeframe,
individuals involved, and final decision-making body/individual(s).

2. If financial resources include grant monies, specify the type, amount and termination date of the grant.
What is the primary use of these funds? Upon termination of the grant(s), how will these funds be replaced?
(Exhibit 1 is suggested for presenting this information)

3. Describe the five-year plan developed to assist the program in ensuring stable and adequate funding.
(Append a copy of the five-year plan)

4. Provide information on the program’s budget for the previous, current and ensuing fiscal year. (Exhibit
2 is suggested for presenting this information)

Examples of evidence to demonstrate compliance may include:

Program budgetary records
Self-Study: Provide above items in the appendix. Exhibit 1 is suggested.
Budget information for previous, current and ensuing fiscal year
Self-Study: Provide above item in the appendix. Exhibit 2 is suggested.

1-5 All arrangements with co-sponsoring, affiliated institutions, or extramural facilities must be formalized
by means of written agreements that clearly define the roles and responsibilities of the parties involved.

Intent: Institutions include entities such as private practices. The items that are covered in inter-institutional
agreements do not have to be contained in a single document. They may be included in multiple agreements,
both formal and informal (e.g., addenda and letters of mutual understanding).

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Self-Study Analysis:
1. If the program is co-sponsored, briefly describe the nature of this relationship (i.e. division of major
responsibilities for educational components of the curriculum, fiscal oversight, and overall program
management, etc., including the reporting/authority structure).

2. If written agreements between co-sponsors, affiliates or extramural facilities (including all off-campus
training sites) do not exist or if the existing agreements provided as documentation with the self-study do not
clearly define the current roles and responsibilities of each institution, please explain rationale or any plans for
securing such agreements.

3. For each affiliated institution or extramural facility, or off-campus training site, provide the information
requested in Exhibit 3. Include any optional or enrichment experience training sites.

Examples of evidence to demonstrate compliance may include:

Written agreements
Self-Study: for each affiliate, provide Exhibit 3 in the appendix
On-Site: have signed written agreements available for review by visiting committee

1-6 There must be opportunities for program faculty to participate in institution-wide committee activities.

Self-Study Analysis:
1. Describe the opportunities available for program faculty to participate in institution-wide committee
activities.

Examples of evidence to demonstrate compliance may include:

Bylaws or documents describing committee structure
Copy of institutional committee structure and/or roster of membership by dental faculty
Self-Study: Provide related bylaws or documents in the appendix
On-Site: Have complete bylaws document available for review

1-7 Orofacial pain residents must have the same privileges and responsibilities provided residents in other
professional education programs.

Self-Study Analysis:
1. Do the residents enjoy the same privileges and responsibilities as residents in other professional
education programs?
____ Yes
____ No

If no, describe exceptions and the effect, if any, on the orofacial pain residents’ educational experience.

Examples of evidence to demonstrate compliance may include:

Bylaws or documents describing resident privileges
Self-Study: Provide related bylaws or documents in the appendix or cross-reference with Standard 1-6
On-Site: Have complete bylaws available for review

1-8 The medical staff bylaws, rules, and regulations of the sponsoring, co-sponsoring, or affiliated hospital
must ensure that dental staff members are eligible for medical staff membership and privileges.

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Intent: Dental staff members have the same rights and privileges as other medical staff of the sponsoring, co-
sponsoring or affiliated hospital, within the scope of practice.

Self-Study Analysis:
1. Do the bylaws, rules and regulations of each institution listed above ensure that dental staff members
are eligible for medical staff membership and privileges?
____ Yes

____ No

If no, please describe plans or activities underway to address this situation.

Examples of evidence to demonstrate compliance may include:

All related hospital bylaws
Self-Study: Provide relevant portions of bylaws in the appendix
On-Site: Have complete bylaws available for review
Copy of institutional committee structure and/or roster of membership by dental faculty
Self-Study: Provide above item(s) in the appendix

1-9 The program must develop overall program goals and objectives that emphasize:

a. orofacial pain,
b. resident education,
c. patient care, and
d. research.

Intent: The “program” refers to the Advanced General Dentistry Education Program in Orofacial Pain that is
responsible for training residents within the context of providing patient care. The overall goals and objectives
for resident education are intended to describe general outcomes of the residency training program rather than
specific learning objectives for areas of residency training as described in Standard 2-2. Specific learning
objectives for residents are intended to be described as goals and objectives of resident training or
competencies and proficiencies and included in the response to Standard 2-2. An example of overall goals
can be found in the Goals section on page 8 of this document.

Self-Study Analysis:
1. Do the overall program goals and objectives emphasize the following:

Area of Emphasis Yes No

Orofacial Pain
Resident Education
Patient Care
Research

If an area of emphasis is not included with the stated goals and objectives, please explain.

Examples of evidence to demonstrate compliance may include:

Overall program goals and objectives
Self-Study: Provide overall program goals and objectives in the appendix. (Please note goals and
objectives for resident training in required curriculum areas will be requested in Standard 2 – Curriculum)

1-10 The program must have a formal and ongoing outcomes assessment process that regularly evaluates
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the degree to which the program’s stated goals and objectives are being met and make program improvements
based on an analysis of that data.

Intent: The intent of the outcomes assessment process is to collect data about the degree to which the overall
goals and objectives described in response to Standard 1-9 are being met.

The outcomes process developed should include each of the following steps:
1. development of clear, measurable goals and objectives consistent with the program's
purpose/mission;
2. implementation of procedures for evaluating the extent to which the goals and objectives are
met;
3. collection of data in an ongoing and systematic manner;
4. analysis of the data collected and sharing of the results with appropriate audiences;
5. identification and implementation of corrective actions to strengthen the program; and
6. review of the assessment plan, revision as appropriate, and continuation of the cyclical
process.
Self-Study Analysis:
1. Describe the program’s established formal outcomes assessment process. If this exists in a formal
document, please provide a copy in the appendix. (Exhibit 4 is suggested for presenting this information)

2. For each of the overall program goals and objectives, describe the outcomes measurement
mechanism(s) utilized to determine the degree to which the goal or objective is being met. (Exhibit 4 is
suggested for presenting this information)

3. For each of the oval program goals and objectives, provide assessment data collected, or summaries of
the data collected, in the appendix. (Exhibit 4 is suggested for presenting this information)

4. For each of the overall program goals and objectives, illustrate by providing documented examples,
how the program has followed its formal assessment plan from the stage of evaluating results of the specific
assessment data through the stage of determining whether to make programmatic changes. (Exhibit 4 is
suggested for presenting this information)

Examples of evidence to demonstrate compliance may include:

Overall program goals and objectives
Self-Study: Provide above item(s) in the appendix or cross-reference with Standard 1-9.
Outcomes assessment plan and measures
Self-Study: Provide the outcomes assessment plan and measures in the appendix; Exhibit 4 is
suggested.
Outcomes results
Self-Study: Provide outcomes results in the appendix; Exhibit 4 is suggested.
Annual review of outcomes results
Self-Study: Provide review of outcomes results in the appendix
Meeting minutes where outcomes are discussed
Self-Study: Provide review of outcomes results in the appendix
Decisions based on outcomes results
Self-Study: Provide example of decisions made based on outcomes results. Exhibit 4 is suggested.
Successful completion of a certifying examination in Orofacial Pain
Self-Study: Provide evidence of successful completion of certifying examination in the appendix

Ethics and Professionalism

1-11 The program must ensure that residents are able to demonstrate the application of the principles of
ethical reasoning, ethical decision making and professional responsibility as they pertain to the academic

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environment, research, patient care, and practice management.

Intent: Residents should know how to draw on a range of resources such as professional codes, regulatory
law, and ethical theories to guide judgment and action for issues that are complex, novel, ethically arguable,
divisive, or of public concern.

Self-Study Analysis:
1. Describe how residents are exposed to the application of principles of ethical reasoning, ethical
decision making and professional responsibility as they pertain to the academic environment, research, patient
care, and practice management.

2. Describe how the program ensures that residents are able to demonstrate the application of principles
of ethical reasoning, ethical decision making and professional responsibility as they pertain to the academic
environment, research, patient care, and practice management.

Examples of evidence to demonstrate compliance may include:

Didactic course(s)
Self-Study: Provide above item(s) in the appendix; Exhibit 7 is suggested or cross-reference with 2-2.
Course outline and appropriate lectures
Self-Study: Provide above item(s) in the appendix.
Resident evaluations with identifying information removed
On-Site: Have completed evaluations available for review by visiting committee.
Case studies
On-Site: Prepare above item(s) for review by visiting committee.
Documentation of treatment planning sessions
On-Site: Prepare above item(s) for review by visiting committee.
Documentation of treatment outcomes
On-Site: Prepare above item(s) for review by visiting committee.
Patient satisfaction surveys
On-Site: Prepare above item(s) for review by visiting committee.
Examples of literature reviews related to ethics and professionalism
Self-Study: Provide above item(s) in the appendix.

STANDARD 2 – EDUCATIONAL PROGRAM

2-1 The orofacial pain program must be designed to provide advanced knowledge and skills beyond the
D.D.S. or D.M.D. training.

Self-Study Analysis:
1. Describe how the program is designed to ensure training is beyond that of the D.D.S. or D.M.D.

Examples of evidence to demonstrate compliance may include:

Curriculum plan
Self-Study: Provide a copy of the curriculum plan in the appendix. Exhibit 5 is suggested for
presenting this information.

Curriculum Content

2-2 The program must either describe the goals and objectives for each area of resident training or list the
competencies and proficiencies that describe the intended outcomes of resident education.

Intent: The program is expected to develop specific educational goals that describe what the resident will be

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able to do upon completion of the program. These educational goals should describe the resident’s abilities
rather than educational experiences the residents may participate in. These specific educational goals may be
formatted as either goals and objectives of each area of resident training or competencies and proficiencies.
These educational goals are to be circulated to program faculty and staff and made available to applicants of
the program.

Self-Study Analysis:
1. In the appendix, provide a copy of the program’s goals and objectives of resident training or the
competencies and proficiencies.

2. Describe how the program’s goals and objectives of resident training or the competencies and
proficiencies are circulated to program faculty and staff and made available to applicants of the program.

Examples of evidence to demonstrate compliance may include:

Goals and objectives for resident training or competencies and proficiencies
Self-Study: Provide a copy of the goals and objectives for resident training or competencies and
proficiencies in the appendix.

2-3 Written goals and objectives must be developed for all instruction included in this curriculum.

Self-Study Analysis:
1. Have written goals and objectives been developed for all instruction in the curriculum?
If no, please explain

Example of Evidence to demonstrate compliance may include:

Goals and objectives
Self-Study: Provide a copy of the goals and objectives for resident training or competencies and
proficiencies in the appendix or cross-reference with Standard 2-2.
Content outlines
Self-Study: Provide course outlines in the appendix.

2-4 The program must have a curriculum plan that includes structured clinical experiences and didactic
sessions designed to achieve the program’s goals and objectives for resident training or the program’s
competencies and proficiencies.

Intent: The program is expected to organize the didactic and clinical educational experiences into a formal
curriculum plan.

For each specific goal or objective or competency and proficiency statement described in response to
Standard 2-2, the program is expected to develop educational experiences designed to enable the resident to
acquire the skills, knowledge, and values necessary in that area. The program is expected to organize these
didactic and clinical educational experiences into a formal curriculum plan.

Self-Study Analysis:
1. Provide the program’s curriculum management plan in the appendix. (Exhibit 5 is suggested for
presenting this information or cross-reference with Standard 2-1)

2. For each year of the program, provide an overview of the distribution of the residents’ time in the major
areas of the curriculum: ambulatory care, inpatient care, assignments to other services, formal classes,
conference and seminars, research, etc. (Exhibit 6 is suggested for presenting this information)

3. For the previous calendar year, provide a monthly schedule and the responsible faculty member.

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4. For each course or seminar, list the director, the course objectives and the specific competencies or
goals and objectives for resident training and evaluation mechanisms that this course addresses. (Exhibit 7 is
suggested for presenting this information)

5. For each resident position, provide a month-by-month list of activities. (Exhibit 8 is suggested for
presenting this information)

Examples of evidence to demonstrate compliance may include:

Curriculum plan with educational experiences tied to specific goals and objectives or competencies and
proficiencies
Self-Study: Provide a copy of the curriculum plan in the appendix. (Exhibit 5 is suggested for
presenting this information or cross-reference with Standard 2-1)
Distribution of residents’ time in major curriculum areas
Self-Study: Provide above item in appendix. Exhibit 6 is suggested for presenting this information
Didactic Schedules
Self-Study: Provide a copy of the didactic schedules. Exhibit 7 is suggested presenting this
information.
Clinical schedules
Self-Study: Provide a copy of the clinical schedules. Exhibit 8 is suggested presenting this information.

BIOMEDICAL SCIENCES

2-5 Formal instruction must be provided in each of the following:

a. Gross and functional anatomy and physiology including the musculoskeletal and articular system of the
orofacial, head, and cervical structures;
b. Growth, development, and aging of the masticatory system;
c. Head and neck pathology and pathophysiology with an emphasis on pain;
d. Applied rheumatology with emphasis on the temporomandibular joint (TMJ) and related structures;
e. Sleep physiology and dysfunction;
f. Oromotor disorders including dystonias, dyskinesias, and bruxism;
g. Epidemiology of orofacial pain disorders;
h. Pharmacology and pharmacotherapeutics; and
i. Principals of biostatistics, research design and methodology, scientific writing, and critique of literature.

Self-Study Analysis:
1. Describe how residents receive formal instruction in the areas noted in items a-i listed above. If the
information presented does not reflect instruction related to items a-i as listed in this Standard, please explain
and note plans underway to address this situation.

Examples of evidence to demonstrate compliance may include:

Course outlines
Self-Study: Provide course outlines in the appendix
Didactic Schedules
Self-Study: Provide didactic schedules in the appendix. Exhibit 7 is suggested or cross-reference with
Standard 2-4
Resident Evaluations
On-Site: Have completed evaluations available for review by the visiting committee

2-6 The program must provide a strong foundation of basic and applied pain sciences to develop
knowledge in functional neuroanatomy and neurophysiology of pain including:

a. The neurobiology of pain transmission and pain mechanisms in the central and peripheral nervous
systems;

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b. Mechanisms associated with pain referral to and from the orofacial region;
c. Pharmacotherapeutic principles related to sites of neuronal receptor specific action pain;
d. Pain classification systems;
e. Psychoneuroimmunology and its relation to chronic pain syndromes;
f. Primary and secondary headache mechanisms;
g. Pain of odontogenic origin and pain that mimics odontogenic pain; and
h. The contribution and interpretation of orofacial structural variation (occlusal and skeletal) to orofacial
pain, headache, and dysfunction.

Self-Study Analysis:
1. Describe how a strong foundation of basic and applied pain sciences, as noted in items a-h listed
above, is provided to the residents. If the information presented does not reflect instruction related to items a-h
as listed in this Standard, please explain and note plans underway to address this situation.

Examples of evidence to demonstrate compliance may include:

Course outlines
Self-Study: Provide course outlines in the appendix
Didactic Schedules
Self-Study: Provide didactic schedules in the appendix. Exhibit 7 is suggested or cross-reference with
Standard 2-4
Resident Evaluations
On-Site: Have completed evaluations available for review by the visiting committee

BEHAVIORAL SCIENCES

2-7 Formal instruction must be provided in behavioral science as it relates to orofacial pain disorders and
pain behavior including:

a. cognitive-behavioral therapies including habit reversal for oral habits, stress management, sleep
problems, muscle tension habits and other behavioral factors;
b. the recognition of pain behavior and secondary gain behavior;
c. psychologic disorders including depression, anxiety, somatization and others as they relate to orofacial
pain disorders; and
d. conducting and applying the results of psychometric tests.

Self-Study Analysis:
1. Describe how residents receive formal instruction in the areas noted in items a-d listed above. If the
information presented does not reflect instruction related to items a-d as listed in this Standard, please explain
and note plans underway to address this situation.

Examples of evidence to demonstrate compliance may include:

Course outlines
Self-Study: Provide course outlines in the appendix
Didactic Schedules
Self-Study: Provide didactic schedules in the appendix. Exhibit 7 is suggested or cross-reference with
Standard 2-4
Resident Evaluations
On-Site: Have completed evaluations available for review by the visiting committee

CLINICAL SCIENCES

2-8 A minimum of 50% of the total program time must be devoted to providing orofacial pain patient
services, including direct patient care and clinical rotations.

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Self-Study Analysis:
1. Describe how it is ensured that a minimum of 50% of the total program time is devoted to providing
orofacial pain services. (Exhibit 6 is suggested for presenting this information)

Examples of Evidence to demonstrate compliance may include:

Distribution of residents’ time in major curriculum areas
Self-Study: Provide above item in appendix. Exhibit 6 is suggested for presenting this information or cross-
reference with Standard 2-4.

2-9 The program must provide instruction and clinical training for the clinical assessment and diagnosis of
complex orofacial pain disorders to ensure that upon completion of the program the resident is able to:

a. Conduct a comprehensive pain history interview;

b. Collect, organize, analyze, and interpret data from medical, dental, behavioral, and psychosocial
histories and clinical evaluation to determine their relationship to the patient’s orofacial pain complaints;
c. Perform clinical examinations and tests and interpret the significance of the data;

Intent: Clinical evaluation may include: musculoskeletal examination of the head, jaw, neck and shoulders;
range of motion; general evaluation of the cervical spine; TM joint function; jaw imaging; oral, head and neck
screening, including facial-skeletal and dental-occlusal structural variations; cranial nerve screening; posture
evaluation; physical assessment including vital signs; and diagnostic blocks.

d. Function effectively within interdisciplinary health care teams, including the recognition for the need
of additional tests or consultation and referral; and

Intent: Additional testing may include additional imaging; referral for psychological or psychiatric evaluation;
laboratory studies; diagnostic autonomic nervous system blocks, and systemic anesthetic challenges.

e. Establish a differential diagnosis and a prioritized problem list.

Self-Study Analysis:
1. Describe how the residents receive formal instruction in the areas reflected in items a-e noted above.
Provide the course outline(s) as an appendix. If the course outline(s) does not reflect instruction related to
items a-e as listed above, please explain and note plans to address this situation.

2. Describe how the residents receive clinical training in the areas reflected in items a-e noted above. If
residents do not receive clinical training in items a-e as listed above, please explain and note plans to address
this situation.

Examples of evidence to demonstrate compliance may include:

Goals and objectives of resident training or competencies and proficiencies organized by the areas described
above
Self-Study: Provide above item(s) in the appendix; Exhibit 9 is suggested and may be cross-referenced with 2-
2
Didactic Schedules
Self-Study: Provide didactic schedules in the appendix. Exhibit 7 is suggested or cross-reference with
Standard 2-4
Clinical Schedules
Self-Study: Provide clinical schedules in the appendix. Exhibit 8 is suggested or cross-reference with
Standard 2-4
Resident Evaluations
On-Site: Have completed evaluations available for review by the visiting committee

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Treatment planning sessions
On-Site: Have documentation available for review by the visiting committee
Documentation of Chart reviews
On-Site: Have documentation available for review by the visiting committee
Case simulations
On-Site: Have available for review by the visiting committee

2-10 The program must provide instruction and clinical training in multidisciplinary pain management for the
orofacial pain patient to ensure that upon completion of the program the resident is able to:

a. Develop an appropriate treatment plan addressing each diagnostic component on the problem
list with consideration of cost/risk benefits;
b. Incorporate risk assessment of psychosocial and medical factors into the development of the
individualized plan of care;
c. Obtain informed consent;
d. Establish a verbal or written agreement, as appropriate, with the patient emphasizing the
patient’s treatment responsibilities;
e. Have primary responsibility for the management of a broad spectrum of orofacial pain patients in a
multidisciplinary orofacial pain clinic setting, or interdisciplinary associated services. Responsibilities should
include:
1. intraoral appliance therapy;
2. physical medicine modalities;
3. sleep-related breathing disorder intraoral appliances;
4. non-surgical management of orofacial trauma;
5. behavioral therapies beneficial to orofacial pain; and
6. pharmacotherapeutic treatment of orofacial pain including systemic and topical medications and
diagnostic/therapeutic injections.
Intent: This should include judicious selection of medications directed at the presumed pain mechanisms
involved, as well as adjustment, monitoring, and reevaluation.

Common medications may include: muscle relaxants; sedative agents for chronic pain and sleep management;
opioid use in management of chronic pain; the adjuvant analgesic use of tricyclics and other antidepressants
used for chronic pain; anticonvulsants, membrane stabilizers, and sodium channel blockers for neuropathic
pain; local and systemic anesthetics in management of neuropathic pain; anxiolytics; analgesics and anti-
inflammatories; prophylactic and abortive medications for primary headache disorders; and therapeutic use of
botulinum toxin injections.

Common issues may include: management of medication overuse headache; medication side effects that alter
sleep architecture; prescription medication dependency withdrawal; referral and co-management of pain in
patients addicted to prescription, non prescription and recreational drugs; familiarity with the role of preemptive
anesthesia in neuropathic pain.

Self-Study Analysis:
1. Describe how the residents receive formal instruction in the areas reflected in items a-e noted above.
Provide the course outline(s) as an appendix. If the course outline(s) does not reflect instruction related to
items a-e as listed above, please explain and note plans to address this situation.

2. Describe how the residents receive clinical training in the areas reflected in items a-e noted above. If
residents do not receive clinical training in items a-e as listed above, please explain and note plans to address
this situation.

Examples of evidence to demonstrate compliance may include:

Didactic Schedules

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 Self-Study: Provide didactic schedules in the appendix. Exhibit 7 is suggested or cross-reference with
Standard 2-4
Clinical Schedules
Self-Study: Provide clinical schedules in the appendix. Exhibit 8 is suggested or cross-reference with
Standard 2-4
Resident Evaluations
On-Site: Have completed evaluations available for review by the visiting committee
Treatment planning sessions
On-Site: Have documentation available for review by the visiting committee
Documentation of Chart reviews
On-Site: Have documentation available for review by the visiting committee
Case simulations
On-Site: Have available for review by the visiting committee
Records of resident clinical activity (such as case logs) including procedures performed in each area
described above
On-Site: Have records available for review by the visiting committee
Patient records
On-Site: Have records available for review by the visiting committee

2-11 Residents must participate in clinical experiences in other healthcare services (not to exceed 10
percent of total training period).

Intent: Experiences may include observation or participation in the following: oral and maxillofacial surgery to
include procedures for intracapsular TMJ disorders; outpatient anesthesia pain service; in-patient pain rotation;
rheumatology, neurology, oncology, otolaryngology, rehabilitation medicine; headache, radiology, oral
medicine, and sleep disorder clinics.

Self-Study Analysis:
1. For each assigned experience in other healthcare services, provide the information contained in
Exhibit 10.

Examples of evidence to demonstrate compliance may include:

Distribution of residents’ time in major curriculum areas
Self-Study: Provide above item in appendix. Exhibit 6 is suggested for presenting this information
Clinical Schedules
Self-Study: Provide clinical schedules in the appendix. Exhibit 8 is suggested or cross-reference with
Standard 2-4
Description and schedule of rotations, including supervising faculty
Rotation/Experience objectives
Self-Study: Provide above items in appendix. Exhibit 10 is suggested.
Resident Evaluations
On-Site: Have evaluations available for review by visiting committee

2-12 For each assigned rotation, or experience in an affiliated institution or extramural facility, there must be:

a. objectives that are developed in cooperation with the department chairperson, service chief, or facility
director to which the residents are assigned;
b. resident supervision by designated individuals who are familiar with the objectives of the rotation or
experience; and
c. evaluations performed by the designated supervisor.
Intent: This standard is intended to apply to all rotations, whether they take place in the parent institution or an
affiliated institution or extramural facility.

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Self-Study Analysis:
1. For each assigned experience or rotation, provide the information contained in Exhibit 10.

Examples of evidence to demonstrate compliance may include:

Description and schedule of rotations, including supervising faculty
Rotation/Experience objectives
Self-Study: Provide above items in appendix. Exhibit 10 is suggested or cross-reference with Standard
2-11
Resident Evaluations
On-Site: Have evaluations available for review by visiting committee

2-13 Residents must gain experience in teaching orofacial pain.

Intent: Residents should be provided opportunities to obtain teaching experiences in orofacial pain (i.e. small
group and lecture formats, presenting to dental and medical peer groups, predoctoral student teaching
experiences, and/or continuing education programs.

Self-Study Analysis:
1. Describe the residents’ experiences in teaching orofacial pain.

2. Indicate the number of hours residents participate in teaching activities.

Examples of evidence to demonstrate compliance may include:

Schedule of residents’ orofacial pain teaching activities
Self-Study: Provide schedules(s) in the appendix

2-14 Residents must actively participate in the collection of history and clinical data, diagnostic assessment,
treatment planning, treatment, and presentation of treatment outcome.

Self-Study Analysis:
1. Describe how the residents participate in the collection of history and clinical data, diagnostic
assessment, treatment planning, treatment and presentation of treatment outcome.

Examples of evidence to demonstrate compliance may include:

Documentation of treatment planning sessions/conferences where treatment outcomes are discussed
On-Site: Have documentation available for review by the visiting committee
Documentation of Chart reviews
On-Site: Have documentation available for review by the visiting committee
Case simulations
On-Site: Have available for review by the visiting committee
Records of resident clinical activity (such as case logs) including procedures performed in each area
described above
On-Site: Have records available for review by the visiting committee
Patient records
On-Site: Have records available for review by the visiting committee
Resident evaluations
On-Site: Have evaluations available for review by the visiting committee

2-15 The program must provide instruction in the principles of practice management.

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Intent: Suggested topics include: quality management; principles of peer review; business management and
practice development; principles of professional ethics, jurisprudence and risk management; alternative health
care delivery systems; informational technology; and managed care; medicolegal issues, workers
compensation, second opinion reporting; criteria for assessing impairment and disability; legal guidelines
governing licensure and dental practice, scope of practice with regards to orofacial pain disorders, and
instruction in the regulatory requirements of chronic opioid maintenance.
Self-Study Analysis:

1. Does the program provide instruction in the following topics? (check all that apply)

____ management of allied dental professionals and other office personnel

____ quality management
____ principles of peer review
____ business management and practice development
____ principles of professional ethics
____ jurisprudence and risk management
____ alternative health care delivery systems
____ managed care

2. Describe the intended outcomes of instruction either in terms of goals and objectives for resident
training or competencies and proficiencies

The instruction in this area is intended to enable the resident to:

Examples of evidence to demonstrate compliance may include:

Course outlines
Self-Study: Provide the outlines in the appendix

2-16 Structured patient care conferences must be held at least every other week.

Intent: Conferences should include diagnosis, treatment planning, progress, and outcomes. These
conferences should be attended by residents and faculty representative of the disciplines involved. These
conferences are not to replace the daily faculty/resident interactions regarding patient care.

Self-Study Analysis:
1. Are patient care conferences held every other week? ____ Yes ____ No
If no, please explain and describe any plans underway to ensure that such conferences are held
at least every other week.

2. Describe how patient care conferences are organized.

3. Who is in attendance at patient care conferences?

Examples of evidence to demonstrate compliance may include:

Conference schedules
Self-Study: Provide schedules in the appendix

2-17 Residents must be given assignments that require critical review of relevant scientific literature.

Intent: Residents are expected to have the ability to critically review relevant literature as a foundation for

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lifelong learning and adapting to changes in oral health care. This should include the development of critical
evaluation skills and the ability to apply evidence-based principles to clinical decision-making.

Relevant scientific literature should include current pain science and applied pain literature in dental and
medical science journals with special emphasis on pain mechanisms, orofacial pain, head and neck pain, and
headache.

Self-Study Analysis:
1. Describe how residents learn to identify and critically review scientific literature.

2. Describe a typical literature review assignment and provide an example in the appendix.

3. Residents participate in the following: (check all that apply)

____ Journal Club

____ Literature Reviews
____ Development of Journal Abstracts

Examples of evidence to demonstrate compliance may include:

Evidence of experiences requiring literature review
Self-Study: Provide examples of experiences in the appendix

Program Length

2-18 The duration of the program must be at least two consecutive academic years with a minimum of 24
months, full-time or its equivalent.

Self-Study Analysis:
1. Is the program at least two consecutive academic years with a minimum of 24 months, full-time
or its equivalent?
If no, please explain.

Examples of evidence to demonstrate compliance may include:

Program schedules
Self-Study: Provide schedules in the appendix
Curriculum plan
Self-Study: Provide curriculum plan in the appendix or cross-reference with Standard 2-1

2-19 Where a program for part-time residents exists, it must be started and completed within a single
institution and designed so that the total curriculum can be completed in no more than twice the duration of the
program length.

Intent: Part-time residents may be enrolled, provided the educational experiences are the same as those
acquired by full-time residents and the total time spent is the same.

Self-Study Analysis:
1. Are residents at this institution able to pursue a part-time program?

If yes, please describe the program’s policies related to the length of time for completion of a part-time
program and provide a part-time schedule.

Examples of evidence to demonstrate compliance may include:

Description of the part-time program

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Documentation of how the part-time residents will achieve similar experiences and skills as full-time residents
Program schedules
Self-Study: Provide the above items in the appendix
Evaluation

2-20 The program’s resident evaluation system must assure that, through the director and faculty, each
program:

a) periodically, but at least two times annually, evaluates and documents the resident’s progress
toward achieving the program’s goals and objectives of resident training or competencies and
proficiencies using appropriate written criteria and procedures;
b) provides residents with an assessment of their performance after each evaluation. Where
deficiencies are noted, corrective actions must be taken; and
c) maintains a personal record of evaluation for each resident that is accessible to the resident and
available for review during site visits.

Intent: While the program may employ evaluation methods that measure a resident’s skills or behavior at a
given time, it is expected that the program will, in addition, evaluate the degree to which the resident is making
progress toward achieving the specific goals and objectives of resident training or competencies and
proficiencies described in response to Standard 2-2.

Self-Study Analysis:
1. Describe the process used to evaluate the resident’s progress toward achieving the program’s goals
and objectives of resident training or competencies and proficiencies. Include the written criteria and
procedures used including:

a. frequency of evaluation
b. written criteria and procedures used, including the maintenance of records
c. who participates in the evaluations
d. how a determination is made regarding the resident’s progress toward achieving the
program’s goals and objectives of resident training or competencies and proficiencies
e. how residents are informed of the results of the evaluations
f. how corrective actions are undertaken when deficiencies are noted.

2. If evaluations are not conducted at least two times a year, please explain any activities
underway to address this situation.

Examples of evidence to demonstrate compliance may include:

Evaluation criteria and process
Evidence that corrective actions have been taken
Self-Study: Provide in response above or in appendix
Resident evaluations with identifying information removed
Personal record of evaluation for each resident
Self-Study: Provide a blank evaluation form in appendix
On-Site: Have completed evaluations available for review by visiting committee

STANDARD 3 – FACULTY AND STAFF

3-1 The program must be administered by a director who is board certified or educationally qualified in
orofacial pain and has a full-time appointment in the sponsoring institution with a primary commitment to the
orofacial pain program.

Self-Study Analysis:

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 1. Is the program director board certified or educationally qualified in orofacial pain?
____ Yes ____ No
If yes, please provide date of board certification or date of completion of an orofacial pain
program of at least two years in length.
If no, please explain

2. Does the program director have a full-time appointment in the sponsoring institution with a
primary commitment to the orofacial pain program?
____ Yes ____ No
If no, please explain

Examples of evidence to demonstrate compliance may include:

Program Director’s BioSketch (Exhibit 13)
Copy of board certification certificate
Letter from board attesting to current/active board certification
Self-Study: Provide above items in appendix

3-2 The program director must have sufficient authority and time to fulfill administrative and teaching
responsibilities in order to achieve the educational goals of the program.

Intent: The program director’s responsibilities include:

a. program administration;
b. development and implementation of the curriculum plan;
c. ongoing evaluation of program content, faculty teaching, and resident performance;
d. evaluation of resident training and supervision in affiliated institutions and off-service rotations;
e. maintenance of records related to the educational program; and
f. resident selection; and
g. preparing graduates to seek certification by the American Board of Orofacial Pain.

In those programs where applicants are assigned centrally, responsibility for selection of residents may be
delegated to a designee.

Self-Study Analysis:
1. Provide the following factual information:
Program Director’s Name:
Number of hours per week at sponsoring institution ____
Number of hours per week devoted to the orofacial pain program _____

2. Provide a copy of the program director’s job description in the appendix.

3. Does the program director’s job description include the following responsibilities?

Responsibility Yes No
Program administration
Development and implementation of curriculum plan
Ongoing evaluation of program content, faculty teaching,
and resident performance
Evaluation of resident training and supervision in affiliated
institutions and off-service rotations
Maintenance of records related to the educational program
Resident selection
Preparing graduates to seek certification by the American
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 Board of Orofacial Pain

4. Describe the program director’s participation in each of the above activities.

Examples of evidence to demonstrate compliance may include:

Program director’s job description
Job description of individuals who have been assigned some of the program director’s job responsibilities
Formal plan for assignment of program director’s job responsibilities as described above
Self-Study: Provide above items in the appendix
Program records
On-Site: Prepare above items for review by visiting committee

3-3 The program must be staffed by faculty who are qualified by education and/or clinical experience in the
curriculum areas for which they are responsible and have collective competence in all areas of orofacial pain
included in the program.

Self-Study Analysis:
1. Provide data regarding faculty responsibilities and qualifications (Exhibits 11 and 12 are
suggested for presenting this information)

2. Describe how the teaching staff members are oriented to the philosophy and objectives of the
program.

3. In the event of a change in program personnel, how is program continuity ensured?

4. Assess the adequacy of the size and time commitment of the teaching staff

Examples of evidence to demonstrate compliance may include:

Full and part-time faculty rosters
Self-Study: Provide above items in the appendix. Exhibits 11 and 12 are suggested for presenting this
information.
Program and faculty schedules
Completed BioSketch of faculty members with major responsibilities to the program (Exhibit 13)
Criteria used to certify a non-specialist faculty member as responsible for a specialty teaching area
Self-Study: Provide above items in the appendix
Documentation that non-specialist faculty members are responsible for a specialty teaching area
On-Site: Prepare the above items for review by the visiting committee

3-4 A formally defined evaluation process must exist that ensures measurements of the performance of
faculty members annually.

Intent: The written annual performance evaluations should be shared with the faculty members. The program
should provide a mechanism for residents to confidentially evaluate instructors, courses, program director, and
the sponsoring institution.

Self-Study Analysis:
1. Describe how the faculty is evaluated. Include the frequency of evaluations, who performs the
evaluation, whether it is documented, and whether written performance evaluations are shared with individual
faculty. If an evaluation form is used, provide a blank copy in the appendix.

Examples of evidence to demonstrate compliance may include:

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Faculty files
On-Site: Prepare the above items for review by the visiting committee
Performance appraisals
Self-Study: Provide a blank faculty performance evaluation form if utilized
On-Site: Prepare above items for review by visiting committee

3-5 A faculty member must be present in the clinic for consultation, supervision, and active teaching when
residents are treating patients in scheduled clinic sessions.

Intent: This standard does not preclude occasional situations where a faculty member cannot be available.

Faculty members should contribute to an ongoing resident and program/curriculum evaluation process. The
teaching staff should be actively involved in the development and implementation of the curriculum.

Self-Study Analysis:
1. Describe how it is ensured that a faculty member is present in the dental clinic for consultation,
supervision, and active teaching when residents are treating patients in scheduled clinic sessions.

2. Provide a monthly faculty clinic schedule in the appendix; include only one page if the schedule
remains the same for all 12 months.

Examples of evidence to demonstrate compliance may include:

Faculty clinic schedules
Self-Study: Provide the schedules in the appendix

3-6 Adequate support staff, including allied dental personnel and clerical staff, must be consistently
available to allow for efficient administration of the program.

Intent: The program should determine the number and participation of allied support and clerical staff to meet
the educational and experiential goals and objectives.

Self-Study Analysis:
1. Indicate the number of positions and total number of hours per week devoted to this program and
provide support staff schedules in the appendix.

Type of Support Staff Number of Total # Hours/week

Positions Allocated to this Program
Dental Assisting
Dental Hygiene
Secretarial/Clerical
Other (please describe)

2. Assess whether adequate allied dental personnel are consistently available to the program. If the
support is inadequate please describe how this affects the residents’ educational experience. In addition,
describe efforts that have been taken to remedy this situation.

3. Assess whether adequate clerical personnel are consistently available to the program. If the support is
inadequate please describe how this affects the residents’ educational experience. In addition, describe efforts
that have been taken to remedy this situation.

Examples of evidence to demonstrate compliance may include:

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Staff schedules
Self-Study: Provide schedules in the appendix

3-7 There must be evidence of scholarly activity among the orofacial pain faculty.

Intent: Such evidence may include: participation in clinical and/or basic research; mentoring of orofacial pain
resident research; publication in peer-reviewed scientific media; development of innovative teaching materials
and courses; and presentation at scientific meetings and/or continuing education courses at the local, regional,
or national level.

Self-Study Analysis:
1. Describe how the orofacial pain faculty are involved in scholarly activity.

Examples of evidence to demonstrate compliance may include:

Publication in peer-reviewed scientific media
Teaching materials developed
Scientific meeting presentations
On-Site: Have items above available for review by the visiting committee

3-8 The program must show evidence of an ongoing faculty development process.

Intent: Ongoing faculty development is a requirement to improve teaching and learning, to foster curricular
change, to enhance retention and job satisfaction of faculty, and to maintain the vitality of academic dentistry
as the wellspring of a learned profession.

Self-Study Analysis:
1. Describe the faculty development process and how the program ensures faculty involvement in the
process.

Examples of evidence to demonstrate compliance may include:

Participation in development activities related to teaching, learning, and assessment
Attendance at regional and national meetings that address contemporary issues in education and patient care
Mentored experiences for new faculty
Scholarly productivity
Presentations at regional and national meetings
Examples of curriculum innovation
Maintenance of existing and development of new and/or emerging clinical skills
Documented understanding of relevant aspects of teaching methodology
Curriculum design and development
Curriculum evaluation
Resident assessment
Cultural Competency
Ability to work with residents of varying ages and backgrounds
Use of technology in didactic and clinical components of the curriculum
Evidence of participation in continuing education activities

STANDARD 4 – EDUCATIONAL SUPPORT SERVICES

4-1 The sponsoring institution must provide adequate and appropriately maintained facilities and learning
resources to support the goals and objectives of the program.

Intent: The facilities should permit the attainment of program goals and objectives. Clinical facilities suitable

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for privacy for patients should be specifically identified for the orofacial pain program. Library resources that
include dental resources should be available. Resource facilities should include access to computer,
photographic, and audiovisual resources for educational, administrative, and research support. Equipment for
handling medical emergencies and current medications for treating medical emergencies should be readily
accessible. “Readily accessible” does not necessarily mean directly in the dental clinic. Protocols for handling
medical emergencies should be developed and communicated to all staff in patient care areas.

Self-Study Analysis:
1. Provide data regarding accessibility of equipment for the dental equipment. (Exhibit 14 is suggested for
presenting this information)

2. Clinical Facilities
a. Indicate the total number of functional operatories in the dental clinic:
b. How many of these operatories are designated for use by the program?
c. Assess the availability of operatories when residents are scheduled to provide direct patient care.
d. Describe and assess the adequacy of the dental clinic’s facilities and equipment
e. Assess the ability of the institution to provide privacy for patients of the orofacial pain program.

3. Emergency Equipment and Protocols

a. Comment on the accessibility of current emergency medications and equipment.
b. Describe procedures and documentation used to ensure that these medications and equipment are
regularly inspected.
c. Describe protocols for treating medical emergencies.

4. Radiology Facilities
a. Describe and assess the radiographic imaging facilities within the institution.
b. Assess the adequacy of the services provided by these facilities.
c. Assess the adequacy of available radiographic equipment in the clinic.

5. Library Resources
a. Describe the accessibility and hours of operation of the sponsoring institution’s library and any other
learning resource centers utilized by the program.
b. Assess the scope of holdings and available resources, including:
1. Computerized information retrieval capabilities
2. Interlibrary loan arrangements
3. Audiovisual equipment and supplies
4. Dental resources

6. Distance Education Resources (if applicable)

a. Describe the distance education resources utilized, including the videoconferencing equipment.
b. Describe the facility (location, room size) where the videoconferencing sessions are held.

Examples of evidence to demonstrate compliance may include:

Description of facilities
Self-Study: Provide the above items in the appendix. Exhibit 14 is suggested.

4-2 There must be provision for a conference area separated from the clinic for rounds discussion and
case presentations, sufficient to accommodate the multidisciplinary team.

Self-Study Analysis:
1. Describe the availability of conference areas separated from the clinic for rounds and case
presentations, sufficient to accommodate the multidisciplinary team.

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Examples of evidence to demonstrate compliance may include:
Description of the facilities
Self-Study: Provide the description of the facilities in the appendix. Exhibit 14 is suggested or cross-
reference with Standard 4-1

4-3 Dental and medical laboratory, dental and medical imaging, and resources for psychometric
interpretation must be accessible for use by the orofacial pain program.

Self-Study Analysis:
1. Describe the availability of dental and medical laboratory, dental and medical imaging, and resources
for psychometric interpretation for the orofacial pain program.

Examples of evidence to demonstrate compliance may include:

Description of the facilities
Self-Study: Provide the description of the facilities in the appendix. Exhibit 14 is suggested or cross-
reference with Standard 4-1

4-4 Lecture, seminar, study space, and administrative office space must be available to conduct the
educational program.

Self-Study Analysis:
1. Describe the availability of lecture, seminar, study space and administrative office space to conduct the
educational program.

Examples of evidence to demonstrate compliance may include:

Description of the facilities
Self-Study: Provide the description of the facilities in the appendix. Exhibit 14 is suggested or cross-
reference with Standard 4-1

Selection of Residents

4-5 Applicants must have one of the following qualifications to be eligible to enter the advanced general
dentistry education program in orofacial pain:

a. Graduates from a predoctoral dental education program accredited by the Commission on Dental
Accreditation;
b. Graduates from a predoctoral dental education program in Canada accredited by the Commission on
Dental Accreditation of Canada; and
c. Graduates from an international dental school with equivalent educational background and standing as
determined by the institution and program.

Self-Study Analysis:
1. Are program applicants graduates from a predoctoral dental education program accredited by
the Commission on Dental Accreditation?

2. Are program applicants graduates from a predoctoral dental education program in Canada
accredited by the Commission on Dental Accreditation of Canada?

3. If the program accepts graduates from international dental schools, what is the process used to
ensure that the applicant’s educational background and standing is equivalent?

Examples of evidence to demonstrate compliance may include:

Appropriate qualifying documentation

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Educational equivalency or other measures to demonstrate eligibility
Self-Study: Provide above item(s) in the appendix
Diplomas of enrollees
On-Site: Prepare above item(s) for review by visiting committee.

4-6 Specific written criteria, policies and procedures must be followed when admitting residents.

Intent: Written non-discriminatory policies are to be followed in selecting residents. These policies
should make clear the methods and criteria used in recruiting and selecting residents and how applicants are
informed of their status throughout the selection process.

Self-Study Analysis:
1. Describe and/or provide as an appendix, the program’s admission criteria, policies and
procedures.

Examples of evidence to demonstrate compliance may include:

Written admission criteria, policies and procedures
Self-Study: Provide above item(s) in the appendix; items such as a brochure, catalog or formal
description of the program containing the statement may be used.

4-7 Admission of residents with advanced standing must be based on the same standards of achievement
required by residents regularly enrolled in the program. Residents with advanced standing must receive an
appropriate curriculum that results in the same standards of competence required by residents regularly
enrolled in the program.

Intent: Advanced standing refers to applicants that may be considered for admission to a training program
whose curriculum has been modified after taking into account the applicant’s past experience. Examples
include transfer from a similar program at another institution, completion of training at a non-CODA accredited
program, or documented practice experience in the given discipline. Acceptance of advanced standing
residents will not result in an increase of the program’s approved number of enrollees. Applicants for
advanced standing are expected to fulfill all of the admission requirements mandated for residents in the
conventional program and be held to the same academic standards. Advanced standing residents, to be
certified for completion, are expected to demonstrate the same standards of competence as those in the
conventional program.

Self-Study Analysis:
1. Does the orofacial pain program admit residents with advanced standing? If yes, describe the
policies and methods for awarding advanced standing credit. Indicate the type of courses for which advanced
standing is granted and the maximum number of credits that can be awarded.

2. Describe how the program ensures that transfer residents with advanced standing receive an
appropriate curriculum that results in the same standards of competence required by residents regularly
enrolled in the program

Examples of evidence to demonstrate compliance may include:

Policies and procedures on advanced standing
Self-Study: Provide above item(s) in the appendix
Course equivalency or other measures to demonstrate equal scope and level of knowledge
On-Site: Prepare above item(s) for review by the visiting committee
Results of appropriate qualifying examinations
On-Site: Prepare above item(s) for review by the visiting committee

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4-8 The program’s description of the educational experience to be provided must be available to program
applicants and include:

a. a description of the educational experience to be provided;

b. a list of program goals and objectives; and
c. a description of the nature of assignments to other departments or institutions.

Intent: This includes applicants who may not personally visit the program and applicants who are deciding
which programs to apply to. Materials available to applicants who visit the program in person will not satisfy
this requirement. A means of making this information available to individuals who do not visit the program is to
be developed.

Self-Study Analysis:
1. Describe how information regarding the educational experiences (including the list of the program’s goals
and objectives and the nature of assignments to other departments or institutions is made available to
program applicants.

Examples of evidence to demonstrate compliance may include:

Brochure or application documents
Program’s website
Description of system for making information available to applicants who do not visit the program
Self-Study: Provide above item(s) in the appendix.

Due Process

4-9 There must be specific written due process policies and procedures for adjudication of academic and
disciplinary complaints that parallel those established by the sponsoring institution.

Intent: Adjudication procedures should include institutional policy that provides due process for all individuals
who may be potentially involved when actions are contemplated or initiated that could result in dismissal of a
resident. Residents should be provided with written information that affirms their obligations and
responsibilities to the institution, the program and the faculty. The program information provided to the
residents should include, but not necessarily be limited to, information about tuition, stipend or other
compensation, vacation and sick leave, practice privileges and other activity outside the educational program,
professional liability coverage, due process policy, and current accreditation status of the program.

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Self-Study Analysis:
1. Provide a copy of the specific written due process policies and procedures for adjudication of academic
complaints in the appendix.
2. Do the procedures provide due process for all individuals who may potentially be involved when actions are
contemplated or initiated that could result in dismissal of a resident?
3. Do the due process procedures parallel those established by the sponsoring institution? YES
NO If no, please explain:
4. Are residents provided with written information that affirms their obligations and responsibilities to the
institution, the program and the faculty?
5. Program information provided to residents includes (check those that apply):
___ tuition, stipend or other compensation information
___ vacation and sick leave
___ practice privileges and other activity outside the program
___ professional liability coverage
___ due process policy
___ current accreditation status of the program

Examples of evidence to demonstrate compliance may include:

Policy statements and/or resident contract
Self-Study: Provide above item(s) in the appendix.

Health Services

4-10 Residents, faculty, and appropriate support staff must be encouraged to be immunized against and/or
tested for infectious diseases, such as mumps, measles, rubella, and hepatitis B prior to contact with patients
and/or infectious objects or materials, in an effort to minimize the risk to patients and dental personnel.

Self-Study Analysis:
1. How are residents encouraged to be immunized against and/or tested for infectious diseases prior to
contact with patients and/or infectious objects or materials?

Examples of evidence to demonstrate compliance may include:

Immunization policy and procedures
Self-Study: Provide above item(s) in the appendix.
On-Site: Prepare above item(s) for review by visiting committee.

STANDARD 5 – PATIENT CARE SERVICES

5-1 The program must ensure the availability of patient experiences that afford all residents the opportunity
to achieve the program’s stated goals and objectives of resident training or competencies and proficiencies.

Intent: Patient experiences should include evaluation and management of head and neck musculoskeletal
disorders, neurovascular pain, neuropathic pain, sleep-related disorders, and oromandibular movement
disorders.

Self-Study Analysis:
1. Describe the method used to monitor the adequacy of the patient experiences available to the residents
(include frequency of reviews, individuals responsible, and how data collected is correlated with the program’s
goals and objectives of resident training or competencies and proficiencies.)

2. Explain how and when corrective actions are taken if one or more residents is not receiving adequate
patient experiences.

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3. Assess the current patient pool in terms of providing adequate patient experiences and note, if
applicable, any plans currently underway to identify and secure additional sources of patient experiences.

Examples of evidence to demonstrate compliance may include:

Records of resident clinical activity, including specific details on the variety and type and quantity of cases
treated and procedures performed.
Self-Study: Provide a sample of the reporting format utilized or a sample record of clinical activity for one
resident to familiarize the visiting committee with the format in advance of the visit.
On-Site: Prepare above item(s) for review by visiting committee on-site. Have available, complete records of
all residents’ clinical activities.

5-2 Patient records must be organized in a manner that facilitates ready access to essential data and be
sufficiently legible and organized so that all users can readily interpret the contents.

Intent: Essential data is defined by the program and based on the information included in the record review
process as well as that which meets the multidisciplinary educational needs of the program. The patient record
should include a diagnostic problem list, use of pain assessment and treatment contracts, progress sheets,
medication log, and outcome data, plus conform to SOAP notes format.

The program is expected to develop a description of the contents and organization of patient records and a
system for reviewing records.

Self-Study Analysis:
1. Describe the process of record review. Include how frequently the records are reviewed and the criteria
used in the review.

2. Define essential data used by the program in its record review and multidisciplinary education.

3. Assess the adequacy of the mechanism to ensure that ambulatory and inpatient records are organized
in a manner that facilitates ready access to essential data and are sufficiently legible and organized so that all
users can readily interpret the contents.

Examples of evidence to demonstrate compliance may include:

Patient records
Self-Study: Provide blank ambulatory and inpatient record review forms and documentation of record
review process
On-Site: Prepare above items for review by visiting committee
Record review plan
Documentation of record reviews
Self-Study: Provide the items listed above in the appendix

5-3 The program must conduct and involve residents in a structured system of continuous quality
improvement for patient care.

Intent: Programs are expected to involve residents in enough quality improvement activities to understand the
process and contribute to patient care improvement.

Self-Study Analysis:
1. Briefly describe and/or provide in the appendix the program’s quality improvement plan for patient care.

2. Explain how the program involves residents in the quality improvement system.

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Examples of evidence to demonstrate compliance may include:
Description of quality improvement process including the role of residents in that process
Self-Study: Provide the description in the appendix
Quality improvement plan and reports
Self-Study: Provide quality improvement plan and copies of quality improvement reports for the last six months
in the appendix
On-Site: Have available any reports generated after completion of the self-study

5-4 All residents, faculty, and support staff involved in the direct provision of patient care must be
continuously recognized/certified in basic life support procedures, including cardiopulmonary resuscitation.

Intent: ACLS and PALS are not a substitute for BLS certification.

Self-Study Analysis:
1. Describe the procedures used to assure that all residents, faculty and support staff involved in the
direct provision of patient care are recognized/certified in basic life support procedures, including
cardiopulmonary resuscitation.

2. How and when are residents trained and certified in basic life support?

3. Describe the procedure used, if any, to document and maintain records of any resident who is
medically or physically unable to perform basic life support procedures.

Examples of evidence to demonstrate compliance may include:

Certification/recognition records demonstrating basic life support training or summary log of
certification/recognition maintained by the program
Exemption documentation for anyone who is medically or physically unable to perform such services
Self-Study: Provide in the appendix a copy of recognition policy and procedures.
On-Site: Prepare up-to-date recognition/certification records for all residents, faculty and
support staff.

5-5 The program must document its compliance with the institution’s policy and applicable regulations of
local, state and federal agencies, including, but not limited to, radiation hygiene and protection, ionizing
radiation, hazardous materials, and blood-borne and infectious diseases. Polices must provide to all
residents, faculty and appropriate support staff and continuously monitored for compliance. Additionally,
policies on blood-borne and infectious diseases must be made available to applicants for admission and
patients.

Intent: The policies on blood-borne and infectious diseases should be made available to applicants for
admission and patients should a request to review the policy be made.

Self-Study Analysis:
1. Provide information regarding the program’s procedures to document compliance with the institution’s
policies and applicable governmental regulations in the four areas specified in the standard. (Exhibit 15 is
suggested for presenting this information.)

2. Explain how these policies are provided to all residents, faculty and appropriate support staff and how
monitoring for compliance is achieved. (Exhibit 15 is suggested for presenting this information.)

3. Describe how policies on blood-borne infectious diseases are made available to applicants for
admission. (Exhibit 15 is suggested for presenting this information.)

198
4. Describe how policies on blood-borne infectious diseases are made available to patients. (Exhibit 15 is
suggested for presenting this information.)

Examples of evidence to demonstrate compliance may include:

Narrative Response Table is suggested – Exhibit 15
Infection and biohazard control policies
Radiation policy
Self-Study: Provide above item(s) in the appendix.

5-6 The program’s policies must ensure that the confidentiality of information pertaining to the health status
of each individual patient is strictly maintained.

Self-Study Analysis:
1. Describe and/or provide the program’s policies on confidentiality.

2. Explain where these records are kept, by whom, and how this ensures that the confidentiality of information
pertaining to the health status of each individual is strictly maintained.

Examples of evidence to demonstrate compliance may include:

Confidentiality policies
Self-Study: Provide above item(s) in the appendix.

STANDARD 6 - RESEARCH

6-1 Residents must engage in research or other scholarly activity and present their results in a
scientific/educational forum.

Intent: The research experience and its results should be compiled into a document or publication

Self-Study Analysis:
1. Describe how the residents are engaged in scholarly activity or research.

Examples of evidence to demonstrate compliance may include:

List of resident research/scholarly activity projects
Self-Study: Provide above item(s) in the appendix.

SUMMARY

Provide a standard-by-standard summary of the program’s strengths and weaknesses. Describe actions
planned to correct any identified weaknesses.

Standard 1 – Institutional and Program Effectiveness

Strengths:

Weaknesses:

Standard 2 – Educational Program

Strengths:

199
Weaknesses:

Standard 3 – Faculty and Staff

Strengths:

Weaknesses:

Standard 4 – Educational Support Services

Strengths:

Weaknesses:

Standard 5 – Patient Care Services

Strengths:

Weaknesses:

Standard 6 – Research

Strengths:

Weaknesses:

200
APPENDICES

STD DOCUMENTATION Appendix Document and/ or Prepare for

Number Suggested Exhibit review on-site*

STANDARD 1 -- INSTITUTIONAL AND PROGRAM EFFECTIVENESS

1-1 Accreditation certificate or current official certificate/listing None

listing of accredited institutions
Evidence of successful achievement of Evidence of
Service-specific inspection criteria achievement

1-2 Written agreement(s) None Agreements

Contracts between the institution/program None Contracts
and sponsor(s) (For example:
contract(s)/agreement(s) related to
facilities, funding, faculty allocations, etc.)

1-4 Table of resources for current year Exhibit 1 None

Budget information for previous, current Exhibit 2 Budget plans
and ensuing fiscal years

1-5 Written agreements Exhibit 3 Agreements

(for each affiliate)

1-6 Bylaws or documents describing Bylaws excerpts Bylaws

committee structure
Copy of institutional committee structure Committee structure None
and/or roster of membership by dental and/or membership
faculty by dental faculty

1-7 Bylaws or documents describing resident Bylaws excerpts Bylaws-See 1-6

privileges

1-8 Bylaws or documents describing Bylaws excerpts Bylaws

committee structure
Copy of institutional committee structure Committee structure None
and/or roster of membership by dental and/or membership
faculty by dental faculty

1-9 Overall program goals and objectives Goals and None

objectives

201
STD DOCUMENTATION Appendix Document and/ or Prepare for
Number Suggested Exhibit review on-site*

1-10 Overall program goals and objectives Goals and objectives None
See 1-9
Outcomes assessment plan and Plan/Exhibit 4 None
measures
Outcomes results Results/Exhibit 4 Updated Results
Annual review of outcomes results Annual review None
Meeting minutes where outcomes are Minutes None
discussed
Decisions based on outcomes results Decisions/Exhibit 4 None

1-11 Didactic courses Schedules/Exhibit 7 None

Course outlines Outlines None
Resident evaluations None Evaluations
Case studies None Case Studies
Documentation of treatment planning None Documentation
sessions
Documentation of treatment outcomes None Documentation
Patient satisfaction surveys None Surveys
Example of literature reviews None Literature reviews

STANDARD 2 - EDUCATIONAL PROGRAM

2-1 Curriculum plan Curriculum None
Plan/Exhibit 5

2-2 Goals and objectives for resident Goals/Objectives or None

training or competencies and Competencies and
proficiencies Proficiencies

2-3 Goals and objectives Goals and objectives None

Content Outlines Outlines None

2-4 Curriculum Plan with experiences tied to Curr Plan/Exhibit 5 None

specific goals and objectives or
competencies and proficiencies
Overview of distribution of time in major Overview/Exhibit 6 None
curriculum areas
Didactic Schedules Schedules/Exhibit 7 None
Clinical Schedules Schedules/Exhibit 8 None

202
STD DOCUMENTATION Appendix Document and/ or Prepare for
Number Suggested Exhibit review on-site*
2-5 Course Outlines Course Outlines None
Didactic Schedules Schedules/Exhibit 7 None
Resident evaluations with identifying None Evaluations
information removed

2-6 Course Outlines Course Outlines None

Didactic Schedules Schedules/Exhibit 7 None
Resident evaluations with identifying None Evaluations
information removed

2-7 Didactic Schedules Schedules/Exhibit 7 None

Course outlines Outlines None
Resident evaluations with identifying None Evaluations
information removed

2-8 Overview of distribution of time in major Overview/Exhibit 6 None

curriculum areas

2-9 Goals and objectives of resident training Goals/Objectives or None

or competencies and proficiencies Competencies and
organized by the areas described above Proficiencies or see 2-
2/Exhibit 9
Didactic Schedules Schedules/Exhibit 7 None
Clinical Schedules Schedules/Exhibit 8 None
Resident evaluations with identifying None Evaluations
information removed
Documentation of Treatment Planning None Documentation
Sessions
Documentation of Chart Reviews None Documentation
Documentation of Case Simulations None Documentation

2-10 Didactic Schedules Schedules/Exhibit 7 None

Clinical Schedules Schedules/Exhibit 8 None
Resident evaluations with identifying None Evaluations
information removed
Documentation of Treatment Planning None Documentation
Sessions
Documentation of Chart Reviews None Documentation
Documentation of Case Simulations None Documentation
Records of resident clinical activity None Records
(such as case logs)
Patient Records None Records
STD DOCUMENTATION Appendix Document and/ or Prepare for
Number Suggested Exhibit review on-site*

2-11 Distribution of residents time in major Exhibit 6

curriculum areas
Clinical Schedules Schedules/Exhibit 8 None
Description and schedule of rotations Schedules None
203
 Rotation/Experience objectives Objectives/Exhibit 10 None
Resident evaluations with identifying None Evaluations
information removed

2-12 Description and schedule of rotations Schedules or see 2-11 None

Rotation/Experience objectives Objectives/Exhibit 10 None
Resident evaluations with identifying None Evaluations
information removed

2-13 Schedule of orofacial pain teaching Schedule None

experiences

2-14 Documentation of Treatment Planning None Documentation

Sessions/conferences where outcomes
are discussed
Documentation of Chart Reviews None Documentation
Documentation of Case Simulations None Documentation
Records of resident clinical activity None Records
(such as case logs) including
procedures performed in each area
described above

Patient Records None Records

Resident evaluations with identifying None Evaluations
information removed

2-15 Course outlines Outlines None

2-16 Conference schedules Schedules None

2-17 Evidence of experiences requiring Evidence None

literature review

2-18 Program Schedules Schedules None

Curriculum Plan Curr Plan/Exhibit None
5/See Standard 2-1

204
STD DOCUMENTATION Appendix Document and/ or Prepare for
Number Suggested Exhibit review on-site*

2-19 Description of the part-time program Description None

Documentation of how part-time Description None
residents will achieve similar
experiences and skills as full-time
residents
Program Schedules Schedules None

2-20 Evaluation criteria and process Criteria (in response) None

Resident evaluations with identifying Blank evaluation form Evaluations
information removed
Personal record of evaluation for each Record None
resident
Evidence that corrective actions have Corrective actions None
been taken taken

STANDARD 3 - FACULTY AND STAFF

3-1 Program Director’s BioSketch Completed BioSketch None
(Exhibit 13)
Copy of board certification certificate Certificate None
Letter from Board attesting Letter None
current/active certification

3-2 Program Director’s Job description Description None

Job description of individuals who have Description None
been assigned some of the program
director’s job responsibilities
Formal plan for assignment of program Plan None
director’s job responsibilities
Program records None Program Records

3-3 Program and faculty schedules Schedules None

Full and part-time faculty rosters Exhibits 11 & 12 None
Completed BioSketch for faculty Completed BioSketch None
members (Exhibit 13)
Criteria used to certify non-specialist Criteria None
faculty member as responsible for a
specialty teaching area
Documentation that non-specialist None Documentation
faculty members are responsible for
specialty teaching area

205
STD DOCUMENTATION Appendix Document and/ or Prepare for
Number Suggested Exhibit review on-site*
3-4 Faculty files None Files
Performance appraisals Blank Evaluation Completed Forms
Form

3-5 Faculty clinic schedules Schedules None

3-6 Staff schedules Schedules None

3-7 Publication in peer-reviewed scientific None Publications

media
Teaching materials developed None Teaching materials
Scientific meeting presentations None Presentations

3-8 Evidence of participation in development Evidence None

activities related to teaching, learning and
assessment
Attendance at regional/national meeting Evidence None
were contemporary issues in education
and patient care are addressed
Mentored experiences for new faculty Description of None
experiences
Scholarly productivity Scholarly works None
Presentations at regional and national Sample None
meetings presentations
Examples of curriculum innovation Curriculum None
innovations
Maintenance of existing and development Description of how None
of new and/or emerging clinical skills skills are maintained
or new skills are
developed
Understanding of relevant aspects of Documented None
teaching methodology understanding
Curriculum design and development Redesigned or None
developed
curriculum
Curriculum evaluation Evidence of None
curriculum
evaluation
Resident assessment Sample Assessments
Assessments
STD DOCUMENTATION Appendix Document and/ or Prepare for
Number Suggested Exhibit review on-site*
Cultural competency Evidence of cultural None
competency
Ability to work with residents of varying Documented None
ages and backgrounds evidence
Use of technology in didactic and clinical Documented None
components of the curriculum evidence

206
 Evidence of participation in continuing Documented None
education experiences evidence

STANDARD 4 - EDUCATIONAL SUPPORT SERVICES

4-1 Description of facilities Exhibit 13 None

4-2 Description of facilities Exhibit 13 or 4-1 None

4-3 Description of facilities Exhibit 13 or 4-1 None

4-4 Description of facilities Exhibit 13 or 4-1 None

4-5 Diplomas of enrollees None Diploma

Appropriate qualifying documentation Documentation None
Educational equivalency or other measures Documentation None
to demonstrate eligibility

4-6 Written criteria, policies and procedures Criteria, policies, None

procedures

4-7 Policies and Procedures Policies and None

procedures
Results of appropriate qualifying None Results of exams
examinations
Course equivalency or other measures as None Documentation
described

4-8 Brochure or application documents Documents None

Program’s website Website address or
paper copy of
information on
website
Description of system for making Description None
information available to applicants who do
not visit the program

207
STD DOCUMENTATION Appendix Document and/ or Prepare for
Number Suggested Exhibit review on-site*

4-9 Policy statements and/or resident contract Statements/ None

contracts

4-10 Immunization policy and procedure None None

documents

STANDARD 5 - PATIENT CARE SERVICES

5-1 Records of resident clinical activity Sample Record Records

5-2 Patient records Blank Record Records

Review Form
Record Review Plan Record review plan None
Documentation of record reviews Documentation None

5-3 Quality improvement plan and reports Copy of Plan and Updated Reports
Reports (6 mos.)
Description of quality improvement Description None
process including the role of residents in
the process

5-4 Certification/recognition records Copy of Policy Current Records

demonstrating life support training or Summary log
summary log of certification/recognition
Exemption documentation for anyone Copy of policy Current Records
medically or physically unable to perform
such services

5-5 Narrative Response Table Exhibit 14 None

Infection and biohazard control policies Copy of Policies None
Radiation policy Copy of Policy None

5-6 Confidentiality policies Copy of Policy None

208
 STD DOCUMENTATION Appendix Document and/ or Prepare for
Number Suggested Exhibit review on-site*

STANDARD 6 - RESEARCH

6-1 List of residents engaged in scholarly List of projects None

activity or research

* It should be understood that “None” in the “Prepare for review on-site column” implies that the program
should be prepared to provide updated information related to written material provided in the self-study.

209
INDEX OF SUGGESTED EXHIBITS

Exhibit Standard(s) Title

Self-
Study:
Provide above
items in the
appendix
1 1-4 Financial Resources

2 1-4 Program Budget Information

3 1-5 Off-Campus Training sites

4 1-10 Outcomes Assessment

5 2-1, 204 Curriculum Management Plan

6 2-4, 2-8 Resident Total Program Time

7 2-4, 2-5, 2-6, Didactic Program

2-7, 2-9, 2-10

8 2-9, 2-10, Clinical Schedules

2-11

9 2-9, 2-10 Required Curricular Areas

10 2-11, 2-12 Assignments to Other Services

11 3-3 Full-Time Faculty

12 3-3 Part-Time Faculty

13 3-1, 3-3 BioSketch

14 4-1 Facilities

15 5-5 Radiation, Hazard and Infection Control Policies and

Procedures

210
EXHIBIT 1

FINANCIAL RESOURCES

Using the following format, identify the sources of fiscal support for the program and the percentage of the
program’s total budget that each source constitutes:

Current fiscal year: __________

A. State support $_______________ _______________

%
B. Local support $_______________ _______________
%
C. Grant

federal $_______________ _______________

%
state $_______________ _______________
%
local $_______________ _______________
%
private $_______________ _______________
%
D. Tuition $_______________ _______________
%
E. Other _____________________ $_______________ _______________
(specify) %

TOTAL $_______________ ____________100

%

211
EXHIBIT 2
PROGRAM BUDGET INFORMATION

Using the following form, provide information on the advanced education in general dentistry program’s budget
for the previous, current and ensuing fiscal years.
Previous Year Current Year Ensuing Year
20__ to 20__ 20__ to 20__ 20__ to 20__
I. Capital Expenditures
A. Construction $__________ $__________ $__________
B. Equipment _ _ _
1. Clinic (dental unit, chair, etc.)
2. Radiography (including
darkroom) ___________ ___________ ___________
3. Laboratory
4. Reception Room ___________ ___________ ___________
5. Faculty & Staff offices
6. Instructional equipment ___________ ___________ ___________
7. Other (specify)
___________ ___________ ___________
TOTAL
___________ ___________ ___________

___________ ___________ ___________

___________ ___________ ___________

___________ ___________ ___________

$__________ $__________ $__________
_ _ _
II. Non-capital expenditures
A. Instructional materials, e.g., slides, $__________ $__________ $__________
films _ _ _
B. Clinic supplies
C. Laboratory supplies ___________ ___________ ___________
D. Office supplies
E. Program library collection ___________ ___________ ___________
1. Institutional
2. Departmental ___________ ___________ ___________
F. Equipment maintenance and
replacement __________ __________ __________
G. Other (specify) _ _ _
_____________________
____________________________ ___________ ___________ ___________
______
TOTAL ___________ ___________ ___________

___________ ___________ ___________

___________ ___________ ___________

$__________ $__________ $__________
_ _ _
III. Faculty
A. Salaries $__________ $__________ $__________

212
 B. Benefits _ _ _
C. Professional Development __________ __________ __________
D. Other (specify) _ _ _
_____________________
____________________________ ___________ ___________ ___________
______
TOTAL ___________ ___________ ___________

___________ ___________ ___________

$__________ $__________ $__________
_ _ _
IV. Staff
A. Secretarial Support $__________ $__________ $__________
B. Allied Support (specify) _ _ _
______________________
_________________________________ ___________ ___________ ___________
____
TOTAL ___________ ___________ ___________
$__________ $__________ $__________
_ _ _
V. Other Categories, if any $__________ $__________ $__________
(specify)___________ _ _ _
_________________________________
____ ___________ ___________ ___________
TOTAL $__________ $__________ $__________
_ _ _
GRAND TOTAL $__________ $__________ $__________
_ _ _

EXHIBIT 3

OFF--CAMPUS TRAINING EXPERIENCES

Please make copies of this form as needed for each off-campus training experience; number sequentially

a. Official name, city, state of off-campus training site:

__________________________________________________________________

b. Length and purpose of the rotation (number of weeks, hours per week). Indicate if required or
optional/enrichment:

c. Is the institution accredited by an agency recognized by the United States Department of Education or
accredited by an accreditation organization recognized by the Centers for Medicare and Medicaid Services
(CMS)? See Examples of Evidence for list of agencies.

_____YES _____NO _____ N/A

If another accrediting body, please list:

d. Distance from the training site to sponsoring institution:

e. One-way commuting time:

213
f. Indicate why this training site was selected, the nature of training provided to residents, teaching staff
responsible for conducting the program and supervising residents at the training site, and how these
educational experiences supplement training received at the sponsoring institution. Indicate if the experiences
are optional/enrichment or required for accreditation or program requirements.

g. If written agreements have not been updated to include this program, please provide timetable for updating
the agreement.

EXHIBIT 4

OUTCOMES ASSESSMENT

This table provides one example of a format which may be utilized to present the program’s outcomes
assessment plan and process. A copy should be made for each of the program’s overall goals and objectives.
If an alternative format is used, please be sure it includes the information below.

Overall Goal or Objective #________:

Overall Goal or Objective

Outcomes Assessment
Mechanism

How often conducted

Date to be conducted/
finished by

Results expected

Results achieved

Assessment of results

Program improvement as a
result of data analysis

Date of next assessment

214
EXHIBIT 5

CURRICULUM MANAGEMENT PLAN

Using the format illustrated below, present the curriculum management plan, listing
competency, proficiency and program requirements or goals and objectives of resident training
outlined in Standard 2. Include the didactic instruction and clinical experience designed to
achieve program requirements and the evaluation mechanisms used. Reproduce this exhibit as
needed.

Goal and Objective/ Didactic Clinical Evaluation

Competency and Proficiency/or Instruction Experience Mechanism(s)
Program Requirement

215
 217

EXHIBIT 6

RESIDENT TOTAL PROGRAM TIME

Estimate the percent of time devoted by the residents to each of the following:

AREA First Year* Second Year*

Didactics % %

Clinical Activities
Orofacial Pain % %
Other % %
Rotations/assignment to other services % %

Conferences/seminars % %

Laboratory activities % %

Teaching % %

Investigative Work % %

Other (please specify) % %

% %
TOTAL 100% 100%

*Above calculations are based on an average of _________hours per week.

217
 218

EXHIBIT 7

DIDACTIC PROGRAM

This table provides one example of a format which may be utilized to present the
program’s educational programs. Complete one page for each course. Please attach
the most recent course syllabus for each course or seminar series.

Course or Seminar:

Course/Seminar Name

Course/Seminar Director

When Course/Seminar is
offered and how many total
hours.

Course/Seminar
Objective(s)

Specific Goals and

Objectives or
Competencies to be
achieved

Evaluation Mechanism

218
 219

EXHIBIT 8

RESIDENT CLINICAL SCHEDULES

Using this suggested format or another format, please provide a month-by-month listing
of each resident’s activities. If this is a two-year program please include a schedule for
both years.

Month Resident #1 Resident #2

July Orientation Clinic Orientation Clinic

August Clinic Physical Clinic Physical

Diagnosis Diagnosis
September Anesthesia Rotation Clinic

October Clinic Anesthesia Rotation

November ER Rotation Clinic Clinic ER Rotation

December Clinic Clinic

January Medicine Clinic Clinic Medicine

Rotation Rotation
February OMS Rotation Clinic

March OMS Rotation Clinic Clinic OMS

Rotation
April Clinic OMS Rotation

May Clinic Clinic

June Clinic Clinic

219
 220

EXHIBIT 9

REQUIRED CURRICULUM AREAS

INTENDED OUTCOMES, DIDACTIC INFORMATION, CLINICAL EXPERIENCES

Copy the form as needed and complete one form for each required area.

Required Area: ___________________________________________________

Years Offered: _____________________

A. Describe the intended outcomes of resident training in the area listed above either in
terms of goals and objectives for resident training or competencies and proficiencies.
(Use additional sheets if necessary.)
The curriculum in this area is intended to enable the resident to:

B. Describe the educational experiences that make up the curriculum in this area:

Didactic instruction in this area is provided through:

________ Dental departmental seminar, conference, lecture program

________ Formal course(s) –title(s)_________________________________
________ Off-service rotation to:___________________________________
________ Other (specify):_________________________________________
________ No formal instruction is provided.

Total hours of didactic instruction in this area are: ______

The topics covered in didactic instruction in this area are:

C. Describe the nature and amount of clinical experience residents receive in this area.
Identify specific procedures performed by residents in this area.

220
 221

EXHIBIT 10

ASSIGNMENTS TO OTHER SERVICES/ROTATIONS

Provide the information listed below for each assignment to other services or rotation.
Duplicate the page as needed for each assignment/rotation.

Service:________________________________________________________________
_

Length of Rotation or Experience (in weeks):__________

Number of Hours per Week:___________

1. Describe the intended objectives of this rotation or experience.

2. Were these objectives developed in cooperation with the department chairperson,

service chief, or facility director? ____Yes ____No If no, please comment:

3. Describe how residents are advised of the written objectives of each rotation or
experience.

4. Describe how the faculty designated to provide resident supervision are made
familiar with the objectives of the rotation or experience.

5. Describe the process and evaluation instruments utilized by the designated faculty to
evaluate resident performance.

EXHIBIT 11

FULL-TIME FACULTY
TIME COMMITMENT, ASSIGNMENTS AND QUALIFICATIONS FOR SUBJECTS
TAUGHT

On the table below, indicate the members of the teaching staff who are scheduled to
devote ONE-HALF DAY OR MORE PER WEEK specifically to the program. Indicate
whether each staff member listed is a general practitioner or specialist, the number of
hours per week, and the number of weeks per year devoted to the program. If the staff
member is a specialist, indicate the specialty and board status. Be sure to include the
program director.

221
 222

Nam Disciplin Board Hour Week Assignment Subjec Qualificatio

e e/ Status (If s s s* ts ns related
Specialt Speciali per per Taught to subjects
y st) week year taught

*Use the following codes to indicate assignments:

SC—Supervision of residents in clinic T—Teaching Didactic Sessions (lectures,
seminars, courses) PA—Program Administration

EXHIBIT 12

PART-TIME FACULTY
TIME COMMITMENT, ASSIGNMENTS, AND QUALIFICATIONS FOR SUBJECTS
TAUGHT

Starting with the individual who has the greatest time commitment to the program, list
members of the attending staff or consultants who are scheduled to devote LESS THAN
ONE-HALF DAY PER WEEK, BUT AT LEAST ONE-HALF DAY (OR MORE) PER
MONTH specifically to the program. Indicate whether each individual listed is a general
practitioner (GP) or specialist, the number of days per month, and the number of weeks
per year devoted to the educational program. If the staff member or consultant is a
specialist, indicate specialty and board status.

Name Discipline/ Board Days Weeks Assignments* Subjects Qualifications

Specialty Status (If per per Taught related to
Specialist) month year subjects taught

*Use the following codes to indicate assignments:

SC—Supervision of residents in clinic T—Teaching Didactic Sessions (lectures,
seminars, courses) PA—Program Administration

222
 223

EXHIBIT 13
BioSketch
Do not attach Curriculum Vitae.
Print or Type Only
Name:

Current Institution:

Address: City, State, Zip:

Phone: Fax: E-mail:

EDUCATIONAL BACKGROUND (Begin with college level)

Yr of Certificate or
Name of School, City and State Area of Study
Grad. Degree

LICENSURE
License (Do not include license number) From (Year) To (Year)

BOARD CERTIFICATION
Certifying Organization Specialty Date certified

CE COURSES TAKEN (last 5 years)

Course Title Course Content and Provider Month and Year

TEACHING APPOINTMENTS (Begin with current)

Subjects/Content
From To
Name of Institution, City and State Rank AreasTaught/ Administrative
(Year) (Year)
Responsibilities

223
 224

CURRENT TEACHING RESPONSIBILITIES

Name of Institution, City, Course Title Discipline and Total Contact Hours Per Year
State Level of Students
(Year)
Didactic Clinic/Labora
tory

HOSPITAL APPOINTMENTS (Begin with current)

From To
Name of Hospital City State
(Year) (Year)

PRACTICE EXPERIENCE
Location (City and State) Type of Practice From To
(Year) (Year)

MEMBERSHIP, OFFICES OR APPOINTMENTS HELD IN LOCAL, STATE OR

NATIONAL DENTAL OR ALLIED DENTAL ORGANIZATIONS, INCLUDING
APPOINTMENTS TO STATE BOARDS OF DENTISTRY AND CODA
Name of Organization Title From To
(Year) (Year)

PUBLISHED WORKS (For the most recent five years, list articles in which you were the
principal author that appeared in refereed journals or text books, by author(s), title,
publication, and date)
Author(s) Title Publication Date

224
 225

EXHIBIT 14

FACILITIES

For each item listed below, indicate whether the item is located within the dental clinic,
outside the dental clinic but readily accessible to it, or not available (check appropriate
response.)

Facilities, Within Clinic Readily Accessible Not Available

Capabilities/Equipment
Intraoral radiographic facilities
Extraoral radiographic facilities
Dental laboratory facilities
Staff offices
Study areas
Conference rooms
Library Resources including Dental
Resources
Dental recovery area
Sterilization capabilities:
Autoclave
Ethylene oxide
Dry heat
Emergency drugs
Emergency equipment:
Oxygen under pressure
Suction
Resuscitative equipment
Distance Education Resources
(videoconferencing equipment,
etc.)

225
EXHIBIT 15

RADIATION, HAZARD AND INFECTION CONTROL POLICIES AND PROCEDURES

Radiation Ionizing Hazardous Blood-borne

Hygiene Radiation Materials and
And Infectious
Protection Diseases
Institution’s Policies and any
Applicable Governmental
Regulations
(name documents containing
policies)

Who maintains documentation

of compliance?

How are policies provided to

residents?

How is resident compliance

monitored?

How are policies provided to

faculty?

How is faculty compliance

monitored?

How are policies provided to

support staff?

How is support staff

compliance monitored?

How are policies made

available to applicants for
admission?
How are policies made
available to patients?

Orofacial Pain Self-Study Application (fully-developed programs)

226
PROTOCOL FOR CONDUCTING A SITE VISIT

Introduction: The Commission recognizes that there may be considerable latitude in determining
procedures and methodology for site visits. Experience has shown that the conference method for
conducting a site visit is widely favored and has been found most satisfactory.

Conferences with administrators and faculty should be scheduled in an adequately-sized and well-
ventilated meeting room with a conference table which is large enough to accommodate the visiting
committee and faculty member participants. It is suggested that all conferences be scheduled for the
same room. If more than one program is to be evaluated, an additional conference room for each
program (within close proximity) will be required.

Briefing Faculty, Administrators and Residents on the Site Visit: It is presumed that the program’s
faculty, residents and administration will be apprised of the Commission’s visit. The program director
should inform the faculty that they will be expected to explain course objectives, teaching methods,
particular skills and abilities expected of residents upon completion of the course and the measures
used to evaluate resident performance.

Focus of the Accreditation Review: Commission action on accreditation status is based upon the
program in operation at the time of the site visit. It is not based upon any proposed changes in the
program. The visiting committee will, however, expect to be apprised of any facility, faculty or curricular
changes that are contemplated but not yet implemented.

Resources/Materials Available On-Site: It is expected that additional sources of information will be

made available to the visiting committee on-site. Materials may include, but are not limited to: affiliation
agreements, institution by-laws, the institution’s infection and hazard control protocol,
inpatient/outpatient records, resident files, resident and teaching staff evaluation records, and a record
of resident complaints as appropriate.

Visiting Committee Schedule: While it is expected that all arrangements will be determined by the
program director, experience indicates that administrators welcome suggestions by the Commission for
the conduct of site visits. Although a more detailed suggested schedule of conferences will be
forwarded to the program director prior to the scheduled visit, the Commission expects that an
evaluation visit will include the following components:

1. An opening conference with the appropriate institutional administrators and program director at
the beginning of the visit to include an overview and description of the institution and its programs. The
purpose of this initial conference is to orient visiting committee members to a program’s particular
strengths and weaknesses. This session is also intended to orient the administrators and program
director to the methods and procedures of the visiting committee. Topics frequently covered in this
session include: program goals, administration, faculty recruitment and evaluation, finances, facilities,
curriculum development, assessment of outcomes, long-term planning and program development.

2. Tours of the program facilities and related learning resources facilities.

3. Conferences with faculty who have teaching or administrative responsibilities for the program.
4. Interviews with residents. The purpose of these resident interviews is to determine general
reactions to the program and to learn whether the residents understand the objectives of the various
components. Interviews can be conducted as a group or individually, as preferred by the site visitor.
Faculty members should not be included.
5. If the program utilizes off-campus sites for clinical experiences or didactic instruction, please
review the Commission’s Policy on Accreditation of Off-Campus Sites found in the Evaluation and
Operational Policies and Procedures manual (EOPP). Please be aware that the visiting committee may
visit any and all off-campus sites. In preparation for the site visit, the program will be asked to complete
227
the “Sites Where Instruction Occurs” form. Completed forms will be provided to the visiting committee
who will determine if a visit to any off-campus sites is warranted.

6. A final conference, with the director of the program will be conducted at the end of the visit. The
visiting committee will, at that time, summarize its recommendations relating to the educational
program. The program director may choose to include other individuals, such as faculty members, in
the final conference. This conference may be combined with the final conference with institutional
administrators (see #7).

7. Following the final conference with the program director, another conference, with the
institution’s chief executive officer will be conducted. The visiting committee will report briefly on the
findings and recommendations related to the evaluation. Such a meeting also affords the chief
executive officer an opportunity to relate plans for the entire institution that will involve the dental
program. The director of the program is usually present during the conference with the institution’s
administrator(s).

Guidelines and Protocol for the Site Visit: The Commission has approved the following guidelines for
visiting committee members describing their responsibilities during site visits.

1. Committee members cannot accept social invitations from host administrators. The
Commission believes firmly that the primary function of a visiting committee is program evaluation and
review.

2. Self-study reports are mailed to committee members at least 60 days prior to a site visit.
Committee members are expected to review all materials and to be familiar with academic and
administrative aspects of the program as described in the self-study report prior to the site visit.

3. Committee members meet in executive sessions to review, evaluate and discuss all aspects of
the program. An executive session is generally held in the evening preceding the site visit and at
scheduled intervals during the site visit.

4. Although committee members discuss general findings and recommendations with the
administrator during the final conference, a decision regarding the accreditation status of the education
program will be made only by the Commission at its regularly scheduled meeting following discussion
and in-depth review of the committee’s report and the institution’s response.

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Appendix III. Practice Patterns for Orofacial Disorders: A Survey of General Dentists, Dental
Specialists and Orofacial Dental Specialists

John O. Look, D.D.S., M.P.H., Ph.D.

James R. Fricton, D.D.S., M.S.

Look J, Fricton J. Practice Patterns for Orofacial Disorders: A Survey of General Dentists, Dental
Specialists

ABSTRACT
Orofacial disorders include a classification of disorders that affect the orofacial structures causing pain
and dysfunction. They include masticatory and cervical neuromuscular pain disorders,
temporomandibular joint disorders, benign headache disorders, neuropathic and neurovascular
orofacial pain disorders, burning mouth pain, chronic regional pain syndrome, atypical dental and facial
pain, orofacial cancer and AIDS pain, orofacial sleep disorders, and oromotor dysfunction conditions
such as dyskinesias and dystonias. Because the orofacial structures have more density of innervation
and vascularity of tissues than other areas of the body, the prevalence of these disorders is high at over
40% of the general population. A survey of practice patterns for the diagnosis and treatment of patients
with orofacial disorders was sent to a defined population of general dentists and dental specialists who
are members of the Minnesota Dental Association (MDA). Of the 1200 surveys mailed to the MDA
members, 426 (35.5%) were returned by 329 general dentists and 97 dental specialists. The results
demonstrated that on the average, 95% of the general dentists and dental specialists choose to refer
these patients to an orofacial care dentists who specializes in managing these conditions. Yet, there
very few dentists who focus their practices in these fields of Dentistry creating a large access to care
problem. The need to expand training of more orofacial care specialists are needed to meet this need.

INTRODUCTION
Orofacial Pain is the discipline of dentistry that focuses on the assessment, diagnosis and treatment of
patients with chronic orofacial pain disorders. These conditions include masticatory and cervical
neuromuscular pain disorders, temporomandibular joint disorders, benign headache disorders,
neuropathic and neurovascular orofacial pain disorders, burning mouth pain, chronic regional pain
syndrome, atypical dental and facial pain, orofacial cancer and AIDS pain, orofacial sleep disorders,
and oromotor dysfunction conditions such as dyskinesias and dystonias. Changes in the U. S.
population demographics and an increasing awareness of these disorders by the public have
contributed to a rapidly expanding demand for orofacial pain services (1). The dental profession has a
great responsibility to meet this demand in terms of differentiating orofacial pain by type and
mechanism, performing a proper clinical assessment, and developing appropriate treatment plans for
these patients (2).

The professional training received by most dentists has been traditionally oriented toward treating
caries and periodontal disease, rather than to meet such new challenges (1, 3). However, OFP shows a
similar prevalence to that of caries and periodontal disease in the U.S. adult population. For example,
the NHANES III survey found 40.5 % of the U.S. population, aged 18 to 74, had at least one tooth or
tooth space meeting criteria defined as compromised structural integrity, dysfunction or disease (non-
periodontal) that may benefit from treatment (4). Similarly, 30% of the population, aged 13-65, was
determined to have a gingival pocket depth ≥ 4 mm, and 4% had a pocket ≥ 6 mm in depth (5). A 1989
national orofacial pain survey of 45,711 households found that 22% of adults had suffered some type of
orofacial pain during the previous six months (6). A 1986 survey of the city of Toronto found 40% of
respondents had experienced dental or facial pain during the previous four weeks (7).

Temporomandibular disorders (TMD), which constitute just one of the orofacial pain disorders, are
present in about 5-6% of the adult population at a severity that would benefit from treatment (1, 6, 8, 9).
When all facial pain disorders are considered, a conservative estimate for OFP treatment needs in the
adult population would be at least 7% (6, 10). In the U.S. civilian non-institutionalized population 18
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years and over, that total could number from 11 to 12 million. Studies in children indicate they may also
experience similar levels of temporomandibular signs and symptoms (1). Thus, combining adults and
children, the prevalence of OFP in the American population could easily surpass 13 million.

Perhaps more important than the caseload is OFP's association with disability. It was estimated by a
1986 Harris Poll that 156.9 million work days were lost due to head pain (11). Wedel and Carlsson (12)
found that 10% of 350 consecutive patients referred for OFP treatment, had been on sick-leave. In the
1986 survey of Toronto, 70% of the respondents with dental or facial pain reported worry or concern
over their conditions, and one or more behavioral impacts occurred in 58% of them (7).

For many less complex orofacial pain conditions such as simple TMD, a conservative initial therapy
consisting of explanations about the condition, home care instructions, and a short-term use of mild to
moderate analgesics and anti-inflammatory medication may be sufficient (13). The clinical problem
presenting for many dentists is knowing when more intensive therapy is indicated, and providing this
care. When such pain persists, it can become entrenched in one's life and may lead to dependent
relationships, emotional disturbances, disability, and significant behavioral and psychosocial problems
(14). If treatment of the orofacial pain disorder is inadequate or inappropriate, the outcome can be
tragic in terms of personal effects and financial costs (7, 12). A frustrating medical and dental picture
may result with such patients undergoing costly treatments, diagnostic tests, long-term medications,
and an ongoing dependency on the health care system. These issues highlight an important question
to be answered by the profession of dentistry: Where can OFP patients turn when their pain evolves
into a chronic and complex (i.e., disabling) problem?

Roper Starch Worldwide recently surveyed 805 individuals in the general population with a persistent
pain disorder (12). Fifty-six percent of respondents had suffered pain for more than 5 years, 47% had
switched care providers at least once, and 40% reported that their pain was out of control. Two studies
have found that OFP patients have seen an average of five clinicians and suffered with their pain an
average of more than six years prior to consulting an orofacial pain dentist (16, 17). Since uncertainty
may exist among dental professionals as to who currently treats patients with chronic orofacial pain
disorders, there is a need to: 1) identify who treats these patients, 2) determine the practice patterns
and the limitations of the various disciplines within organized dentistry, and 3) assess whether it is
necessary to further develop the field of orofacial pain care in order to address societal needs. The
purpose of this paper is to present results of a recent survey of dentists who described their clinical
practice patterns relative to the diagnosis and treatment of OFP.

METHODS
A survey of practice patterns for the diagnosis and treatment of patients with chronic orofacial pain
disorders was sent to a defined population of general dentists and dental specialists who are members
of the Minnesota Dental Association (MDA), and to orofacial pain dentists who are members of
American Academy of Orofacial Pain (AAOP). Of the 1200 surveys mailed to the MDA members, 426
(35.5%) were returned by 329 general dentists and 97 dental specialists. Of the 255 surveys sent to
practicing orofacial pain dentists, 120 (47.1%) were returned.

The surveys were introduced with a letter stating that a study was being conducted to determine the
types of treatment provided by the dental profession for chronic orofacial pain disorders. This request
for information was limited to a single mailing, with no follow-up appeals or other pressure directed
toward those who failed to respond. As a result, the response rates were modest and similar to what
other investigators have observed (18).
The Statistical Analysis System software (SAS Institute) was used to analyze practice differences
between orofacial pain dentists versus general dentists, and between orofacial pain dentists versus
dental specialists. The primary group differences being investigated were: 1) frequencies of treatment
decisions as to treat or refer OFP patients; 2) frequencies of specified OFP diagnostic skills; and 3)
frequencies of specified OFP treatment skills. Reported frequencies by group and by item were entered

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into 2X2 contingency tables, and chi-square tests were employed to estimate the statistical significance
of the group differences.
Additional descriptive data were collected on the questionnaires. All participants were polled as to the
percent of their practices devoted to treatment of OFP patients. The general dentists and dental
specialists were questioned as to which dental or medical specialists they referred OFP patients, and
whether they would prefer to refer these patients to an orofacial pain specialist, if one were available.
They were also asked to indicate the reasons why they preferred to not treat the OFP patients whom
they referred. The orofacial pain dentists were asked to estimate the average number of new OFP
patients they see per month, the number of previous clinicians these patients had seen for their
orofacial pain condition, and the number of years these patients had experienced pain prior to
consulting an orofacial pain dentist. Finally, all recipients of the questionnaire were queried as to their
support for recognition by the American Dental Association (ADA) of orofacial pain dentistry as a dental
specialty.

RESULTS
Treatment versus referral of OFP patients: General dentists and dental specialists reported that
they referred from 75% to nearly 100% of all patients with the disorders in Table 1. In contrast, the
orofacial pain dentists treat nearly all of the myofascial pain disorders and complex TMD cases, as well
as from 65% to 79% of cervical muscle pain, benign headache, neurovascular pain, neuropathic pain,
burning mouth pain, atypical pain and sleep disorders cases. Finally, they treat from 30% to 40% of
cancer pain cases, sympathetically mediated pain cases, and dyskinesias or dystonias.
Statistical comparisons of practice patterns relative to each disorder were performed. For each
contrast, the orofacial pain dentists differed significantly from the general dentists with chi-squares
ranging from 62 to 283. Based on 1 degree of freedom, a chi-square value greater than 10.83 has an
associated p-value < 0.001. Likewise, practice differences between orofacial pain dentists and dental
specialists were highly significant with chi-squares ranging from 17 to 163.

OFP diagnostic skills: The diagnostic skills that were surveyed are listed in Table 2. They included
the use of a diagnostic classification to differentiate orofacial disorders, the ability to perform head, neck
and intra-oral exams, the use of appropriate radiographic diagnostic techniques, and provocative pulp
testing. Other skills included the ability to perform sleep disorder diagnostics, psychosocial interviews
and psychometric testing, and diagnostic injections for muscle, neural and joint blockades. Finally, a
question was asked relative to electronic diagnostic testing for orofacial disorders. This diagnostic
modality was considered by many in each group to have limited application, and it was the only item
showing close agreement between all three groups (p > 0.3), with 84-89% never employing it.
Excluding use of electronic diagnostic testing, a large majority of orofacial pain dentists reported the
diagnostics skills noted above, although just 74% of them performed psychometric testing. In contrast,
more than half of the general dentists and dental specialists did not use, even on an occasional basis,
60% or more of these diagnostics methods. The statistical differences between orofacial pain dentists
versus general dentists and between orofacial pain dentists versus dental specialists were highly
significant with chi-square values greater than 18 for contrasts relative to any of these diagnostic skills,
with the exception, of course, of the electronic diagnostic testing.

OFP treatment skills: Table 3 shows 28 treatment modalities that are employed for orofacial pain
disorders. This list is not exhaustive, but it served as the basis for this survey. This table includes the
percent of practitioners who reported frequent use of the treatment modalities, and the percent who
never used them.
About one half of the orofacial pain dentists were not involved in chemical abuse management,
detoxification treatment, intramuscular injection for dystonias, and cervical nerve blocks. In addition,
nearly three quarters did not perform stellate ganglion blocks. The majority of them did, however, offer
the other services listed in the questionnaire. In contrast, more than half of the general dentists and
dental specialists reported mainly the use of stabilization splints, NSAIDs, home exercise programs,
and heat/cold therapy for treatment of orofacial pain disorders. The between-group differences in
services were highly statistically significant. For contrasts comparing orofacial pain dentist with general
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dentists, the chi-square was 31 or greater. For the orofacial pain dentist/dental specialist contrasts, the
chi-square values were 22 or greater.

Descriptive findings from the survey

Figure 1 shows that more than 90% of general dentists and dental specialists devote less than 5% of
their time to the treatment of orofacial pain disorders. Twenty-one percent of orofacial pain dentists
devote less than 25% of their time to these services, but 50% of them devote 75% or more of their
practice to orofacial pain dentistry.
Figure 2 shows that approximately 85% of general dentists and dental specialists currently refer
orofacial pain patients to orofacial pain dentists. Fifty-nine percent of general dentists also refer some of
these patients to oral surgeons, but less than 25% of either group refers to the other specialties listed.
The survey revealed that 93.7% of general dentists and 95.6% of dental specialists would prefer to
refer their patients to an orofacial pain dentist with ADA specialty status, if such a person were
available.
As to the reasons for referral of OFP patients, about one half or more of the general dentists and dental
specialists indicated that they were not sufficiently trained, and that the orofacial disorders were too
complex. One quarter to one third cited the difficulties in reimbursement, the lack of equipment and the
time required to provide these services (see Figure 3).

Specialty status for the discipline of orofacial pain was supported by a 6 to 1 margin among dentists
and dental specialists. Specifically, 62.9% of general dentists and 58.8% of dental specialists supported
this specialty while 9.1% and 14.4%, respectively, were opposed. Nearly one fourth of this sample was
undecided. Of the AAOP members, 119 out of 120 supported specialty status for this field.
As seen in Figure 4, orofacial pain dentists in this sample indicated that they see an average of 20.3
new OFP patients per month, with a mode of 10. Of these new patients, 53% had to wait less than two
weeks for their appointment, 36% had a wait time of two to four weeks, and 11% were waiting longer
than four weeks for their assessment. These OFP patients had already seen an average of 6.2
clinicians (mode = 2), and had experienced their pain an average of 3 years (mode of 2).

DISCUSSION
This study suggests that general dentists and dental specialists overwhelmingly prefer to refer patients
with chronic orofacial pain disorders to orofacial pain dentists. This accords with the observation of
Bohannen (3) that today's practitioners are "highly oriented toward and supported by a variety of
specialists." This study also shows that orofacial pain dentists provide a high level of care for the
chronic orofacial pain disorders. General dentists and dental specialists provide primarily palliative care
for the less complex temporomandibular disorders, and cite their lack of training and experience as the
principal reason for their practice preferences.

Methodological considerations
It has long been observed that the most willing and ready candidates for studies are those who have
characteristics, or possess skills that are being studied. This response is analogous to the volunteer
bias that is also the antithesis of the nonrespondent bias (19). Because the volunteer bias is known for
its association with positive health attitudes and behaviors, one would anticipate that OFP services
would be less prevalent on the average among the nonrespondents (20). It is not known, however,
whether the observed differences in practice patterns between orofacial pain dentists and their non-
AAOP colleagues would hold true for the nonrespondents in each of these groups. Furthermore, based
on a 47% response rate, it is statistically impossible to generalize these current results to all the AAOP
dentists, although, as noted above, it is reasonable to believe the nonresponders would be no better
trained in OFP, or more active in this field. Finally, we do not know how Minnesota dentists compare to
those in other states. We would anticipate that OFP practice patterns are not less prevalent in
Minnesota than in the other states for two reasons: All undergraduate dental students have received
formal training in TMD and orofacial pain since 1970. In addition, Minnesota was in 1987 the first state
to mandate reimbursement for OFP services by medical insurance carriers (21).

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The need for orofacial pain care providers.
Using data of a large health organization in Seattle, Von Korff and colleagues found that 12 % of the
members had experienced a facial pain condition in the previous six months, that 23% of these had
sought care, and that 9.1 % had experienced limitation of their activities due to the pain (10). This
portion (9.1%) of the 13 million people affected by OFP would represent about 1.2 million complex
cases. It is estimated there are currently 500 orofacial pain dentists in private practice, or staff at
hospitals and universities, who devote a significant part of their practice to this field. It is also estimated
that a full-time orofacial pain dentist treats about 500 OFP cases per year (22). Based on these figures,
treatment for all the complex OFP cases at any given time would require about 2000 additional
orofacial pain dentists. Not surprisingly, this figure is consistent with the number of specialists in other
disciplines of dentistry (22). Given the increasing demand for these services by patients presenting with
non-complex disorders, a greater part of OFP care will also need to be rendered by general dentists as
well as the practitioners of the existing dental specialties.

Limitations that dictate practice patterns.

It is the responsibility of the dental profession to address the problems of orofacial pain sufferers. The
first step is to recognize the facial pain conditions when they present. It is considered appropriate for all
dental patients to receive a TMD and orofacial pain screening examination that might typically include a
questionnaire, brief history and an examination (23). For a description of this screening examination,
the reader can also refer to Okeson (24). It must be recognized, however, that there are serious
disincentives that can deter general dentists and dental specialists from serving OFP patients. These
include problems related to diagnosis, treatment and reimbursement.

If a screening is positive for the likely presence of an orofacial disorder, then a comprehensive history,
physical examination and behavioral/psychological assessment should be undertaken. Along with the
recognition of the type of OFP that is present (Axis I diagnosis), there is a need to conceptualize signs
and symptoms based on potential Axis II factors. Axis I relates to the physical disorder, while Axis II
factors include the psychosocial, behavioral and functional disturbances common to chronic pain
patients. The Axis II association may also become stronger as the duration of the chronic pain becomes
greater, and the pain becomes more a part of the patient's daily routine. Dworkin and Massoth (25)
have characterized these distinctions as disease versus illness. Disease would thus relate to pathologic
changes and dysfunction, whereas illness and illness behaviors describe the patient's "subjective
experience" that needs to be managed in the treatment of all chronic pain conditions. It has been
shown for both dentists and physicians that their initial clinical impression is not typically adequate for
identifying psychological problems (26). The effects of psychological states such as stress, anxiety,
depression and somatization on persistent pain have been extensively discussed in the literature (14,
25, 27, 28). Issues such as maladaptive behaviors, secondary gain and operant learning have also
been identified as significant contributing factors that need to be addressed for some chronic pain
conditions to improve (29, 30).

Based on the diagnosis and prognosis of an orofacial pain condition, various multi-modal and multi-
disciplinary treatment strategies have to be implemented (17). Twenty-eight of the commonly used
treatments are listed in Table 3. The problem is that these treatments include psychotropic and neuro-
active medications, muscle, joint and neural blocks, rehabilitation procedures, and cognitive-behavioral
strategies that are often not familiar to general dentists and dental specialists. Nonetheless, all dentists
should be aware of the existence of such treatments and their indications (14).

While dental care by general dentists and existing dental specialties is often billed by procedure
through dental codes, orofacial pain services are billed by time using the Current Regional Value
System and Current Procedural Terms (CPT) medical codes. Over 20 states have passed legislation
that places insurance coverage of orofacial pain disorders under medical insurance in a manner similar
to some dental services in oral surgery and oral medicine. These rules are applied whether or not the
services are provided by a dentist. Thus, ICD-9 (International Classification of Diseases) medical

233
diagnosis codes are required along with CPT medical codes, in addition to a patient accounting system
that is different from that which is used in many dental offices.

Future considerations relative to OFP services

A large majority of general dentists and dental specialists indicated a lack of training as the reason why
they are not more involved in the treatment of OFP patients. Their responses summarized in Tables 2
and 3 corroborated this self-assessment.
Knowledge in pain science and neuropharmacology has expanded so rapidly that it has been difficult
for any dentist to adjust to these changes. The same is true for the existing curriculums in pre- and
post-doctoral dental programs where this training is nearly absent. Although chronic pain syndromes
have been recognized for years, the concept of chronic pain has only recently been applied to orofacial
pain. Chronic pain rehabilitation programs used in the treatment of orofacial pain have met with
success similar to programs for chronic back pain (31). This shift in knowledge has added to the skills
and knowledge required of dentists to provide more successful care. Formal programs in dental
education (32, 33) and continuing education for dentistry (34) must respond to the need for this training.
It is not reasonable to expect that all dentists should be trained to treat the most complex OFP cases
(1). However, many of these cases are less complex, and would respond favorably to simpler treatment
strategies (13).

The Department of Health and Human Welfare has authorized the American Dental Association (ADA)
through the Commission of Dental Accreditation to provide accreditation for dental training in the United
States. Thus, the ADA has a responsibility to be proactive in assuring that orofacial pain patients
receive quality care. This will require encouraging pre- and post-doctoral programs to provide
adequate training and experience for high quality diagnosis and treatment of these disorders. As clinical
practice in orofacial pain disorders has escalated, ten U.S. dental schools have responded by
developing an accredited 2-year program for advanced education in this field. More than twenty
orofacial pain dentists are graduating from these programs every year. In view of the unquestionable
need for this advanced training, ADA support for a specialty status in orofacial pain dentistry would
improve care for OFP patients in several ways. First, the ADA would be able to ensure by means of
their credentialing authority that clinicians who focus their practices in this field are well trained,
knowledgeable and experienced. Secondly, this sense of recognition would encourage general
dentists, dental specialists, and dental students to become better trained in this field. Thirdly, this
credentialing process would be reassuring to the 94% of general dentists and 96% of dental specialists
who indicated that they would prefer to refer OFP patients to an orofacial pain dentist with ADA
specialty status. Tables 1, 2 and 3 demonstrate that the scope of OFP practice is already a de facto
specialty, avoiding most overlap with the practice of general dentistry and existing dental specialties. It
is important to remember that the field of OFP dentistry focuses primarily on chronic orofacial pain
disorders. If we must conclude that it is not reasonable for all dentists to be prepared to treat the more
complex cases (1), then we should also be ready to recognize those who make the effort to render
these services.

SUMMARY
At any given time, more than 13 million people in the U.S. suffer from an orofacial pain disorder that
can progress to a condition with a significant personal and societal impact. An unacceptable number of
Americans are still living through years of pain and multiple clinicians without resolution of their pain
problems. In addition, the demand for treatment from this segment of our population is increasing.
Although organized dentistry shares the responsibility for improving care for these people, this study
provides evidence that the dental profession is not currently in a position to address the needs of all
patients who may need treatment. It is concluded that changes are required, including an increase in
the training opportunities for general dentists in orofacial pain disorders, and support for advanced
dental training in orofacial pain. Finally, official support for a new specialty in orofacial pain would be a
positive step toward encouraging more dentists to consider a career in orofacial pain dentistry, and
ensuring they are appropriately trained. This survey suggests that orofacial pain dentistry is presently a
234
de facto specialty, having little overlap with other dental practices. The well-trained orofacial pain
specialist is an important link in the chain of services needed to maintain the American public's high
confidence in the dental profession.

ACKNOWLEDGMENTS
The authors gratefully acknowledge the assistance of Ms. Kara Kersteter and Ms. Manya Harsch in
data management and computer programming. They appreciate also the cooperation of the Minnesota
Dental Association and the American Academy of Orofacial Pain in making their membership lists
available for this survey of practice patterns.

References.
1. Rugh JD, Solberg WK. Oral health status in the United States: temporomandibular disorders. J Dent
Educ 1985; 49(6):398-405.
2. Okeson JP. Bell's Orofacial Pain. 5th ed. Chicago: Quintessence Publishing; 1995, pp. 4-5.
3. Bohannen HM. The Impact of decreasing caries prevalence: Implications for dental education. J Dent
Res 1982; 61(Spec Iss.):1369-1377.
4. White BA, Albertini TF, Brown LJ, Larach-Robinson D, Redford M, Selwitz RH. Selected restoration
and tooth conditions: United States, 1988-1991. J Dent Res 1996; 75(Spec Iss):661-671.
5. Brown LJ, Brunelle JA, Kingman A. Periodontal status in the United States, 1988-1991: prevalence,
extent, and demographic variation. J Dent Res 1996; 75(Spec Iss):672-683.
6. Lipton JA, Ship JA, Larach-Robinson D. Estimated prevalence and distribution of reported orofacial
pain in the United States. JADA 1993; 124(11):115-121.
7. Locker D, Grushka M. The impact of dental and facial pain. J Dent Res 1987; 66(9):1414-1417.
8. Solberg WK, Woo MW, Houston JB. Prevalence of mandibular dysfunction in young adults. JADA
1979; 98(1):25-34.
9. Schiffman EL, Fricton JR, Haley DP, Shapiro BL. The prevalence and treatment needs of subjects
with temporomandibular disorders. JADA 1990; 120(3):295-303.
10. Von Korff M, Dworkin SF, Le Resche L, Kruger A. An epidemiologic comparison of pain complaints.
Pain 1988; 32:173-183.
11. Sternbach RA. Survey of pain in the United States: the Nuprin pain report. Clin J Pain 1986; 2:49-
53.
12. Wedel A, Carlsson GE. Sick-leave in patients with functional disturbances of the masticatory
system. Swed Dent J 1987; 11:53-59.
13. Greene CS. Managing TMD patients: initial therapy is the key. JADA 1992; 123(6):43-45.
14. Donaldson D, Kroening R. Recognition and treatment of patients with chronic orofacial pain. JADA
1979; 99(12): 961-966.
15. Anonymous. New survey of people with chronic pain reveals out-of-control symptoms, impaired
daily lives. (Survey report posted online: www.ampainsoc.org) American Pain Society, April 14, 1999 (3
pages).
16. Fricton JR, Kroening R, Haley D, Siegert R. Myofascial pain syndrome of the head and neck: a
review of clinical characteristics of 164 patients. Oral Surg Oral Med Oral Pathol 1985; 60(6): p. 615-
623.
17. Fricton JR, Hathaway KM, Bromaghim C. Interdisciplinary management of patients with TMJ and
craniofacial pain: characteristics and outcome. J Craniomandib Disord Facial Oral Pain 1987; 1(2): 115-
22.
18. Just JK, Perry HT, Greene CS. Treating TM disorders: a survey on diagnosis, etiology and
management. JADA 1991; 122(9):55-60.
19. Sackett DL. Bias in Analytical Research, J Chron Dis 1979; 32:51-63).
20. Horowitz AM, Drury TF, Goodman HS, Yellowitz JA. Oral pharyngeal cancer prevention and early
detection. JADA 2000; 131:453-462.
21. Fricton J, Gibilisco J . The effects of an insurance coverage mandate and practice parameters on
care for TM disorders in Minnesota. J Craniomandib Disord Facial Oral Pain 1991; 5:7-9.

235
22. Okeson J, Fricton J, Talley R, Pullinger A, Gelb M, Simmons C. Application for recognition of
orofacial pain as a dental specialty of the American Dental Association. Mount Royal, New Jersey:
American Academy of Orofacial Pain; 1999, pp. 120-122.
23. Griffiths RH. Report of the President's conference on the Examination, diagnosis, and management
of temporomandibular disorders. JADA 1983; 106(1):75-77.
24. Okeson JP, ed. Orofacial Pain: Guidelines for Assessment, Diagnosis, and Management. 3rd ed.
Chicago: Quintessence Publishing ; 1996, pp. 19-44.
25. Dworkin SF, Massoth DL. Temporomandibular disorders and chronic pain: disease or illness? J
Prosthet Dent 1994; 72:29-38.
26. Oakley ME, McCreary CP, Flack VF, Clark GT, Solberg WK, Pullinger AG. Dentists' ability to detect
psychological problems in patients with temporomandibular disorders and chronic pain. JADA 1989;
118(6):727-730.
27. Fricton JR. Behavioral and psychosocial factors in chronic craniofacial pain. Anesth Prog 1985;
32(1):7-12.
28. Greene CS, Olson RE, Laskin DM. Psychological factors in the etiology, progression, and treatment
of MPD syndrome. JADA 1982; 105(3):443-448.
29. Fordyce WE, Roberts AH, Sternbach RA. The behavioral management of chronic pain: a response
to critics. Pain 1985; 22:113-125.
30. Roberts AH, Reinhardt L. The behavioral management of chronic pain: long-term follow-up with
comparison groups. Pain 1980; 8(2):151-62.
31. Fricton JR. Recent advances in temporomandibular disorders and orofacial pain. (Review). JADA
1991; 122(11):24-32.
32. Anonymous. Curriculum guidelines for the development of predoctoral programs in
temporomandibular disorders and orofacial pain. J Dent Educ 1992; 56(9):646-649.
33. Anonymous. Curriculum guidelines for the development of postdoctoral programs in
temporomandibular disorders and orofacial pain. J Dent Educ 1992; 56(9):650-658.
34. Anonymous. Curriculum guidelines for the development of continuing education programs in
temporomandibular disorders and orofacial pain. J Dent Educ 1992; 56(9):659-662.

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Table 1: Treatment and Referral Practice Patterns for Orofacial Pain (OFP) Dentists (n=120),
General Dentists (n=329) and Dental Specialists (n=97) Relative to Twelve Orofacial Pain
Disorders.
Group OFP Dentist General Dentist Dental Specialist
Practice Patterns Practice Patterns Practice Patterns
Orofacial Pain Percent Percent Percent Percent Percent Percent
Disorders Treated Referred Treated Referred Treated Referred
Myofascial Pain
Disorder 99.1 0.9 12.1 87.9 11.0 89.0
Complex TMD
94.9 5.1 9.5 90.5 19.1 80.9
Cervical Muscle
Pain 70.7 29.3 7.9 92.1 5.2 94.8
Benign
Headache 75.8 24.2 19.9 80.1 10.5 89.5

Neurovascular
Pain 65.0 35.0 2.2 97.8 7.5 92.5
Neuropathic Pain
66.9 33.1 2.9 97.1 2.6 97.4
Burning Mouth
and oral lesions 74.5 25.5 26.2 73.8 25.0 75.0
Sympathetically
Mediated Pain 51.8 48.2 8.2 91.8 4.2 95.8
Atypical Dental
and FacialPain 79.0 21.0 9.7 90.3 13.4 86.6
Oral cancer
pains 31.9 68.1 2.7 97.3 5.6 94.4

Dyskinesias and
Dystonias 43.0 57.0 3.3 96.7 1.4 98.6
Sleep Disorders
65.3 34.7 17.0 83.0 4.1 95.9

Statistical contrasts for each of the orofacial pain disorders comparing OFP dentists with general
dentists and OFP dentists with dental specialists showed chi-square values > 17, and the associated p-
values < 0.001.

237
 Table 2: Diagnostic Skills Reported by Orofacial Pain (OFP) Dentists (n=120), General Dentists
(n=329) and Dental Specialists (n=97) Relative to Orofacial Pain Disorders.

Group OFP Dentist General Dentist Dental Specialist

Diagnostic Skills Diagnostic Skills Diagnostic Skills
Diagnostic Skills & Percent Percent Percent Percent Percent Percent
Frequencies Employed Often Never Often Never Often Never
Diagnostic Classifications
87.3 3.6 27.8 36.1 44.1 22.6
Head, Neck and Intra-oral
Exam 98.2 0.0 70.4 10.3 71.1 8.9
Plain Film Radiographs
and Tomography 77.3 0.0 27.3 48.1 43.0 30.2
Provocative Pulp Testing
39.5 7.3 47.5 20.1 27.6 46.0
Sleep Disorder Exam and
History 63.1 3.6 21.0 39.5 9.4 55.3
Psychosocial Interviewing
59.1 5.5 9.7 66.6 7.0 69.8
Psychometric Testing
23.3 26.2 0.3 96.0 1.2 92.9
Diagnostic Neural
Blockade 38.7 7.2 0.7 86.2 2.3 72.1
TMJ and/or
Auriculo-temporal Blocks 30.6 13.5 1.0 94.0 2.3 83.7
Diagnostic Intra-muscular
Injections 39.6 10.8 0.3 94.6 1.2 84.8
Electronic Diagnostic
Testing 3.7 84.1 2.4 87.9 4.8 89.3

No difference in the use of electronic diagnostic tests was observed between OFP dentists, general
dentists and dental specialists (chi-square values < 2.2, p > 0.3). Statistical contrasts for all other
diagnostic skills comparing OFP dentists with general dentists and OFP dentists with dental specialists
each showed chi-square values > 18, and the associated p-values < 0.001.

238
 Table 3: Treatment Skills Reported by Orofacial Pain (OFP) Dentists (n=120), General Dentists
(n=329) and Dental Specialists (n=97) for Orofacial Pain Disorders.

Group OF Dentist General Dentist Dental Specialist

Treatment Skills Treatment Skills Treatment Skills
Treatment Modalities & Percent Percent Percent Percent Percent Percent
Frequency Employed Often Never Often Never Often Never
Stabilization Splint
86.7 0.0 32.5 19.9 25.3 43.7
Anterior Positioning Splint
27.9 14.4 8.6 53.8 3.7 63.0
Intra-oral Sleep Apnea
Appliance 15.9 28.3 4.1 54.6 1.2 86.6
Cognitive-Behavioral
Therapies 43.8 11.6 9.4 65.3 8.6 72.8
Oral Habits Reversal
Therapies 54.4 6.1 13.4 47.3 14.8 55.6
Biofeedback Stress
Management 46.9 10.6 5.8 74.0 4.9 79.0
Chronic Pain Behavior
Treatment 56.8 2.7 4.2 77.8 4.9 76.8
Muscle Relaxant
Medications 55.8 6.2 2.4 54.0 5.9 58.8
Sedative Medications
31.0 17.7 1.0 77.7 1.2 73.5
Narcotic Medications
14.2 20.3 1.0 76.2 2.4 78.3
Anti-depressant
Medications 56.6 13.3 0.3 95.9 1.2 83.3
Anti-convulsive
Medications 22.7 28.2 0.7 92.2 2.4 90.4
NSAIDS
74.3 0.9 35.6 24.2 36.0 27.1
Chemical Abuse
Management 7.1 46.9 0.0 92.8 1.2 89.2
Detoxification Strategies
4.5 49.1 0.3 97.6 1.2 95.2
Trigger Point Injections
39.0 15.0 0.0 95.8 2.4 88.1
Intra-muscular Injections
for Dystonias 4.4 54.9 0.0 99.0 1.2 92.6
Stellate Ganglion Blocks
1.8 71.8 0.0 99.7 1.2 97.6
Trigeminal Nerve Blocks
16.4 32.7 0.3 93.5 3.6 83.1
Upper Cervical Nerve
Blocks 6.3 56.8 0.0 100.0 1.2 95.1
Temporomandibular Joint
Injections 21.4 17.9 0.0 97.9 2.4 86.6

Home Exercises Program

78.7 1.8 14.2 38.2 21.4 39.3
Cold or Heat Therapy
239
 88.5 0.9 28.2 16.2 36.8 24.1
Physical Therapy
Modalities 84.1 0.9 9.6 54.0 18.1 54.2
Joint and Muscle
Mobilization 69.4 1.8 4.5 72.2 10.8 61.5
Postural Awareness
Training 70.8 6.2 10.0 53.4 11.0 63.4
Team Treatment
Strategies 75.9 0.9 3.8 68.8 24.1 54.2
Multi-modal Treatment
Strategies 76.2 1.8 3.2 75.4 16.2 62.5

Statistical contrasts for each of the treatment modalities comparing OFP dentists with general dentists
and OFP dentists with dental specialists showed chi-square values > 22, and the associated p-values <
0.001.

Figure 1: Percent of General Dentists, Dental Specialists and

Orofacial Pain Dentists by Percent of Their Practices Devoted to
Orofacial Pain Dentistry.
Percent of Practitioners

100 92 94 General Dentists (n=326)

90
80 Dental Specialists (n=97)
70 50
60 Orofacial Pain Dentists (n=120)
50 29
40
30 21
20
10 7 5 1 1
0
<5% 5-24% ≥25% <25% 25-74% ≥75%
Percent of Practice in Orofacial Pain Disorders

240
 Figure 2: Referral Preferences of General Dentists and Dental Specialists for Orofacial
Pain (OPD) Patients.

100
87
90 84
Percent of Referrals

80
General Dentists
70
59
Dental Specialists
60
50
40
25
30 22 21
20 19
15 12 10
7 9 6 7
10 2 3 3 5 4 4
0

Dental/Medical Specialties to Which OPD Patients Are Referred.

241
 Figure 3: Reasons Reported by General Dentists and Dental Specialists for
Referral of Orofacial Pain (OPD) Patients to Clinicians Outside of Their
Practices.
Percent of Practitioners Reporting

90 81
80
70 67
60
60 49
50
40 34 26 33
30 23 25 25 18
20
10 7
0

Time Required
Not Trained

Other
Not Equipped
Too Complex

Reimbursement
Issues

General Dentists
Dental Specialists

Reasons for Referral of OPD Patients

Figure 4: New OPD Patients Seen by Orofacial Pain Dentists:

Average Number/Month, Number of Previous Clinicians and
Number of Years in Pain.

20.3
25
20
15
6.2
10 3.0
5
0
# new OPD # previous # years with pain
patients/month clinicians

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Appendix IVa. Improving Access to Care and Specialty Issues in Emerging Fields of Dentistry
Dr. James Fricton and Dr. Jeff Crandall, American Board of Orofacial Pain

The Problem of Orofacial Disorders. Among the chronic pain conditions, orofacial disorders are one
of the most common and complex disorders with a collective prevalence that ranges from 42% to 50%
of the population (Table 1).1-5 Because oral and facial structures have close associations with functions
of eating, communication, sight, and hearing as well as form the basis for appearance, self-esteem and
personal expression, persistent pain or disease in this area can deeply affect an individual both
psychologically and systemically. Furthermore, there is a higher degree of sensory innervation in the
face and mouth than in any other area of the body.6 A national poll found more adults working full-time
miss work from head and face pain than any other site of pain.7 Unfortunately, access to care for
patients with these disorders is often difficult because the limited number of dentists who specialize in
this area and the fact that the care often lies within both medicine and dentistry. As a result, patients
often seek care from an array of medical and dental specialists and are at risk of receiving multiple
medications, surgeries, and other treatments that may not be beneficial. A survey of 405 health
professionals found that 95% either do or would like to refer these patients to a specialist because of
their complex nature of these conditions.8

Emerging Fields of Dentistry. Because of problems with access to care, Oral Medicine and Orofacial
Pain have emerged as new specialties of Dentistry addressing this problem. These providers are
involved in the clinical assessment, diagnosis and management of these orofacial disorders as well as
the pursuit of understanding the underlying pathophysiology and contributing mechanisms. The high
prevalence, personal impact, and complicated nature of diagnosis and management, as well as lack of
ready access to care, suggest the need for an expanded role of dentistry in developing and marketing a
diagnostic discipline in dentistry. Furthermore, recent major scientific advances in diagnostic and
treatment strategies for dental and orofacial conditions including pharmacological treatment, risk
assessment, salivary analysis, tissue biomarker analysis, genetic testing, quantitative sensory testing,
cone beam CT imaging, neuroscience advances, and many others support the need to train dentists
who specialize in the clinical application of these new diagnostic, treatment, and management
strategies.

Table 1. Common orofacial disorders that require special diagnostic and treatment needs with
estimated prevalence. 1-9
Orofacial Pain Disorders Estimated prevalence
Temporomandibular disorders 5-12%
Orofacial pain disorders (burning mouth, neuropathic, atypical pain, 2-3%
neurovascular)
Headache disorder (tension-type headaches, migraine, mixed, cluster) 10-20%
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 2-3%
disease)
Total Estimated Prevalence in General Population 30% to 40%

Need for Improved Access to Care for Patients with Orofacial Disorders. There is a great need for
dental specialists who care for patients with a broad range of orofacial disorders to provide optimal
evidence-based and cost-effective care for these disorders. Care is implemented by an
interdisciplinary integrative care system with dental specialists, medical specialists, physical therapists,
and health psychologists and includes defined patient-centered clinical protocols with evidence-based
treatments, risk assessment, cognitive-behavioral training, health coaching, and care coordination.
Treatment includes an array of both complex medical and dental treatments that may vary from

243
medications and physical therapy to splints and occlusal therapies. Training focuses on teaching
patients to reduce risk factors and enhance protective factors to minimize delayed recovery.

Dental Specialties in Orofacial Disorders will strengthen the profession of Dentistry. Currently,
there are several organizations and boards that represent about 1000 dentists who provide care for
patients with these orofacial disorders. Currently, there are also over 20 CODA accredited advanced
training programs in these disciplines. The American Board of Orofacial Pain and the American Board
of Oral Medicine have achieved specialty status through the American Board of Dental Specialties.
These boards have expressed interest in collaborating to improve care for patients with orofacial
disorders. With leadership and guidance from the State Board of Dentistry, these groups can be
brought together to support this clinical area of Dentistry and strengthen the profession’s ability to
provide care for these patients. This will not only increase access to care by increasing the number of
trained specialists but also increases the strength of academic programs, research, and pre-doctoral
teaching of these new areas.

Improving access to care. Unfortunately, access to care for patients with these disorders is often
difficult because of the limited number of dentists who focus their practices in this area, the lack of
coverage by health or dental benefit plans, and the lack of recognition of this specialties by ADA and
State Boards. The inability of these specialists to advertise and announce that they have advanced
knowledge and skills for these conditions has limited recognition by the general public and other health
professions. It is important to note that the lack of practical training about these disorders in medical
and dental school motivate most health care providers to choose to refer these patients to a specialist.
Specialty is recognized, access to care is not likely to improve since both dental and medical insurers
as well as Medicare are limiting reimbursement to general dentists managing these disorders and
physicians do not treat them. Health care providers, thus, do not know to whom to refer these patients
to.

Legal Decisions regarding Specialty Status in Dentistry. Several legal decisions have supported
the concept of an independent and objective process for recognizing certifying boards for Dental
Specialties. A group comprised of the American Academy of Implant Dentistry, American Academy of
Oral Medicine, the American Society of Dentist Anesthesiologists, and the American Academy of
Orofacial Pain in conjunction with dentists who practice these specialties in the State of Texas,
prevailed in litigation in the Texas District Court. This decision prohibits the Texas State Board of Dental
Examiners from solely deferring to the American Dental Association (ADA) for the recognition of
‘specialties’ in dentistry. This decision is consistent with previous, similar decisions in Florida and
California and has implications for every state board across the United States. In summary, these
decisions prohibit state boards from deferring to the ADA, a trade organization, as the sole resource for
the specialty recognition process. This also prohibits the establishment of regulations that restrict the
advertising of board-certification for recognized specialties in Dentistry.

The Emergence of the American Board of Dental Specialties. With this background, the American
Board of Dental Specialties (ABDS) has evolved with the stated mission of encouraging the further
development of the profession of Dentistry through independent recognition of certifying boards,
improving the quality of care, and protecting the public. The ABDS requires that applicant specialty
boards demonstrate advanced evidence-based knowledge and clinical decision-making skills in its
respective field by the evaluation of competency with written and oral board examinations of candidates
using valid, reliable, and calibrated testing methods. Successful achievement of these standards is
established through the support from accredited Schools of Dentistry to establish these advanced
education programs. Each specialty board is responsible for the development of its high quality,
validated Board Certification process. Accordingly, this is accomplished through a rigorous process of
reviewing objective criteria submitted by each field. The criteria include;
1. Reflect a distinct and well-defined area of expertise in dental practice, above and beyond that
provided at the level of pre-doctoral dental education, that is founded in evidence-based science,
contributes to professional growth and education, and concerns the practice of dentistry.
244
2. Develop a rigorous standard of preparation and evaluation in the dental specialty area.
3. Provide evidence of psychometric evaluation of the written and oral examination processes for a
period of time sufficient to ensure validity and reliability.
4. Provide an effective mechanism to maintain certification.
5. Exist as an independent, self-governing entity whose main purpose is to evaluate candidates for
board certification in a field of dentistry.
The ABDS has recognized the board from four new dental specialties: Dental Anesthesiology, Implant
Dentistry, Orofacial Pain, and Oral Medicine. The ABDS welcomes both existing and emerging dental
specialties to apply because it believes that dentistry should continue to grow through research and
advanced education programs and certifying boards. Moreover, there is strength in new dental
specialties representing the continued evolution and growth of the profession.
ADA Resolution 65. The American Dental Association (ADA) House of Delegates responded to the
new landscape of specialty status at their meeting in Denver, Colorado of October of 2016. After much
discussion, the House of Delegates passed Resolution 65 submitted by the Council on Ethics, Bylaws
and Judicial Affairs. This Resolution permits “educationally qualified dentists practicing in areas of
dentistry recognized as specialties in their jurisdictions, but not by the ADA, to announce as
specialists”. The passage of Resolution 65 by the ADA House of Delegates is a milestone in the
development of an independent and objective process for recognizing certifying boards for both Dental
Specialties (Level 1) and Subspecialties (Level 2) within the Profession of Dentistry. In addition, the
resolution also improves access to care by freeing up specialist to be able to provide essential general
dental care in addition to their specialty care. Consistent with ABDS and ADA requirements, each new
dental specialty board has assembled and submitted appropriate documentation to demonstrate that
each of the objective criteria for specialty recognition have been met.
Implications for State Dental Boards. Resolution 65 has opened the door for State Boards of
Dentistry to recognize an independent, objective-based path for the recognition of specialty fields and
to determine who may announce and be approved for licensure as a dental specialist. It also relieves
State Boards from the legally precarious position of having a trade organization, the ADA, serve as the
sole determinant of dental specialty status. This task is the responsibility of State Dental Boards and
they are now able to recognize all dental specialties based upon specific criteria. State boards will be
evaluating the impact of Resolution 65 on their specialty determination process and some have already
expressed interest in utilizing the ABDS process as a more objective and a valid resource for certifying
dental specialty boards. Most state Boards also recognize the importance of offering a national,
objective, and independent process for evaluating and certifying qualified dental specialties and
subspecialties while keeping the issue out of the courts and in the hands of dentists.

National Commission on Recognition of Dental Specialties and Certifying Boards. As a result of

the litigation against state boards, the National Commission on Recognition of Dental Specialties and
Certifying Boards was established to provide a more objective assessment of the need for specialty
status and provide clear objective evidenced-based documentation for new field of Dentistry. The
National Commission will help ensure that the Profession of Dentistry improve the access to high
quality evidence-based care for patients cared for by dentists in the new specialties such as Dental
Anesthesiology, Orofacial Pain and Oral Medicine.

Response by Board of Dentistry. In Minnesota, Washington and other states, the Boards of Dentistry
have also approved changes to address deficiencies in access to care. They approved orofacial pain as
a dental specialty by allowing specialty license by credentials to orofacial pain specialists and voted to
allow them to advertise as an orofacial pain dental specialist. This will apply to all specialty areas of
Dentistry that are recognized by Commission on Dental Accreditation with their board approved by the
American Board of Dental Specialties or the National Commission on Recognition of Dental Specialties
and Certifying Boards. In addition to the application procedures, an applicant for a specialty license
shall:
1. Have successfully completed a postdoctoral specialty education program accredited by the
Commission on Dental Accreditation (All advanced education programs in emerging dental
245
 specialties have been approved by CODA), or have announced a limitation of practice before
1967;
2. Have been certified by a specialty examining board approved by the Minnesota Board of
Dentistry, or provide evidence of having passed a clinical examination for licensure required for
practice in any state or Canadian province, or in the case of oral and maxillofacial surgeons
only, have a Minnesota medical license in good standing;
3. Have been in active practice or a postdoctoral specialty education program or United States
government service at least 2,000 hours in the 36 months prior to applying for a specialty
license.

In addition, the Board may grant a specialty license in the specialty areas of dentistry to Internationally-
educated Dental Specialist if they have the following criteria.
1. Completed dental education equivalent to or greater than the dental education provided at a
school that is accredited by the Commission on Dental Accreditation (CODA), and
2. Graduated with at least a 2.5 Grade Point Average (GPA). Regardless of GPA, if an individual
has failed the same course twice, he/she will not be eligible for licensure.

References
1) Lipton, J.A., J.A. Ship, and D. Larach-Robinson, Estimated prevalence and distribution of reported
orofacial pain in the United States. Journal of the American Dental Association, 1993. 124(10): p. 115-
21.
2) Petti S. Pooled estimate of world leukoplakia prevalence: a systematic review. Oral Oncology 2003;
39: 770-780.
3) Lozada-Nur F, Miranda C: Oral lichen planus: Pathogenesis and Epiemiology. Seminars in
Cutaneous Medicine and Surgery 1997; 16:290-295
4) Ruhnke M. Skin and Mucous Membrane Infections. In: Calderone RA: Candida and Candidiasis.
Washington, DC: ASM Press, 2002, pp 307-326.
5) Bailey, D, Attanasio, R, (editors): Sleep Disorders: Dentistry’s Role, Dent Cl N Am, Oct 2001;45(4)
6) The Neural Basis of Oral and Facial Function. edited by Ronald Dubner, Barry Sessle, and Arthur
Storey. Chapter 2, Springer, 1978
7) Taylor, H. and N.M. Curran, The Nuprin Pain Report, 1985, Louis Harris and Associates: New York
8) Look, J and Fricton, J Access to care for patients with orofacial pain: A survey of dentists. AAOP
newsletter, 1999
9) Ferreira J, Fricton J, Rhodus N. Orofacial Disorders: Current Therapies in Orofacial Pain and Oral
Medicine, Springer, 2017

246
Appendix IVb. Systematic Review of RCTs for Treatment of Orofacial Pain an
Temporomandibular Disorders including References.

Table 1. The Number and Percent of Studies Meeting CONSORT methods criteria for Level I, the Percent Range of all Criteria Met by
each Treatment Type, and the Mean percent and Standard Deviations for Quality Scores (Percent Criteria met) by Treatment Type.
Treatment Number of % of Level I Criteria Met Range of % for Criteria Mean % and S.D.
RCTs Met
Physical medicine/ 82 13 (n=11) 20 to 93 58 + 17
Injections
Orthopedic appliances 46 13 (n=6) 27 to 87 53 + 15
Occlusal therapy 9 11 (n=1) 33 to 67 45 + 11
Pharmacologic therapy 44 9 (n=4) 27 to 87 67 + 14
Cognitive-behavioral/ 24 8 (n=2) 33 to 80 54 + 12
psychological therapy
Temporomandibular joint 7 14 (n=1) 33 to 100 55 + 22
surgery
Totals/ Mean 212 11 (n-=25) 33 to 67 45 + 11

Systematic Review of Exercise and Physical Therapies and Injections for Temporomandibular Disorders:
44 RCTs reviewed
.
Table 1. CRITERIA APPLIED IN THE CRITICAL APPRAISAL OF TMJD RCTs.
These criteria are defined in the paper entitled: “Critical Appraisal of Methods in Randomized
Controlled Trials for Temporomandibular Disorders.” Their application has been determined to have
adequate inter-rater reliability (Intraclass correlation coefficient of 0.88)
Level Criteria % of physical therapy studies
meeting criteria
Level I: 1. Selection bias: Defined and concealed 24%
Essential design randomization process with rater and subject blind of
criteria for group assignment
Internal Validity
to minimize 2. Measurement bias: Blinding of clinician and subjects 58%
systematic bias to outcome measures
3. Comparison group bias: Interventions equal 96%
between groups and include baseline comparison
4. Attrition bias: Drop-outs and cross-overs less than 31%
15% and considered in analysis
Level II: 5. Relevant and reliable multi-dimensional measures 80%
Additional criteria used
for Internal 6. Ceiling and floor effects considered. (e.g., Pain > 47%
Validity 5/10)
7. Pre and post measures included 100%
8. Temporal characteristics of symptoms considered 64%
9. Follow-up schedule defined and appropriate (> 62%
2mos)
10. Wash out period for concomitant treatments 11%
11. Adherence for treatments monitored 13%
Validity of 12. Power and sample size analysis 4%
Statistical
Conclusions
13. Complete analysis of data 53%
Criteria for 14.Treatment well defined and standardized 96%
External Validity
15. Clear recruitment with inclusion/ exclusion criteria 89%
Mean value 55%

247
 Table 2. Summary of RCT evidence for Therapeutic Exercise and Postural Improvement for Treatment of Temporomandibular Disorders. (chronological
order)
Trial Diagnosis Group Treatment Duration Outcome Measure Treatment NNT Met Quality
Size of follow- efficacy minimum Score (0-1)
up criteria?
Studies with exercise and postural Improvement compared to placebo or no treatment controls
Burgess et al. Myofascial 10 A: Jaw stretching and 3 weeks  50% pain reduction A>B, A>C, A:B 2 no 0.47
198817 pain neck stretching with ice B=C A:C 2
11 B: Reflex inhibition  Vertical jaw opening A=B=C B:C 10
8 C: Non-intervention A=B=C NA
 Muscle palpation pain
NA
Dall’ Arancio Myofascial 11 A: Jaw stretching 4 weeks  Pain reduction pre- A>B NA no 0.73
et al. 199313 pain 11 B: Placebo exercises post (no A vs B
(just 1 finger opening) statistical
test)
Wright et al. TMJD of 30 A. Posture training and 4 weeks  Jaw pain A>B NA no 0.53
200016 masticatory self management  Neck pain A>B NA
muscle origin 30 B. Self management A>B NA
 Pain-free opening
Minakuchi et Painful TMJ 23 A: PALLIATIVE CARE 8 weeks  SYMPTOM A>B=C NA no 0.67
al. 2004108 DD without 25 B: Physical therapy IMPROVEMENT NA
reduction (Splint + mobilization)  DIFFICULTY OF B>A=C NA
21 C: No treatment TREATMENT A=B=C
 Satisfaction
TORELLI ET TENSION- 48 CROSSOVER AT 8 8 WEEKS  REDUCTION IN A>B NA NO 0.8
AL. 200480 TYPE WEEKS: HEADACHE DAYS
HEADACHE: A: STANDARDIZED  SEVERITY A=B NA
50% PHYSIOTHERAPY A=B NA
 DURATION
EPISODIC EXERCISE
50% B: OBSERVATION
CHRONIC
Studies with exercise and postural Improvement compared to other treatments for TMJD
Carlson et al. Masseter 17 Single-treatment After  Recovery from stressor A>B NA no 0.47
199118 myofascial 17 intervention: treatment (measured as change in
pain A: Postural relaxation masseter EMG reading)
B: Stretch relaxation  Self-rated muscle A=B NA
tension
Buchbinder Hypomobility 9 A: AROM+Therabite® 10 weeks  Max. Inter-incisal ROM A>B=C NA no 0.47
et al. 199381 2 to 5 B: AROM
Radiation 7 C: AROM+Wood blade
KOMIYAMA Myofascial 19 A: CBT with progressive 6 months  Pain intensity at max. A>C, B>C NA no 0.60
ET AL. 199912 pain + muscle relaxation+ opening
limited coping  Pain-free max. opening A>C, B>C NA
opening 18 B: CBT + Posture
 Disturbance in daily
14 C: general information A>C, B>C NA
activity
9 months
A>C, B>C NA

248
 12 months  Pain intensity at max.
opening A=B=C NA
 Pain intensity at max.
opening
Magnusson TMJD of 12 A: Flat splint night 6 months  Pain A=B NA no 0.40
and Syren, muscle origin 11 B: Jaw exercises
199914
Carmeli et al., Anterior disc 18 A: Soft anterior 4 weeks  Reduced subjective pain B>A NA no 0.47
2001109 displacement repositioning splint  Improved mouth B>A B:A 2
18 B: Exercises and opening
therapist-performed
mobilization
Grace et al. Muscular 15 A. Splints, exercise, self 2 months  Pain reduction A=B=C NA no 0.53
200283 TMJD care, OTC meds  Maximum opening A=B=C NA
15 B. A + muscle A=B=C NA
 Wellness scale
strengthening device
(BAE)
15 C.Muscle strengthening
device (BAE) with
education
Maloney et al. TMJD not Joint A. Passive jaw motion 8 weeks Joint: no 0.40
200282 responding to group: device therapy  Pain reduction A>B=C NA
flat plane 10, 7, 7 (Therabite®) + flat splint  Range of motion A>B=C NA
intraoral Muscle B. wooden tongue blade Muscle:
appliance group: stretch + flat splint A>B=C NA
 Pain reduction
7, 5, 10 C.Splint only A>B=C NA
 Range of motion
YODA ET AL. TMJ DISC 21 A: THERAPEUTIC 3  CLICKING A>B A:B 2 NO 0.67
200384 DISPLACEME 21 EXERCISE MONTHS
NT B: NO-TREATMENT
CONTROL
Michelotti et Muscle TMJD 36 A: Home exercise w/ 3 months  Success rate A=B A:B 5 no 0.60
al. 200485 education  Pain-free jaw opening A>B NA
34 B: Education only A=B NA
 Headache

Diagnoses - TMJD: Temporomandibular muscle and joint disorder; TMJ: Temporomandibular joint; DD: Disc displacement; ADTMD: Anterior displaced temporomandibular
disc.
Study treatments - AROM: Active range of motion exercises; CBT: Cognitive behavioral therapy; BAE: Bite Assist Exerciser
Outcome acronyms - EMG: electromyography; ROM: Range of motion

249
 Table 3. Summary of RCT evidence for ultrasound, iontophoresis, and phonophoresis, for treatment of temporomandibular disorders. (chronological
order)
Trial Diagnosis Group Treatment Duration of Outcome Measure Treatment NNT Met Quality
size follow-up efficacy minimum score
criteria?
Talaat et al. Myofascial 40 A: Methocarbamol After 2-week Improvements reported No statistical test: no 0.33
198628 pain of the 400mg plus acetyl treatment, F/U for: B,C>A
masticatory salicylic acid 325mg. varied from 6 to Pain intensity B,C>A NA
system 40 B. Shortwave 12 months Palpation pain A=B=C NA
diathermy Mandibular ROM A=B=C NA
40 C: Ultrasonic therapy TMJ Clicking B:A 3
C:A 2
C:B 4
Gray et al. TMJD 27 A. diathermy 1 week Symptom Improvement A=B=C=D>E NA no 0.53
199486 27 B. megapulse 3 months Symptom Improvement A=B=C=D>E A:E 2
30 C. ultrasound B:E 2
29 D. soft laser C:E 2
26 E. placebo D:E 2
Reid et al. Painful TMJ Three treatments 14 days after Pain Relief A=B NA no 0.47
199489 DDR, separated by 1 day: last treatment ROM A=B NA
DDwoR, or 22 A: Ionto with Dex +
OA Lido
31 B: Placebo Saline
Schiffman TMJ Three treatments 7 days after Pain Relief A=B=C NA no 0.67
et al. capsulitis separated by 1 day: treatment SSI A=B=C NA
199688 with 9 A: Ionto Dex +Lido DI A>B=C NA
DDwoR 9 B: Lidocaine ROM improvement A=B=C A:B 3
9 C: Saline A:C 5
B:C 9
Shin et al. TMJ Two treatments on After last Comparisons within no 0.47
199787 arthralgia consecutive days: treatment groups were performed:
10 A : US + Phono with Pain Relief pre-post A>B NA
Indomethacin cream Increased pressure-pain A > B NA
10 B: US + Phono with threshold pre-post (No A vs. B
placebo cream statistical tests)

Diagnoses – TMJD: Temporomandibular muscle and joint disorder; TMJ: Temporomandibular joint; DDR: Disc displacement with reduction; DDwoR: Disc displacement
without reduction; OA: osteoarthritis;
Study treatments - Ionto: Iontophoresis; Phono: Phonophoresis; US: Ultrasound massage; Dex: dexamethasone sodium phosphate; Lido: lidocaine;
Outcome acronyms – F/U: Post-treatment follow-up; SSI: Symptom Severity Index, DI: Dysfunction Index; ROM: Range of motion;

250
Table 4. Summary of RCT evidence for electrical stimulation, pulsed radio frequency energy, and electromagnetic therapy for treatment of
temporomandibular disorders. (chronological order)
Trial Diagnosis Group Treatment Duration Outcome Measure Treatment NNT Met Quality
Size of follow- efficacy minimum score
up criteria?
Hansson and Acute 22 A: High freq TENS 30  50% pain relief A: 7/22 A:C 5 no 0.20
Ekblom, orofacial pain 20 B: Low freq TENS minutes successes B: 9/20 B:C 3
198390 20 C: Placebo TENS C: 2/20
(No statist. test)
Reich et al. Migraine 173 A: relaxation 8-36  HA Pain VAS C>A; C=B=D NA no 0.27
198992 (56%) & 161 B: TENS months  HA freq./hours per C>A; C=B=D NA
tension-type 178 C: biofeedback week
HA (44%) 191 D: Multimodal
Foley-Nolan Chronic (>8 10 A: PEMT 3 weeks  Pain reduction A>B NA yes 0.93
et al., 199096 weeks) 10 B: Placebo PEMT  Cervical ROM A>B NA
cervival pain A>B A:B 2
 Subj. improvement
Bertolucci and Painful DJD 16 A: Mid-laser 3 weeks  Pain A>B>C NA no 0.33
Grey 199593 16 B: MENS  Total ROM A>B>C NA
16 C: Placebo A=B>C NA
 Lateral deviation
Linde et al., TMJ pain and 15 A: Flat splint 24 h/d 6 weeks  Muscle/TMJ Pain A=B NA no 0.53
199545 DD without 16 B: TENS  50% reduction in A>B A:B 2
reduction pain
Kruger et al. Masticatory 5 A: TENS 14 weeks  Pain VAS A=B NA no 0.40
199846 myofascial 5 B: placebo TENS
pain
Sherman et Migraine HA 9 Crossover treatments Post-2-wk Average # HA/week A>B NA yes 0.80
al., 199897 separated by 1 week: treatment
A: PEMT
B: Placebo PEMT
Treacy et al. Bruxism- 8 A: Relaxation 4 months Improvement for: no 0.47
199947 TMJD less 7 B: TENS  Subj. discomfort A=B=C NA
than 6 mos. 8 C: placebo TENS  ROM A>B or C NA
duration A>B or C NA
 Muscle EMG activity
Ahmed et al. Chronic Crossover 2-week 2 weeks  Pain relief VAS A>B NA no 0.53
2000110 headache treatments separated  Improved sleep A>B NA
by 1 week: A>B NA
 Decreased HA
30 A: PENS
impact on activity
30 B. needles only
Wieselmann- Masticatory 10 A: EMG-biofeedback 3 weeks  EMG activity A<B NA no 0.47
Penkner et al. myofacial 10 B: TENS  Skin conductance A=B NA
2001111 pain level
Farina et al. Trapezius 19 A: FREMS Improvement in: yes 0.80
200491 myofacial 21 B: TENS 1 week  Pain and disability A>B NA
pain 1 month  Pain and disability A>B NA
3 months A=B NA
 Pain and disability

251
 Al-Badawi et TMJ 20 A: Pulsed Radio 4 weeks  Pain Relief NRS A>B NA no 0.60
al. 200454 arthralgia Frequency Energy  Mouth opening A>B NA
20 B: Placebo device A>B NA
 Lateral ROM
Peroz et al. TMJD 36 A: Electromagnetic 4 months  Pain intensity A=B NA yes 0.73
200494 therapy (PEMF)  Limited ADL A=B NA
42 B: Placebo PEMF A=B NA
 ROM
Smania et al. Trapezius 17 A: Repetitive Post-  Pain reduction A>C, B>C, A=B NA yes 0.73
200595 myofacial magnetic stim. (rMS) treatment  Pain threshold A>C, B=C, A>B NA
pain 18 B: TENS I month A>C, B=C, A>B NA
 Pain reduction
18 C: Placebo (sham A>C, B=C, A>B NA
ultrasound) 3 months  Pain threshold A>C, B=C, A>B NA
 Pain reduction A>C, B=C, A>B NA
 Pain threshold

Diagnoses – TMJD: Temporomandibular muscle and joint disorder; TMJ: Temporomandibular joint; HA: headache; DJD: Degenerative joint disease; DD: Disc
displacement;.
Study Treatments – TENS: Transcutaneous electrical neuromuscular stimulation; PEMT: Pulsed electromagnetic therapy; PENS: Percutaneous electrical neuromuscular
stimulation, (needles with electricity); FREMS: Frequency modulated neural stimulation; MENS: Microcurrent electrical stimulation; Mid-laser: Infrared, 700 Hz, 27 watts;
PEMF: Pulsed electromagnetic fields; F/U: post-treatment follow-up.
Outcome acronyms – EMG: Electromyographic; VAS: Visual analogue scale; NRS: Numerical rating scale; ROM: range of motion, ADL: activities of daily living.

252
 Table 5. Summary of RCT evidence for soft laser for treatment of temporomandibular disorders. (chronological order)

Trial Diagnosis Group Treatment Duration of Outcome Measure Treatment NNT Met Quality
size follow-up efficacy minimum score
criteria?
Ceccherelli et MPD of 13 A: Infrared Diode Laser Post 2-week Pain reduction A>B NA no 0.60
al. cervical 14 B: Placebo Laser treatment
198998 muscles 3 month F/U Pain reduction A>B NA
Bertolucci and Active DJD 16 A: Mid-laser Post 3-week Pain reduction A>B NA no 0.33
Grey, 199599 16 B: Placebo Mid-laser treatment Vertical opening A>B NA
R/L LD A>B NA
Conti 199752 Arthrogenous 5 A: myogenous + Low-laser 3 weeks Pain reduction A=B=C=D NA no 0.60
TMJD 5 B: arthrogenous + Low-laser Range of Motion A=B=C=D NA
Myogenous 5 C: myogenous + Placebo
TMJD 5 D: arthrogenous + Placebo
Kulekcioglu et Arthrogenic 20 A: low-laser with exercise Post-treatment Pain reduction A=B NA no 0.47
al. 2003100 TMJD 15 B: Exercise only as a control Decreased # of TP A>B NA
Myogenic (stretching motion, posture AROM A>B NA
TMJD training) 1 month F/U Pain reduction A=B NA
Decreased # of TP A>B NA
AROM A>B NA
Ceylan et al. Myofascial 19 A: Infrared laser with Post-10-day Pain reduction A>B NA no 0.60
2004112 pain medication treatment
20 B: Sham laser with Post-9-day Urinary 5-HIAA A>B NA
medication treatment and 5-HT + 5-HTP
Gur et al. Trapezius 30 A: Actual laser Post 3-week 50% improvement A>B A:B 2 yes 0.93
2004102 myofascial 30 B: Placebo laser treatment Reduced pain A>B NA
pain Decreased # of TP A>B NA
10-week F/U Reduced pain A>B NA
Decreased # of TP A>B NA
Disability scale B>A NA
Depression B>A NA
Ilbuldu et al. Trapezius 20 A: Laser with exercise Post 4-week Pain reduction A>B,C NA no 0.6
2004101 myofascial 20 B: Placebo laser with treatment Pain threshold A>B,C NA
pain exercise 6 month F/U Pain reduction A=B=C NA
20 C: Dry needling with exercise Pain threshold A=B=C NA
Altan et al. Cervical 23 A: GaAs laser with exercise Post 2-week Pain reduction A=B NA no 0.73
2005103 myofascial 25 B: Placebo laser with treatment Pain threshold A=B NA
pain exercise Cervical flexion A=B NA
12-week F/U Pain reduction A=B NA
Pain threshold A=B NA
Cervical flexion A=B NA

Diagnoses – TMJD: Temporomandibular muscle and joint disorder; MPD: Myofascial Pain Dysfunction; DJD: Degenerative Joint Disease; TP: Tender points
Study treatments - Low laser: Low Level Laser Therapy;
Outcome acronyms – F/U: Post-treatment follow-up; AROM: active range of motion

253
 Table 6. Summary of RCT evidence for multiple modalities for treatment of TMJD pain. (chronological order)
Trial Diagnosis Group Treatment Duration Outcome Measure Treatment NNT Met Quality
Size of follow- efficacy minimum score
up criteria?
Crockett Myofascial pain 7 A: Stab. Splint and PT 8 weeks Pain reduction A=B=C NA no 0.53
et al., 1986105 of the 7 B: Relaxation/ stress
masticatory therapy
system 7 C: TENS
De Laat et al. Myofascial pain 13 A: 4 weeks of physical 6 weeks Signif. within-group no 0.53
2003106 of the therapy (heat, massage, improvement for:
masticatory ultrasound, muscle Pain reduction A=B NA
system stretching) Pain threshold A=B NA
13 B: 6 weeks of the same Jaw function A=B NA
physiotherapy

Study treatments - TENS: Transcutaneous electrical stimulation; TMJPDS: Temporomandibular joint pain dysfunction syndrome;
Outcome acronyms – F/U: Post-treatment follow-up; ROM: Range of motion

254
Systematic Review of Injection Treatments and Acupuncture for Temporomandibular Disorders: 38 RCTs reviewed
Table 1. Criteria used for critical appraisal of RCTs for TMJD. These criteria are defined in the paper
entitled: “Critical Appraisal of Methods in Randomized Controlled Trials for Temporomandibular
Disorders”. The application of them has been determined to have adequate inter-rater reliability
(intraclass correlation is 0.88)
Level Criteria % of physical medicine
studies meeting criteria
Level I: 1. Measurement bias: Blinding of clinician and subjects 72%
to outcome measures
Essential design 2. Selection bias: Defined and concealed randomization 23%
criteria for Internal process with rater and subject blind of group assignment
Validity to
minimize bias
3. Attrition bias: Drop-outs and cross-overs less than 34%
15% and considered in analysis
4. Comparison group bias: Interventions equal between 95%
groups and include baseline comparison
Level II: 5. Relevant and reliable multi-dimensional measures 72%
used
Additional criteria 6. Ceiling and floor effect considered. (e.g. Pain> 5/10) 45%
for
Internal Validity 7. Pre and post measures included 100%
8. Temporal characteristics of symptoms considered 76%
9. Follow-up schedule defined and appropriate (> 2mos) 72%
10. Wash out period for concomitant treatments 20%
11. Adherence for treatments monitored 8%
Validity of 12. Power and sample size analysis 11%
Statistical
Conclusions
13. Complete analysis of data 55%
External Validity 14.Treatment well defined and standardized 96%
criteria
15, Clear recruitment with inclusion/ exclusion criteria 86%
Mean value 58%

255
 Table 2. Summary of RCT evidence for muscle injections for treatment of masticatory muscle pain. (chronological order)
Trial Diagnosis Group Treatment Duration Outcome Measure Treatment NNT Met Quality
size of follow- efficacy (when minimum score
up possible criteria?
)
Botox Injection Studies
Cheshire MPD: 6 A: 50 MU botulinum toxin 2-4 weeks  Pain VAS A>B NA no 0.67
et al. 199415 cervical and A  Pain intensity A>B NA
shoulder 6 B: placebo saline TPI A>B NA
 Spasm
muscles At 2 sites in same 8 weeks A>B 2
subject at 8 weeks apart Crossover  30% reduction in pain
trial
Rollnik Tension type 11 A: botulinum toxin 200 4 weeks  Pain intensity VAS A=B NA no 0.67
et al. 200016 headache MU injection 8 weeks
10 B: placebo saline 12 weeks
Schmitt et al. Chronic 30 A: Botulinum Toxin A 20 4 weeks  25% reduction in A=B 100 no 0.67
200117 tension type U overall self-report
headache 29 B: Placebo saline  25% reduction in pain A=B 20
8 weeks A=B 33
 25% reduction in
overall self-report
A=B 6
 25% reduction in pain A=B NA
 Analgesics
Nixdorf et al. MPD of jaw 15 A: Botulinum toxin 8 weeks  Pain intensity (VAS) A=B NA yes 0.93
200231 muscles 50 U Crossover  Max opening w/o pain A=B NA
15 B: Placebo saline trial A=B NA
 # of muscular tender
points
von Lindern Chronic 60 A: Botulinum Toxin 4 weeks  Pain severity (VAS) A>B NA no 0.27
et al. 200330 facial pain 30 B: Placebo saline
Kokoska et al. Frontal 20 A: Botulinum Toxin A 50 6 months  Headache intensity A>B NA no 0.87
200429 tension type U  Headache frequency A=B NA
headache 20 B: Placebo saline
Ondo et al. Chronic daily 29 A: Botulinum Toxin A: 12 weeks  # of headache-free A>B NA no 0.67
200428 headache 200 U days
29 B: Placebo saline  Global impression A>B 2
Padberg et al. Chronic 19 A: Botulinum Toxin: 12 weeks  45% reduction in VAS A=B 6 no 0.93
200425 tension type 1 U per kg and max  Pain intensity VAS A=B NA
headache 100 U A=B NA
 Headache days
21 B: Placebo saline A=B NA
 Analgesics
Relja et al. Chronic 16 A: Botulinum Toxin A 2-8 weeks  Headache severity A>B NA no 0.33
200427 tension type 16 B: Placebo Crossover  Tenderness A>B NA
headache trial
Schulte- Chronic 53 A: Botulinum Toxin A: 10 weeks  50% reduction in A=B 28 yes 0.73
Mattler et al. tension type 500 mouse unit headache days
200426 headache 54 B: Placebo saline  Depression A=B NA

256
 Ferrante et al. Cervicothora 32 A: Botulinum Toxin A: 10 0-12  VAS A=B=C=D NA no 0.73
200521 cic U/TP weeks  PPT A=B=C=D NA
myofascial 34 B: Botulinum Toxin A: 25 A=B=C=D NA
 Medication use
pain U/TP
31 C: Botulinum Toxin A: 50
U/TP
35 D: Placebo saline
Kamanli et al. Myofacial 9 A: Botulinum Toxin A 4 weeks  PPT B>A>C NA no 0.53
200518 pain 10 B: Lidocaine  Pain score B>A=C NA
syndrome 10 C: Dry needling A=B>C NA
 VAS
Mathew et al. Chronic Placebo A: Botulinum Toxin A: 180 days  Frequency of A>B NA yes 0.73
200523 headache non- 200 U headache-free days
respond B: Placebo saline  50% reduction in A>B 6
er: headache days
134 210 days A>B NA
 Frequency of
145
headache-free days
Placebo A>B 5
respond  50% reduction in
er: 9 months headache days A>B NA
39  Frequency of
37 headache-free days
Silberstein et Chronic daily 182 A: Botulinum Toxin A: 30 days  Frequency of A,C>B NA no 0.73
al. 200520 headache 225 U headache
168 B: Botulinum Toxin A: 240 days A,B>D NA
150 U  Frequency of
174 C: Botulinum Toxin A: 75 9 months headache B>D NA
U
178 D: Placebo saline
 Frequency of
headache

 Trigger point injection with local anesthesia studies

Hong 199411 Myofascial 26 A: 0.5% lidocaine w/ LTR After  Complete pain relief A=B A:B 10 no 0.60
pain: 15 B: dry needling w/ LTR treatment  Pain intensity A=B NA
trapezius 9 C: 0.5% lidocaine w/o
LTR 2 weeks A>B NA
 Pain intensity
8 D: dry needling w/o LTR
Tschopp et al. Myofascial 40 A: bupivacaine 0.25% 4 sessions,  Improvement in pain A=B=C A:C 77 no 0.27
199612 pain of head 33 B: lignocaine 1% 1 wk apart A:B 6
and neck 34 C: saline 0.9% B:C 6
McMillan Myofascial 10 A:Procaine 1 placebo dry 3 sessions,  Pain intensity A=B=C NA yes 0.90
et al. 19972 pain of jaw needling 1 wk apart  PPT A=B=C NA
muscles 10 B:dry needling + placebo
local anesthetic
10 C:simulated dry needling
+ placebo local
anesthetic

257
 Muller et al. Tendinopathi 20 A1: 2mg tropisetron 3 days  Pain VAS A1>B1 NA no 0.33
200447 es and MPD 20 B1: 10mg prilocaine 7 days  Pain VAS A2=B2 7
20 A2: 5mg tropisetron
 Patients’ assessment A3>B3 2
20 B2: 10mg dexamethason
with 60mg lidocaine
17 A3: 5mg tropisetron
16 B3: 50mg prilocaine
MPD: Myofascial Pain Dysfunction, LTR: Local Twitch Response, TPI: Trigger Point Injection: in most tender point of muscle, PR: Pain Relief, VAS: Visual Analogue Scale,
PPT: pressure pain threshold

Table 3. Summary of RCT evidence for Intrarticular Injections for Treatment of Temporomandibular Joint Disorders. (chronological order)
Trial Diagnosis Gro Treatment Duration Outcome Measure Treatment NNT Met Quality
up Intrarticular Injections of follow- efficacy minimum score
size up criteria?
Kopp et al. TMJD (pain 18 A: 2 x 0.5 ml Sodium 4 weeks Symptom improvement A=B 5 no 0.53
198551 >6 months) Hyaluronate Clinical signs A=B NA
15 B: 2 x 0.5 ml Betamethasone
Kopp et al. TMJ 12 A: 2 x 0.5 ml Sodium 1 year Symptom improvement A=B 6 no 0.60
198752 Arthritis Hyaluronate Clinical signs A=B NA
12 B: 2 x 0.5 ml Betamethasone 2 year Symptom improvement A=B 18
Clinical signs A=B NA
Kopp et al. Rheumatoid 14 A: 2 x 0.7ml Sodium 4 weeks Symptom improvement A=B=C A:B 5 no 0.53
199153 Arthritis Hyaluronate Clinical dysfunction A=B=C B:C 4
involving TMJ 14 B: 2 x 0.7ml ROM A=B>C NA
Methylprednisolone
13 C: 2 x 0.7ml Saline
Bertolami DDR 80 A: 10 mg/ml Sodium 1 month DDR: VAS, HI, APM A>B NA no 0.60
et al. DDN Hyaluronate Dysfunction A=B 7
199332 DJD 41 B: Physiologic Saline improvement
DDN: VAS, HI, APM A>B NA
Dysfunction A>B 2
improvement
DJD: VAS, HI, APM A=B NA
2 months DDR: VAS, HI, APM A>B NA
Dysfunction A>B 2
improvement
DJD: VAS, HI, APM A=B NA
6 months DDR: VAS, HI, APM A>B NA
Dysfunction A>B 5
improvement
DJD: VAS, HI, APM A=B NA
Bryant et Post- 7 A: 1ml normal saline 1-5 days Pain score A=B=C NA no 0.67
al. 199954 arthroscopy 2.5ml normal saline Need for analgesia post- A=B=C NA
TMJD 7 B: 1ml normal saline operatively
patients 1 mg morphine sulphate
7 C: 0.1mg naloxone with
1 mg morphine sulphate
APM: Arthrophonometry HI: Helkimo indices TMJD: Temporomandibular Disorders DDR: Disc Displacement with Reduction

258
DDN: Disc Displacement Non-reduction DJD: Degenerative Joint Disease VAS: visual analogue scale

Table 4. Summary of RCT evidence for acupuncture for treatment of temporomandibular disorders. (chronological order)
Trial Diagnosis Sample Treatment Duration of Outcome Measure Treatment NNT Met Quality
size follow-up efficacy minimum score
criteria?
Raustia TMJD 25 A: Acupuncture 3 months CDS A=B NA no 0.27
198663 25 B: counseling, occlusal TMJ pain A=B NA
adjustment, exercise, ROM A=B NA
splint or combined
Carlsson et al. TTH 23 A: Acupuncture After treatment Intensity B>A NA no 0.60
199061 29 B: Physiotherapy MT B>A NA
(massage, Neck mobility A=B NA
cryotherapy,
TENS, relaxation)
Vincent TTH 14 A: Acupuncture 4 sessions A + 4 Pain reduction Trend: no 0.60
199056 14 B: Placebo Acupuncture sessions B (8 A>B NA
weeks)
Follow-up: 4
months
Johannson CMD: facial 15 A: Acupuncture 3 months Reduced clinical A, B > C A:C 2 no 0.60
et al., 199159 pain, HA 15 B: Stabilization. Splint dysfunction score B:C 2
15 C: No treatment
List et al., Craniomand 40 A: Acupuncture 6-8 weeks Anamnestic Index A>B,C A:C 5 no 0.60
1992 Disorder 40 B: Stabilization splint Score = 0 A>B A:B 3
Part I68 (CMD), 30 C: No treatment Reduced subjective B:C 5
muscle origin symptoms A=B NA
Pain intensity
List et al., CMD, muscle 22 A: Acupuncture 1 year follow-up Subjective symptoms A=B B:A 10 no 0.53
1992 origin 25 B: Stabilization splint C - not
Part 262 C: No treatment analyzed
List et al., CMD 20 A: Acupuncture 6-8 week Measures post- no 0.47
199360 20 B: Stabilization splint treatment treatment: A=B > C NA
15 C: No treatment Clinical dysfunction A=B > C NA
Pain intensity
At 6-month follow-up: A=B NA
Clinical
dysfunction/pain
Elsharkawy TMJD 23 A: Soft splint night 3 months Percent subjectively A=B=C>D A:D 1 no 0.53
and Ali 199567 22 B: Acuhealth symptom free B:D 2
23 C: Acuhealth1splint C:D 1
17 D:Placebo acuhealth
Karst et al. TTH 21 A: Acupuncture 6 weeks Pain VAS A=B NA no 0.60
200055 18 B: Placebo acupuncture PPT A>B NA

259
 White et al. TTH 22 A: Acupuncture 1 month 50% reduction in A=B 5 no 0.67
200057 22 B: Placebo Acupuncture headache days
TTH duration A=B NA
Headache VAS A=B NA
3 months 50% reduction in A=B Infinity
headache days
TTH duration A=B NA
Headache VAS A=B NA
Goddard et al. Myofascial 10 A: Acupuncture 30 min 10 mm or greater A=B 5 no 0.40
200264 pain 8 B: placebo acupuncture VAS reduction in
Pain
Xue et al. TTH 20 A: Electroacupuncture After phase I (4 Headache intensity A>B NA yes 0.8
200465 20 B: Sham weeks) Frequency A>B NA
electroacupuncture Duration A>B NA
Pain threshold A>B NA
3 months after Headache intensity A=B NA
phase II (4 Frequency A=B NA
weeks) Duration A=B NA
Pain threshold A=B NA
Ebneshahidi Chronic TTH 25 A: Low energy 1-3 months Intensity VAS A>B NA no 0.6
et al. 200566 acupuncture Duration of attack A>B NA
25 B: Placebo acupuncture Number of days with A>B NA
headache/month
Melchart et al. TTH 132 A: Acupuncture 24 weeks 50% reduction in A=B 9 yes 0.8
200558 63 B: Minimal acupuncture headache days A>C 2
75 C: Waiting list
SDS: Subjective Dysfunction Score, VAS: Visual Analogue Scale, PPT: Pressure Pain Thresholds,
MT: Muscle Tenderness, CDS: Clinical Dysfunction Score, ROM: Range of Motion

Table 5. Summary of RCT evidence for sphenopalatine injections for treatment of chronic orofacial pain. (chronological order)
Trial Diagnosis Group Treatment Duration Outcome Treatment NNT Met Quality
Size of follow- Measure efficacy minimum score
up criteria?
Janzen et al. Myofascial pain 31 A: SPGB with lidocaine 4 weeks  Pain Relief A=B NA no 0.47
1997138 of head and neck 30 B: SPGB with saline
with fibromyalgia
Ferrante et al. Head, neck and 10 A: SPGB W/ 4% lidocaine 1 week  10 mm and A=B 3 no 0.53
1998137 shoulder 13 B: SPGB W/ saline greater pain
myofascial pain 23 C: TPI w/ 1% lidocaine relief score A<C NA
 Pain intensity

SPGB- Spenopalatal ganglion blocks

TPI- Trigger point injections

Table 7. Summary of RCT evidence for multi-modalities for Treatment of chronic orofacial pain.

260
 Trial Diagnosis Group Treatment Study Measurement Outcome NNT Met Quality
Size Duration minimum score
criteria?
Crockett et al. Chronic facial 7 A. Splint + physical 8 weeks Reduction in A=B=C NA no 0.53
198654 pain 7 therapy worst pain
(muscle) 7 (heat/cold, postural ex,
avoid chewy foods and
ex)
B. Muscle
relaxation,
biofeedback, stress
management
C. TENS
De Laat et al. Myofascial pain A: 4 wks of physical 4 weeks Pain Relief A=B NA no 0.53
200355 of the therapy (heat, massage, to 6
masticatory ultrasound, muscle weeks
system stretching)
B: 6 wks of the same
physical therapy

Ex - exercise
TENS - transcutaneous electrical stimulation

Systematic Review of RCTs evaluating Intraoral Orthopedic Appliances and Occlusal Treatment for Temporomandibular Disorders (55 RCTs)

Table 1. Percent of RCT studies that met criteria used for methodological assessment. The application of these
criteria has been determined to have adequate inter-rater reliability (intraclass correlation is 0.88).

Level Criteria % of appliance % of occlusal

studies meeting studies meeting
criteria (n = 46) criteria (n = 9)
LEVEL I: 1. Selection bias: Defined and concealed 9% 22%
randomization process with rater and subject
Essential design blind of group assignment
criteria to minimize
systematic bias 2. Measurement bias: Blinding of clinician 45% 44%
and subjects to measures
3. Comparison group bias: Interventions 91% 67%
equal between groups and include baseline
comparison
4. Attrition bias: Drop-outs and crossovers 43% 67%
less than 15% and considered in analysis
LEVEL II: 5. Relevant and reliable multidimensional 95% 78%
measures used

261
Additional internal 6. Ceiling and floor effect considered (i.e. 32% 67%
validity criteria selecting subjects with severity sufficient to
show differences)
7. Pre and post measures included 91% 78%
8. Temporal characteristics of symptoms 66% 0%
considered
9. Follow-up schedule defined and 93% 89%
appropriate (> 2mos)
10. Washout period for concomitant 7% 11%
treatments
11. Adherence for treatments monitored 9% 11%
Validity of statistical 12. Power and sample size analysis was 16% 0%
conclusions conducted
13. Complete analysis of data 41% 11%
External validity 14.Treatment was well defined and 93% 56%
standardized
15, Clear recruitment with inclusion/ 91% 78%
exclusion criteria
Mean value 55% 45%

262
Table 2. Summary of RCTs evaluating stabilization splints versus a placebo splint for TMJD (chronological order)
Trial Diagnosis Group Treatment Duration Measure Outcome 1 NNT 2 Minimum Quality
Size of Follow- (p< 0.05) criteria score 4
up met? 3
Rubinoff MPD from 15 A: stabilization splint Not  Pain (0-5) A= B NA no 0.37
et al., general 13 B: non-occluding splint reported  Muscle tenderness A= B NA
198782 population  Inter-incisal opening A= B NA
Dao et al., Muscle 22 A: stab splint 24 hrs/d 7 visits over  Pain intensity VAS A=B=C NA yes 0.87
199464 pain from 20 B: passive control: 10 weeks  Pain unpleasant VAS A = B = C NA
general occlusal splint  Pain on chewing VAS A = B = C NA
population 30min/visit  Quality of life A = B = C NA
19 C: non-occluding
palatal splint 24 hrs/d
Ekberg et TMJ 30 A: Stab appliance 10 weeks  Subjective improvement A>B A:B 3 no 0.73
al., Capsulitis/ during sleep in overall pain &
1998,67 Synovitis 30 B: Palatal splint during discomfort. A>B A:B 6
199866and from clinic sleep  50% reduced TMJ pain. A>B A:B 5
199968 population  TMJ pain-free with lateral
(1998 palpation. A>B A:B 2
study with  Change in condyle-fossa
additional relationship.
reports)
Raphael MFP from 32 A: Hard splint at night 5 visits  Average pain A>B NA yes 0.80
et al,200180 clinic during sleep over  Tenderness A=B NA
population 31 B: Placebo palatal 6 weeks  Jaw function A=B NA
splint during sleep  If widespread pain A=B NA
present A = B A:B 6
 Days of pain interference
Ekberg et TMJD with 30 A: Occlusal 10 weeks  Subjective improvement A>B A:B 2 no 0.67
al., 200369 myofascial Stabilization Appliance in overall pain &
pain from during sleep discomfort. A=B A:B 4
clinic 30 B: Non-occluding  50% of pain reduced. A>B NA
population palatal splint during  Reduced # subjects with
sleep < 40mm maximum
opening.
Ekberg et TMJD with 30 A: Stabilization 6 months  Subjective improvement A>B A:B 2 yes 0.87
al., 200490 myofascial appliance 12 months in overall pain &
(Follow-up pain 30 B: Palatal appliance discomfort at 8 mos
to 2003  Subjective improvement A>B A:B 2
study) in overall pain &
discomfort at 12 mos

263
Wassell et TMJD from 34 A: Lower stabilizing 6 weeks  Pain VAS A=B NA no 0.53
al., 200485 general splint full-time  Muscle tenderness A=B NA
dental 38 B: non-occluding splint  Joint tenderness A=B NA
practice full-time.  Inter-incisal opening A=B NA
1
Outcome defined by whether a statistical significance in outcome measure(s) between groups. A>B means that group A had significant better outcomes that group B.
2
NNT (Number needed to treat): A:B means that outcome of A has a higher rate of treatment success than B regardless of statistical significance between groups.
The NNT # (e.g., A:B 6) means 6 patients need to be treated by treatment A in order for one person to experience a beneficial outcome, or for one more person to have
a benefit than would be true for treatment B. A lower NNT (e.g., 2 to 4) is typically taken to indicate that the intervention is effective. The NNT was calculated if data
was available regardless of statistical difference between groups.
3
Minimum Level I criteria for minimizing systematic bias includes selection bias, measurement (or detection) bias, comparison group (or performance) bias, and
attrition bias
4
The quality assessment score (0-1) was calculated to reflect the percent of all fifteen criteria that was met for each study, thus permitting an overall estimate of the
quality of the evidence base for the treatment of TMJD

264
Table 3. Summary of RCTs of splints versus no treatment or other treatment (chronological order)
Trial Diagnosis Group Treatment Duration Measure Outcome 1 NNT 2 Minimum Quality
size (p< 0.05) criteria score 4
met? 3
Dahlstrom Mandibular 15 A: Flat splint 6-week  Muscle pain at 1 mo A=B NA no 0.47
198262 dysfunction 15 B: Biofeedback treatment.  Pain in movement at 1 mo A=B NA
 Range of motion at 1 mo A=B NA
Okeson et TMJD 12 A: stabilization splint 4- 6 weeks  Muscle tenderness A>B NA no 0.40
al., 198389 12 B: simplified  Incisal opening A>B NA
relaxation therapy
Dahlstrom Mandibular 15 A: Flat splint night 6 week  Pain at 6 wks A=B NA no 0.53
198463 dysfunction 15 B: Biofeedback 12 months  Pain at 12 mos A=B NA

Raustia et TMJD 25 A: Stomatognathic 3 months  Pain (VAS) A=B A:B 4 no 0.27

al., 198581 25 treatment
B: Acupuncture
Crockett Myofascial 7 A:Stab Splint and PT 8 weeks  Pain A=B=C NA no 0.53
et al., pain 7 B: Relax/ stress trt
198661 7 C: TENS
Lundh et Disc 20 A: Disc-repos onlays 6 month  Reduced pain (chief complaint) A>B>C NA no 0.47
al., 198853 displacement 21 B: Flat splint night  Reduced joint dysfunction A=B>C NA
with 22 C: No treatment  Reduced joint pain to palpation A=B A:B 3
reduction A>C A:C 2
B=C B:C 7
Wenneberg CMD & HA 15 A: Occlusal splint 2 months  Reduced subjective A>B NA no 0.33
et al., symptoms 15 B: Occlusal symptoms A>B A:B 3
198884 equilibration  Reduced clinical dysfunction A>B NA
 Headache frequency
Schokker et Headache 23 A: CMD treatment 6 weeks  Headache intensity A>B A:B 3 no 0.47
al., 199083 25 B: Neurological  Headache frequency A>B NA
treatment  Drug intake
Johannson CMD: facial 15 A: Acupuncture 3 months  Reduced clinical dysfunction A,B >C A:C 2 no 0.60
et al., pain and HA 15 B: Stabilization. Splint score B:C 2
199171 15 C: No treatment
List et al., CMD of 40 A: Acupuncture 6-8 weeks  Anamnestic Index Score = 0 A>B,C A:C 5 no 0.60
1992 muscle origin 40 B: Stabilization splint  Reduced subjective A>B A:B 3
Part I73 30 C: No treatment symptoms A=B NA
 Pain intensity
List et al., CMD of 22 A: Acupuncture 1 year  Subjective symptoms A=B B:A 10 no 0.53
1992 muscle origin 25 B: Stabilization splint follow-up C - not
Part 274 C: No treatment analyzed

265
Lundh et Painful disc 25 A: Flat occlusal splint 12 months  Joint and muscle pain A=B NA no 0.53
al., 199276 displacement 26 B: No treatment
without
reduction
List et al., CMD 20 A: Acupuncture 6-8 week  Clinical dysfunction A=B > C NA no 0.47
199375 20 B: Stabilization splint treatment  Pain intensity A=B > C NA
15 C: No treatment  Pain At 6 mos A=B NA
Turk et TMJD clinic 28 A: stabilization splint 6 weeks  Pain at 6 wks A>B>C NA no 0.53
al., patients full-time, 6 months  Muscle tenderness A>B>C NA
199387
30 B: stress  Depression A>B>C NA
management/ A=B>C NA
 Pain at 6 mos
20 biofeedback A=B>C NA
 Muscle tenderness
C: waiting list control B>A>C NA
 Depression
Linde et al., TMJ pain and 15 A: Flat splint 24 h/d 6 weeks  Muscle and TMJ Pain A=B NA no 0.53
199572 DD without 16 B: TENS  50% reduction in pain A>B A:B 2
reduction
Turk et al., TMJD 20 A: Splint 1 Stress 6 months  Reduced muscle palpation A>B NA no 0.60
199688 Management /BFB 1 pain
Cognitive therapy  Reduced TMJ palpation pain A=B NA
21 B: Splint 1 Stress  Unassisted opening without A=B NA
Management / BFB 1 pain
Supportive  Unassisted opening A=B NA
counseling regardless of pain
 Reduction in medication A>B A:B 4
usage
Magnusson TMJD of 12 A: Flat splint night 6 months  Pain A=B NA no 0.40
and Syren, muscle origin 11 B: Jaw exercises
199977
Carlson et Myofascial 23 A: Physical self- 6 week  Reduction in pain at 6 wks A=B NA yes 0.87
al., 200196 pain regulation post-  Improved mouth opening A=B NA
21 B: Stabilization splint treatment  Reduction in pain at 26 wks A>B
NA
with self-care 26 weeks  Improved mouth opening A>B
instructions NA
Alvarez- TMJD with 24 A: Occlusal splint 4 months  Pantographic reproducibility A=B NA no 0.40
Arenal et Bruxism B: Transcutaneous index
al., 200260 electric nerve  Joint clicking A=B NA
stimulation (TENS)  Pain to muscle palpation A=B NA
Wahlund et Adolescents w/ 42 A: Splint + Brief 6 months  50% improved pain intensity A>B=C A:C 3 yes 0.80
al., 200386 TMJD pain Information B:C 11
41 B: Relaxation Therapy  Improvement in mean pain A=B>C NA
+ Brief Information index
39 C: Brief Information

266
Tommaso Chronic 9 A: Intraoral device 2 months  Total Tenderness Score A>B NA no 0.27
et al., tension appliance  Laser-evoked potential A<B NA
200591 headache 9 B: Amitriptyline  Frequency of headache A=B
NA

267
Table 4. Summary of RCTs of various designs and applications of splints (chronological order)
Trial Diagnosis Group Treatment Duration Measure Outcome 1 NNT 2 Minimum Quality
size (p< 0.05) criteria score 4
met? 3
Manns et MPD 25 A; 1 mm splint 3 weeks  Reduced subjective B=C >A NA no 0.60
al., 198378 syndrome 25 B: 4.42 mm splint symptoms
25 C: 8.15 mm splint  Reduced muscle/joint B=C >A NA
pain to palpation
Anderson DD-R, pain 10 A: Flat splint 24 h/d 3 months  Subjective dysfunction B>A B:A 2 no 0.40
et al., 10 B: Repos splint 24 h/d  Functional pain B=A B:A 5
198543  TMJ pain B>A B:A 2
Dahlstrom Mandibular 10 A: Flat splint night 6 weeks  Symptoms and signs A>B A:B 7 no 0.47
198557 dysfunction 9 B: Anterior bite plate  EMG activity A=B NA
Manns et Mandibular 20 A: 1 mm splint 3 weeks  Reduced EMG masseter B=C>A NA no 0.27
al., 198579 dysfunction 20 B: 4.25 mm splint activity
20 C: 8.25 mm splint
Gray et al., TMJ pain 34 A: Stab splint 3 months  Number improving A=B B:A 8 no 0.40
199170 dysfunction 21 B: LOIS splint (ball clinically and subjectively
syndrome clasp)
Elsharkawy TMJD 23 A: Soft splint night 3 months  Percent subjectively A=B=C>D A:D 1 no 0.53
and Ali 22 B: Acuhealth symptom free B:D 2
199540 23 C: Acuhealth1splint C:D 1
17 D:Placebo acuhealth
Wright et MFP 10 A: Soft splint 4-11 weeks  Subjective pain A>B=C NA no 0.53
al., 10 B: Palliative self care  Pain-free opening A>B=C NA
19956 10 C: No treatment  Muscle pain threshold A>B=C NA
Davies and Disc Displ. 25 A: Repos splint 24 3-month  Joint sounds A>B=C NA no 0.47
Gray, Part without hour Treatment:  Joint pain to palpation A=B=C NA
I, reduction 25 B: Repos day time At 1 month:  ROM A>B=C NA
199755 20 C: Repos night time (during trt.) Overall subjective and A>B=C A:B 3
At 3 months: objective improvement A:C 5
(post-trt.) C:B 8
Davies and TMJD Pain 23 A: stabilization splint 3 month  Joint sounds A=B=C NA no 0.53
Gray, Part dysfunction 24 hour  Pain A=B=C NA
II,199765 syndrome 19 B: stab. splint day  Limited opening A=B=C NA
only  Percent improved A=B=C A:B 5
28 C: stab. splint night A:C 7
only C:B 12
Shankland TTH/ 43 A: NTI anterior bite 8 weeks  Greater than 85% A>B A:B 10 no 0.53
et al., Migraine splint reduction in migraine.
200156 51  Percent reduction in A>B NA
tension headache
268
 B: Mandibular full-  Percent reduction in A=B NA
coverage occlusal headache intensity
splint
Carmeli et Anterior disc 18 A: Soft anterior 4 weeks  Reduced subjective pain B>A NA no 0.47
al., 2002 displacement repositioning splint  Improved mouth opening B>A B:A 2
18 B: Exercises and
therapist-performed
mobilization
Fayed et Anterior disc 7 A: Anterior 3 months  MRI-TMJ disc recapture B>A B:A 7 no 0.60
al., 200492 displacement repositioning splint  TMJ disc size & position B>A NA
with 7 B: Stabilization splint
reduction
Magnusson TMJD 14 A: Stabilization splint 3 months  Subjective symptoms A>B A:B 3 no 0.60
et al., 14 B: NTI splint  Anamnestic index A>B NA
200458 6 months  Subjective symptoms A>B A:B 5
 Global improvement A>B A:B 2
Jokstad et TMJD 20 A: Stabilization splint 3 months  Range of motion A=B NA yes 0.73
al., 200594 (Michigan type)  Headache A=B NA
18 B: NTI splint  TMJ pain to palpation A=B NA
 Jaw muscle tenderness A=B NA
 Comfort A=B NA
Schmitter Anterior disc 38 A: Centric splint 6 months  Success defined as 50% A>B NA no 0.67
et al., displacement 36 B: Distraction splint functional pain reduction
200593 without and 20% increase in
reduction mouth opening
Stiesch- Anterior disc 20 A: Stabilization splint 3 months  Jaw mobility A=B NA no 0.67
Scholz et displacement 20 B: Pivot splint  Subjective pain A=B NA
al., 200595 without  Tenderness to palpation A=B NA
reduction score (joint and muscle)

269
Table 5. Summary of RCT evidence of occlusal dental treatment for treatment or for prevention of TMJD. (chronological order)
Trial Diagnosis Group Treatment Duration Measures Outcome 1 NNT 2 Minimum Quality
size (p< 0.05) criteria score 4
met? 3

Forssel et HA (with
48 A: Occlusal A:8 months  Reduction in clinical A>B NA
No 0.47
43 Adjustment B:4 months signs A=B NA
al., 198697 mandidbular
B: Placebo
dysfunction)
Adjustment  Reduction in subjective
symptoms
15 A: Occlusal 2 months  Reduced subjective B>A B:A 2 No 0.33
Wenneberg CMD with
15 Equilibration dysfunction:
et al., headache
198884
B: Splint, exercise,  Reduced clinical B>A B:A 3
and occlusal dysfunction:
adjustment  Number not needing rescue B>A B:A 2
treatment:
25 A: Occlusal 10 days  Helkimo Anamnestic Index A=B NA No 0.53
Tsolka et Craniomandibular
al., 199298 Disorder (CMD)
Adjustment  Helkimo Dysfunction Index A=B NA
22 B: Placebo  Severe Anamnestic A=B A:B 5
Adjustment Dysfunction
25 A:Occlusal Adj. + 3 months  Overall symptoms improved A>B A:B 3 No 0.33
Vallon et Muscular CMD
Counselling Reduced headache freq A=B A:B 13
al., 199599 with headache
25 B: Counseling  Reduction in facial pain A=B A:B 6
 Reduced Dysfunction index A>B NA

 Overall symptoms improved A=B A:B 6

6 months Reduced headache freq A=B A:B 8
 Reduction in facial pain A>B A:B 2
 Reduced Dysfunction index A=B NA
25 A:Occlusal Adj. + 7-year  Number not requiring A>B A:B 3 No 0.33
Vallon et Muscular CMD
Counseling follow-up rescue treatment over 0 to
al., 1998100 with HA
25 B: Counseling 7 years (A = 13; B = 4)
20 A: Occlusal 6 weeks  Improvement in overall pain A=B NA No 0.53
Karppinen Chronic Neck &
Adjustment + at 6 wks
et al., Shoulder Pain
199959 with or without HA
physical therapy (PT)  Reduction in painful/stiff A=B NA
20 B: Placebo head movement at 6 wks
Adjustment + PT 12 months  Improvement in overall pain A>B NA
at 12 mos
 Reduction in painful/stiff A>B NA
head movement at 12 mos
 Reduced headache at 12 A>B A:B 3
mos
A>B NA
270
 60 months  Improvement in overall pain
at 60 mos A=B NA
 Reduction in painful/stiff
head movement at 60 mos A > B A:B 4
 Reduced headache at 60
mos
 Occlusal Adjustment to Prevent TMJD
Kirveskari Health young 30 A:Occlusal 2 years  Increased subjective A<B A:B 4 No 0.40
et al., 1989 adults adjustment to symptoms over follow-up
101 prevent TMJD  Increased muscle sites A=B NA
32 B:Placebo tender to palpation (p=0.08)
adjustment  Range of motion A=B NA
Kirveskari Healthy children 62 A:Occlusal 4 years  Incidence rate of TMD as A<B A:B 9 Yes 0.67
et al., 1998 and adolescents adjustment to (treatment defined by seeking care for
102 prevent TMJD every 6 TMD
67 B:Placebo months)
adjustment
 Restorative Treatment for TMJD
Lundh Disc displacement 20 A: Disc-repos onlays 6 month  Reduced pain related to A>B,C NA no 0.47
et al., with reduction 21 B: Flat splint night chief complaint.*
198853 22 C: No treatment  Joint dysfunction. A=B, A>C, NA
 Joint pain to palpation A=B, B>C, A:B 3
A:C 2
B:C 7
* Symptoms returned after onlays removed

271
Systematic Review of Pharmacological Therapy for Temporomandibular Disorders: 44 RCTs reviewed

Table 1. Criteria used for critical appraisal of RCTs for TMJD. These criteria are defined in a paper in this series entitled: “Critical Appraisal of
Methods in Randomized Controlled Trials for Temporomandibular Disorders”. The application of them has been determined to have adequate
inter-rater reliability (Intraclass Correlation Coefficient = 0.88). 93
Level Criteria % of medication studies
meeting criteria
Level I: 1. Selection bias: Defined and concealed randomization process with rater and 13%
Essential design criteria subject blind of group assignment
for:
Internal Validity to 2. Measurement bias: Blinding of clinician and subjects to measures 93%
minimize systematic bias
3. Comparison group bias: Interventions equal between groups and baseline 100%
comparison performed
4. Attrition bias: Drop-outs and cross-overs less than 15% and considered in 60%
analysis
Level II: 5. Relevant and reliable multi-dimensional measures used 63%
Additional criteria for: 6. Ceiling and floor effect considered. (e.g. Pain Severity is greater than 5 on a 0-10 48%
scale)
Internal Validity 7. Pre and post measures included 100%
8. Temporal characteristics of symptoms considered 80%
9. Follow-up schedule defined and appropriate (> 2mos) 65%
10. Wash out period for concomitant treatments 60%
11. Adherence for treatments monitored 40%
Validity of 12. Power and sample size analysis 20%
Statistical Conclusions 13. Complete analysis of data 75%
External Validity 14.Treatment well defined and standardized 85%
15, Clear recruitment with inclusion/ exclusion criteria 98%
Mean value 67%

272
 Table 2. Summary of RCT evidence of non-steroidal anti-inflammatory agents and acetaminophen for treatment of temporomandibular disorders including
tension-type headache (chronological order)
Trial Diagnosis Group Treatment Duration Measure Outcome NNT Met Quality
size of minimum score
Follow-up criteria?
Mongini et al. Headache and 20 A:Meclofenamate Sodium Crossover Reduced pain severity A>B NA no 0.67
199320 Craniofacial Pain 100 mg BID for 15 days with 15-day Reduced # of painful A>B NA
B:Placebo treatments events
Lange and Lentz Tension-type HA 87 A:Ketoprofen 25mg 4 hours Pain relief A=B=C=D A:B 33 no 0.47
199515 86 B:Ketoprofen 12.5mg A:C 17
87 C:Ibuprofen 200mg D:A equal
85 D:Naproxen 275mg D:C 17
Ekberg et al. Temporomandibular 16 A:Diclofenac Post-2-week Subj. improvement A=B A:B 8 no 0.73
199621 joint pain 16 B:Placebo treatment No joint pain to A=B A:B equal
palpation

2-week Subj. improvement A=B A:B 5

follow-up No joint pain to A=B A:B 4
palpation
Schachtel et al. Tension-type HA 153 A:Ibuprofen 400 mg 4 hours Pain severity A,B>C NA no 0.53
199619 151 B:Acetaminophen 1000 mg
151 C:Placebo
Svensson et al. Exercise-induced jaw 10 A: Ibuprofen topical gel + 3 days Higher pressure pain A>B=C NA no 0.67
199723 pain placebo tablet threshold
10 B: Ibuprofen tablet + Pain tolerance A=B=C NA
placebo gel thresholds
10 C: placebo tablet and gel Maximum voluntary A=B=C NA
occlusal force
Steiner and Lange Tension-type HA 107 A:Ketoprofen 25mg 2 hours Reduced headache A=B>C A:B 10 no 0.80
199813 119 B:Acetaminophen 1000mg after dosing pain intensity A:C 3
113 C:Placebo B:C 4
4 hours A=B=C A:B 7
after dosing A:C 13
B:C 16
Mehlisch et al. Tension-type HA 155 A:Ketoprofen 25mg 4 hours Pain relief A>B=C=D NA no 0.80
199814 158 B:Ketoprofen 12.5mg Onset of pain relief A>C=D, A=B NA
164 C:Acetaminophen 1000mg Subj. improvement A,B>D A:D 7
150 D:Placebo B:D 8
Packman et al. Tension-type HA 60 A:Ibuprofen(liquigel) 400mg 3 hours Onset of pain relief A>B>C NA no 0.60
200016 62 B:Acetaminophen 1000mg Complete pain relief A>B>C A:B 2
32 C:Placebo A:C 2
B:C 5
Diamond et al. Tension-type HA 97 A:Ibuprofen+caffeine 6 hours Reduced pain intensity A>B=C=D NA no 0.53
200017 99 B:Ibuprofen 400mg Subj. improvement
57 C:Caffeine 200mg A>B A:B 8
48 D:Placebo A>C A:C 5
A>D A:D 4

273
Di Rienzo Businco et TMJD 18 A: Oral diclofenac sodium 14 days Pain intensity A=B NA no 0.47
al. 200424 18 B: Topical diclofenac Joint tenderness A=B NA
Opening limitation A=B NA
Ta et al. 200425 TMJ pain due to TMJ 24 A: Celecoxib 6 weeks Reduced joint pain (at B>C, B>A NA yes 0.87
DD with reduction 22 B: Naproxen 3-6 weeks)
22 C: Placebo Increased mandibular B>A=C NA
opening
50% pain reduction B>A=A B:A 7
B:C 2
A:C 3
Minakuchi et al. TMJ disc displacement 23 A: Diclofenac with aldioxa 8 weeks SYMPTOM A>B=C NA no 0.67
(2004)22 without reduction (GI) and self care IMPROVEMENT
25 B: Splint, jaw mobilization TREATMENT- B>A=C NA
and self care RELATED
21 C: Counseling control DIFFICULTIES A=B=C NA
Treatment satisfaction
Cerbo et al. 200518 Tension-type HA 20 A: IndoProCaf (combining 2 hours 50 % Pain reduction A>B A:B 2 yes 0.87
Indomethacin, Mean severity of pain A=B NA
Proclorperizine and 4 hours 50 % Pain reduction A>B A:B 3
Caffeine) Mean severity of pain A=B NA
20 B: Nimesulide (NSAID) 8 hours Mean severity of pain A=B NA
SSRI- Selective serotonin reuptake inhibitor

Table 3. Summary of RCT evidence of tricylic and SSRI antidepressants for treatment of temporomandibular disorders including tension-type headache
(chronological order)
Trial Diagnosis Group size Treatment Duration Measure Outcome NNT Met Quality
of minimum score
Follow-up criteria?
Sharav et al. TMJD pain Group I: A: High dose Amitryptiline Crossover Pain reduction A=B>C NA no 0.67
198774 B vs C (8) (>30mg) with 4-wk
Group II: B: Low dose Amitryptiline treatments
A vs C (11) (10-30 mg)
Group III: C: placebo
A vs B (9)
Langemark et al. Tension-type HA 28 A: Clomipramine (75-150 3 weeks 50% reduction in A=B=C A:B 7 no 0.60
199072 mg)–tricyclic antidepr. overall pain VAS A:C 5
27 B: Mianserin (30-60 mg) – B:C 25
tetracyclic antidepr. 6 weeks 50% reduction in A=B=C A:B 33
35 C: Placebo overall pain VAS A:C 13
B:C 20
Reduced HA pain A,B>C NA

274
Nappi et al. Tension-type HA 19 A: Ritanserin (5-HT2 4 months HA pain total index A=B NA no 0.60
199081 or antagonist) Hamilton scale for A=B NA
tension-type HA 19 B: Amitriptyline depression
& migraine HA Hamilton scale for A=B NA
anxiety
Pfaffenrath et al. Tension-type HA 67 A: Amitriptylinoxide(60-90 16 weeks 50% reduction in A=B=C A:B 13 0.73
199473 mg) primary endpoint - A:C 12
66 B: Amitriptyline (50-75 (HA freq X duration B:C 200
mg) plus HA intensity)
64 C: Placebo
Manna et al. Tension-type HA 20 A:Mianserin (30-60 mg/d) 8 weeks Reduced HA activity B>A for non- NA no 0.87
199479 –tetracyclic antidepr. (frequency and depressed
20 B: Fluvoxamine (50-100 intensity) subjects.
mg/d) - SSRI A>B for NA
depressed
subjects.
Gobel et al. Tension-type HA 24 A: Amitriptyline 75 mg 6 weeks Reduced duration of A>B NA no 0.73
199469 29 B: Placebo daily headache
Saper et al. Chronic daily HA 30 A: Fluoxetine (20-40 mg) - 3 months Improved HA status A>B NA no 0.67
199478 24 SSRI 50% reduced HA A=B A:B 4
B: Placebo Reduced HA freq. A>B NA
Mood A>B NA
Boline et al. Tension-type HA 70 A: Spinal manipulation Post-6-wk Reduced HA intens. A=B NA no 0.73
199576 56 B: Amitriptyline (30 treatment Reduced HA freq. A=B NA
mg/day) Reduced med. use A=B NA

4 weeks Reduced HA intens. A>B A:B 3

after Reduced HA freq. A>B A:B 2
treatment Reduced med. usage A>B A:B 3
Bendtsen et al. Tension-type HA 34 A: Amitriptyline 75 mg/d 3-way Reduction in: no 0.67
199668 34 B: Citalopram (SSIR) 20 crossover Headache duration A>C, C=B NA
mg/d with 8-wk Headache frequency A>C, C=B NA
34 C: Placebo treatments Medication usage A>C, C=B NA
Headache intensity A=B=C NA
Mitsikostas et al. Tension-type HA 22 A: Buspirone (30 mg/d) 12 weeks 50% less HA days A=B B:A 14 no 0.53
199780 27 B: Amitriptyline (50 mg/d) Reduced med. usage B>A NA
Subj. improvement B>A NA
Holroyd et al. Tension-type HA 44 A: Amitryptiline or 6 months Red. HA Index score C=A=B>D NA no 0.73
200171 34 Nortriptiline 50% reduction in C>A C:A 4
40 B: Stress mgmt+placebo headache score C>B C:B 3
26 C: Stress mgmt+TCA C>D C:D 3
D: Placebo A>D A:D 11
B>D B:D 17
Rizzatti-Barbosa TMJD pain 6 A: Amitriptyline (25 mg/d) Post-2-wk Pain reduction A>B NA no 0.27
et al. 2003a75 B: Placebo treatment Discomfort reduction A>B NA
6 1 week Pain reduction A>B NA
follow-up Discomfort reduction A>B NA

275
 Bendtsen et al. Tension-type HA 22 A: Mirtazapine (15to 30 Crossover Reduced HA curve A>B NA no 0.87
200477 mg/d)(tetracyclic) with 8-wk (duration*intensity)
22 B: Placebo treatments
Forssell et al. Atypical facial 18 A: Venlafaxine Crossover Pain intensity A=B NA no 0.80
200494 pain 18 B: Placebo with 4-wk
treatments
SSRI- Selective serotonin reuptake inhibitor

Table 4. Summary of RCT evidence of benzodiazepines and muscle relaxants for treatment of temporomandibular disorders and tension-type headaches
(chronological order)
Trial Diagnosis Group Treatment Duration Measure Outcome NNT Met Quality
size of minimum score
Follow-up criteria?
Talaat et al. 198695 MFP 40 A: Methocarbamol 400mg Up to 12 * Reduced pain B,C>A NA no 0.33
plus acetylsalicylic acid months intensity
325mg. * Reduced muscle B,C>A NA
40 B. Shortwave diathermy pain to palpation
40 C: Ultrasonic therapy * Reduced TMJ B,C>A B:A 2
click/noise C:A 2
Harkins et al. TMJD 10 A: Clonazepam (.25-1 mg, 30 days Palpation pain A=B NA no 0.60
199182 10 mean .375 mg) (muscle or TMJ)
B: Placebo Subj. head pain A=B NA
Subj. TMJ pain A=B NA
Subj, neck pain A<B NA
Fogelholm et al. Tension-type HA 37 A: Tizanidine (6-18 mg/d) 6 weeks Reduced daily pain A>B NA no 0.87
199287 37 B: Placebo Subj. improvement A>B A:B 3
HA-free days A>B NA
Red. analgesic use A>B NA
Singer and Dionne Orofacial pain 39 A: Ibuprofen (2400 mg/d) 4 weeks Pain relief C>A=B=D NA no 0.67
199785 total B: Diazepam (avg 17 mg/d) Pain intensity A=B=C=D NA
C: Ibuprofen+Diazepam Depression A=B=C=D NA
D: Placebo Anxiety A=B=C=D NA
DeNucci et al. TMJD pain 20 A: Triazolam (.25-.5 Crossover Pain intensity A=B NA no 0.80
199883 mg)(Benzo.) w/ 4-day Improved sleep A>B NA
20 B: Placebo treatments quality
Murros et al. Tension-type HA 56 A: Tizanidine MR 6 mg 6 weeks Daily pain ratings A=B=C NA no 0.67
200088 49 B: Tizanidine 12 mg (VAS)
55 C: Placebo HA-free days A=B=C NA
Herman et al. MFP/jaw pain in 13 A: Clonazepam (.5 mg) 3 weeks Morning jaw pain B>A,C NA no 0.47
2002 84 morning 13 B: Cyclobenzaprine (10 mg) A= C NA
15 C: Placebo Sleep quality A=B=C NA
Rizzatti-Barbosa et TMJD 7 A: benzodiazepine(B)-- 21 days Helkimo index A=B=C NA no 0.53
al. 2003b86 orphenadrine citrate(O)--
occlusal splint(S)
7 B: O--S--B

276
 7 C: S--B--O

Table 5. Summary of RCT evidence of other pharmacological agents for temporomandibular disorders (chronological order)
Trial Diagnosis Group Treatment Duration Measure Outcome NNT Met Quality
size of minimum score
Follow-up criteria?
OPIOIDS AND BARBITURATES
Friedman and Tension-type HA 66 A: Butalbital with 4 hours Red. pain severity A,B>C NA no 0.60
DiSerio 198739 acetaminophen Red. tension A>B=C NA
65 B: Acetaminophen w/ Red. muscle stiffness A,B>C NA
codeine Complete pain relief A=B=C A:B 6
67 C: Placebo B:C 8
A:C 3
Friedman et al. Tension-type HA 39 A: Butalbital with codeine 4 hours Percent pain relief A> B, C, and D NA no 0.47
198838 30 mg Red. tension A> B, C, and D NA
41 B: Butalbital alone Red. muscle stiffness A> B, C, and D NA
38 C: Codeine alone 30 mg Subjects with ≥ 50% A> B, C, and D A:B 10
36 D: Placebo pain relief A:C 5
A:D 4
TRIPTANS
Brennum et al. Tension-type HA 36 Subcutaneous injections 1 hr post- Subj. improvement A=B>C A:C 5 no 0.67
199242 36 in 3-way crossover trial: injection B:C 4
A: Sumatriptan 4 mg
36 B: Sumatriptan 2 mg 2 hrs post- Subj. improvement A=B>C A:C 4
C: Saline placebo injection B:C 3
Dao et al. 199541 Temporalis MFP 7 Crossover treatments over 4 hours Pain intensity A=B NA no 0.53
4 episodic pain attacks: post- Pain relief A=B NA
A: Oral Sumatriptan 100 dosing
mg tabs
B: Placebo
GLUCOSAMINE
Nguyen et al. TMJ pain due to 14 A: Glucosamine 12 weeks Subj. improvement A=B NA no 0.67
200189 capsulitis or intra- hydrochloride (1500mg) Daily pain rating A=B NA
articular disorder Chondroitin sulfate (1200 Mood/functioning A=B NA
mg) Muscle/joint palpation A=B NA
20 B: Placebo pain
Thie et al. 200190 Temporalis MFP 21 A: Glucosamine sulfate 90 days Pain-free opening A=B NA yes 0.80
500 mg TID Red. analgesic use A>B NA
18 B: Ibuprofen 400mg TID 20% pain reduction A=B A:B10
during function
OTHER
Ashina et al. Chronic T-T HA 16 Crossover trial using IV 2 hrs post- Reduced HA pain yes 0.87
199957 infusions: dosing intensity RE:
A: L-NMMA (6 mg/kg )* Visual Analog Scale A>B NA
B: Placebo Verbal Rating Scale A>B NA

277
Ribeiro 200058 Chronic T-T HA 34 A: 5-hydroxytryptophan Post-8- Red. HA days A=B NA no 0.80
(100 mg tid) week trt. Red. HA intensity A=B NA
31 B: Placebo Red. analgesic use A=B (p=0.07) NA
Subj. improvement A=B (p=0.09) NA
2-wk FUP Red. HA days at FUP A>B NA
Lobo et al. 200449 Masseter and TMJ 26 A: Theraflex-TMJ cream 3 weeks Pain severity A>B NA no 0.60
pain 26 B: Placebo cream

Systematic Review of Behavioral and Psychological Therapy for Temporomandibular Disorders: 24 RCTs reviewed

Table 1. Criteria used for critical appraisal of RCTs for TMJD. These criteria are defined in the paper entitled: “Critical Appraisal of
Methods in Randomized Controlled Trials for Temporomandibular Disorders” in this issue. The application of them has been
determined to have adequate inter-rater reliability (intraclass correlation is 0.88).

Level Criteria % of behavioral and psychological

therapy studies meeting criteria
Level I: 1. Measurement bias: Blinding of clinician and subjects to 16%
outcome measures
Essential design criteria for 2. Selection bias: Defined and concealed randomization 0%
Internal Validity to minimize bias process with rater and subject blind of group assignment
3. Attrition bias: Drop-outs and cross-overs less than 15% and 56%
considered in analysis
4. Comparison group bias: Interventions equal between groups 96%
and include baseline comparison
Level II: 5. Relevant and reliable multi-dimensional measures used 84%
Additional criteria for 6. Ceiling and floor effect considered. (e.g. Pain> 5/10) 32%
Internal Validity 7. Pre and post measures included 100%
8. Temporal characteristics of symptoms considered 80%
9. Follow-up schedule defined and appropriate (> 2mos) 92%
10. Wash out period for concomitant treatments 12%
11. Adherence for treatments monitored 12%
Validity of Statistical Conclusions 12. Power and sample size analysis 4%
13. Complete analysis of data 60%
External Validity criteria 14.Treatment well defined and standardized 92%
15, Clear recruitment with inclusion/ exclusion criteria 76%
Mean value 54%

278
Table 2. Summary of RCT evidence of Biofeedback (BFB) for Treatment of TMJD and Tension Headache

Trial Diagnosis Group Treatment Duration of Measure Outcome N Minimum Q

Size Follow-up NT Criteria met uality
Score
Placebo-like controlled studies
Carrobles Tension HA 5 A: Frontalis BFB 4 weeks  Improvement in HA A>B NA no 0.40
et al., 19812 4 B: “High expectation of frequency
cure” control
Rokicki et al., Tension HA 30 A: BFB + Relaxation 3 weeks  50% reduction in A>B 3 no 0.47
199721 14 B: “Record only” control headache activity
group  Headache-free days A>B NA
A > B (p = 0.055) NA
 Analgesic consumption
Bussone Juvenile 20 A: BFB-assisted 1 month  Total Pain Index A=B no 0.53
et al., 199822 Tension HA 10 Relaxation 6 months A>B NA
B: “Remain calm and 12 months A>B
relaxed” control group
Other treatments as the comparison groups
Bruhn Severe 13 A: BFB 8 weeks  Reduction in headache A> B 2 no 0.47
et al., 197926 Tension type 10 B: Physical therapy plus severity*
HA meds  Reduction in Drug Intake: A> B
Gale and Chronic TMJ 17 A: Relaxation Post-treatment  Pain severity A=B=C NA no 0.33
Funch, 198431 pain 14 B: BFB 2-year follow-up
11 C: BFB + Relaxation
Erlandsson et Tinnitus w 18 A: BFB/ relaxation/ Post-treatment  TMJD signs B>A NA no 0.40
al., 199124 TMJD /HA 13 counseling  Mood A>B
B: TMJD treatment (stab.
splint, occlusal adj,
exercise)
Flor and Chronic back 19 BP + A: BFB/ relax** 8 weeks  Reduction in pain severity A > C NA no 0.47
Birbaumer, pain (BP) 7 TMJD B: Cog.-Behav. Treat. 6 months  2 SDs reduction in pain A > B, C A:B 4
199312 and TMJD in each C: Medical Interventions severity A:C 3
pain group (medications, PT, 2 years A>C A:C 8
 2 SDs reduction in pain
massage.)
severity
Turk et al., TMJD clinic 28 A: stabilization splint 6 weeks  Pain A>B>C NA no 0.57
1993 25 patients fulltime,  Muscle tenderness A>B>C
30 B: stress management/ A>B>C
 Depression
20 biofeedback
C: waiting list control 6 months A=B>C
 Pain A=B>C
 Muscle tenderness B>A>C
 Depression
Arena et al., Tension HA 8 A: Frontal BFB 3 months  50% improvement in HA B>A=C B:A 2 no 0.47
19953 10 B: Trapezius BFB post-treatment index B:C 2
8  Secondary measures: A=B=C
(headache-free days,
279
 C: Progressive Muscle peak headache activity,
Relax.(baseline C>A=B in medication use)
HA activity)
* Headache Severity: headache intensity times headache duration
** BFB/relax: Electromyographic (EMG)-Biofeedback (BFB) plus home-based tension-perception and tension-reduction exercises.

Table 3. Summary of RCT Evidence of Relaxation Training for Treatment of TMJD and Tension Headache.
Trial Diagnosis Group Treatment Duration of Measure Outcome NNT Minimum Quality
Size Follow-up Criteria Score
met
Placebo-like controlled studies
Blanchard et Tension 19 A: Prog. Muscle Post-treatment  Headache Index B>A=C=D no 0.40
al., 19907 HA Relaxation (PMR) alone (10-11 weekly A > C (p =0.06)
16 B: PMR + Cognitive sessions) A > D (p =0.07)
therapy
16 C: Placebo  50% reduction in Headache A=B=C=D B:A 3
pseudomeditation Index (p = 0.08) B:C 5
15 D: HA self monitoring B:D 2
A=B=C=D
 Medication Index reduction:
(p = 0.08)
Larsson et Tension 31 A: Relaxation therapy 5-week-treatment  Headache Intensity Index A = B (P = 0.08) NA no
al., 19906 HA 17 B: HA Self-monitoring  Headache frequency A > B (P < 0.05) 0.67
A > B (P < 0.05)
 Headache-free days
A=B
 Headache duration
Loew et al., Tension 12 A: Functional 2 months  Reduction in total pain days A>B 14 no 0.53
20004 HA Relaxation  Reduction of high and medium A>B
12 B: Isotonic exercise of intensity pain
hand placebo
Wahlund et Adolescent 42 A: Splint + Brief 6 months  50% improvement in overall A>B=C A:C 3 yes 0.80
al., 200319 s w/ TMJD Information pain intensity: B:C 11
pain 41 B: Relaxation Therapy
+ Brief Information  Improvement in mean value of A=B>C
39 C: Brief Information pain index
placebo
Larsson et Tension 47 A: Therapist-assisted 10 months  Headache pain intensity sum A > C,D,E; B>D,E no 0.67
al., 20055 type relaxation  Headache-free days A > C,D,E; B,C>E
headache 44 B: Nurse-administered A > C,D,E
 Peak headache intensity
relaxation A=B=C=D=E
59 C: Self-help relaxation  Headache mean duration A > B,C,D.E
57 D: Attention-placebo  50% reduction in Headache A:E 1.8
81 control pain intensity sum B:E 2.9
E: Self-monitoring C:E 3.8
D:E 11.5
Other treatments as the comparison groups
280
Arena et al., Tension 8 A: Frontal BFB 3 months after  >50% of improvement in B>A=C B:A 2 no
19953 type HA 10 B: Trapezius BFB treatment headache index score. B:C 2 0.47
8 C: Progressive Muscle  Secondary measures of A=B=C
Relaxation headache activity: (headache-
free days, peak headache
activity, medication use).
Gale and Chronic 17 A: Relaxation Post-treatment  Pain severity A=B=C NA no 0.33
Funch, TMJ pain 14 B: BFB 2-year follow-up
198431 11 C: BFB with Relaxation
VanDyck et Tension 28 A: Autogenic relaxation 4 week treatment  Change in Headache Index A=B NA no
al., 199128 type HA 27 training 0.53
B: Guided imagery with
Hypnosis
Wylie et al., Tension 22 A: Acupuncture Post-treatment  Improvement in Pain Total A=B NA no 0.40
199730 type HA 18 B: Massage + (6 sessions) Index
(only) Relaxation  Improvement in HA Index A=B NA
Fichtel and Tension 30 A: Applied relaxation 6 months  Pain intensity A=B=C no 0.60
Larsson, type 33 B: Relaxation with  Headache-free days A=B=C
200429 headache visualization A=B=C
 Headache frequency
41 C: No treatment control A+B (n = 63) > C (n = (A+B):C 8
group  >50% reduction in headache 41)
intensity

281
Table 4. Summary of RCT evidence of Cognitive-Behavioral Treatment (CBT) for TMJD and Tension Headache
Trial Diagnosis Group Treatment Duration Measure Outcome NNT Minimum Quality
Size of Criteria Score
Follow-up met
Placebo-like controlled studies
Komiyama Myofascial 19 A: CBT with 6 months  Pain intensity at max. opening A > C, B > C NA no 0.60
et al., 19998 pain + progressive muscle  Pain-free max. opening A > C, B > C
limited relaxation+ coping A > C, B > C
 Disturbance in daily activity
opening 18 B: CBT + Posture
14 C: general 9 months A > C, B > C
information control  Pain intensity at max. opening
12 months A=B=C
 Pain intensity at max. opening

Turner et al., TMJD 61 A: CBT for pain 10 weeks  Pain A=B A:B 50 no 0.6
200511 65 management  Interference A>B A:B 5
B: Education/ A>B A:B 5
 Jaw limitation
attention control

Devineni and Chronic 39 A: Internet-based Post-6-week  50% reduction in Headache Disability A>B 3 no 0.67
Blanchard, headache 47 CBT intervention Inventory (frequency, severity,
200513 B: Self monitoring duration)
control  Reduction in medication use A > B (P = 0.08)

Other treatment comparison studies

Holroyd et al., Tension HA 19 A: CBT (Relax + 12 weeks  33% Reduction in headache A>B A:B 3 no 0.60
199114 17 coping; visits at activity A>B A:B 6
weeks 1, 4 and 8)  66% Reduction in headache A>B
B: Amitriptyline activity A=B
(visits at weeks 1, 3  Headache Index A=B
and 5)  Improvements in headache peak A>B
A>B
 Improvements in headache-free days
 Reduction in somatic complaints
 Decrease in locus of control beliefs
Flor and Chronic back 19 BP & A: BFB/relax* 8 weeks  Reduction in pain severity A>C NA no 0.47
Birbaumer, pain (BP) 7 TMJD B: CBT 6 months  2 SDs reduction in pain severity A > B, C A:B 4
199312 and TMJD in each C: Medical A:C 3
pain group Interventions 2 years A>C A:C 8
 2 SDs reduction in pain severity
(medications, PT, B=C B:C 100
massage)

282
Turk et al., TMJD 20 A: CBT (with Splint + 6 months  Muscle palpation pain score A>B NA no 0.60
19969 21 Stress Management)  Reduction in TMJ palpation pain score A=B NA
B: Supportive A=B NA
 Unassisted opening without pain
counseling (with A=B NA
Splint + Stress  Unassisted opening regardless of pain A>B A:B 4
Management)  Reduction in drug usage (3 or more
days per week)

Dworkin et al., TMJD with 59 A: Comprehensive 4 months  Pain reduction A > B (4 months) NA yes 0.80
2002 poor care with CBT  Ability to control pain A > B (4 months)
psychological 58 B: Usual TMJD
adaptation treatment 12 months A = B (12 months)
 Pain reduction
A = B (12 months)
 Ability to control pain

Foster et al., Chronic 11 A: Trager and 6 weeks  Headache frequency, duration, A=B=C NA no 0.6
200415 headache medication intensity
6 B: Attention and  Change in headache quality of life A>B>C
medication
12 C: Medication only A=B>C
 Change in medication usage
control
* BFB/relax: Electromyographic (EMG)-Biofeedback (BFB) plus home-based tension-perception and tension-reduction exercises.

283
Systematic Review of TMJ Surgery and Arthrocentesis for Temporomandibular Disorders: 7 RCTs reviewed

Table 1. Criteria used for critical appraisal of RCTs for TMJD. These criteria are defined in the paper entitled: “Critical Appraisal of Methods in Randomized
Controlled Trials for Temporomandibular Disorders” in this issue. The application of them has been determined to have adequate inter-rater reliability
(intraclass correlation is 0.88).

Level Criteria type of error resulting* % of surgery studies

meeting criteria
Level I: 1. Measurement bias: Blinding of clinician and subjects to outcome I or II 29%
measures
Essential design criteria to 2. Selection bias: Defined and concealed randomization process with I or II 14%
rater and subject blind of group assignment
minimize bias in all RCTs 3. Attrition bias: Drop-outs and cross-overs less than 15% and I or II 57%
considered in analysis
4. Comparison group bias: Interventions equal between groups and I or II 71%
include baseline comparison
Level II: 5. Relevant and reliable multi-dimensional measures used I or II 100%
Additional criteria to. 6. Ceiling and floor effect considered. (e.g. Pain> 5/10) II 71%
minimize bias in TMJD 7. Pre and post measures included I 86%
RCTs 8. Temporal characteristics of symptoms considered I or II 43%
9. Follow-up schedule defined and appropriate (> 2mos) II 100%
10. Wash out period for concomitant treatments I or II 43%
11. Adherence for treatments monitored II 14%
12. Power and sample size analysis II 14%
13. Complete analysis of data I or II 29%
Level III: 14.Treatment well defined and standardized Low generalizability 71%
External Validity 15, Clear recruitment with inclusion/ exclusion criteria Low generalizability 86%
Mean value 55%
 The possibility of a Type I error (false positive) result or Type II (false negative result) is present in those studies that do not meet the criteria.

Table 2. Summary of RCT evidence of TMJ Surgical Treatment for TMJD.

Trial Diagnosis n(size) Treatment Duration Measures Outcome NNT Met Level Quality
I RCT score (0-1)
criteria
Fridrich et al. DD (all stages) 11 A: Arthroscopy 6-24 mos Pain: A=B 14 No 0.53
19968 9 B: Arthocentesis ROM: A=B
% Success? A: 82% vs B:75%
Holmlund et al. Chronic closed 10 A:Arthroscopy with lysis 12 mos Pain: A>B (trend) 10 No 0.60
200113 lock and lavage improved VAS*: A(90%) >B(50%)
10 B:Discectomy ROM: A=B
MFIQ** A=B
McNamara et DD from motor 10 A:Arthroscopy w/mid-laser 3 yrs Pain: A=B NA No 0.53
al. 199611 vehicle accident 10 B:mid-laser/splint Disc position: A>B
Miyamoto et Internal 35 A:Arthroscopy with lysis 12 mos Pain: A=B NA No 0.33
al. 199912 derangement and lavage 1 mo ROM B>A
(Stage III or >) 66 12 mo ROM A=B

284
 B:Diskectomy anterolateral
capsular
release
Petersson et ADD w/o 16 A:Arthrography 8 wks Pain: A=B NA No 0.33
al. 19949 reduction 17 B:Arthrography with lavage ROM: A=B
(arthrocentesis)
Schiffman, et Chronic closed 23 A: Arthroscopic Surgery 3mos Pain A=B=C=D NA Yes 1.0
al. 2005 (in lock 21 B: Arthrotomy Repair Dysfunction: A=B=C=D
review)14 23 C: Non-surgical Rehab 6mos Pain A=B=C=D, B>D
29 D. Medical Management Dysfunction: A=B=C=D
12mos Pain A=B=C=D
Dysfunction: A=B=C=D
> 3mos Crossovers: A=B=C>D
Stegenga et al. DD or 9 A:Arthroscopy and physical 6 mos Subjective Pain A>B 5 No 0.53
199310 Osteoarthritis therapy ROM A>B
12 B:home exercise and Clinical A=B
physical therapy assessment:
:
*Number of subjects scoring < 2 on VAS scale at 1 yr. Follow up
* Mandibular Function Impairment Questionnaire

285
References for Systematic Reviews

Physical Therapy and Exercises

1. Karkow M, Schiffman EL, Decker K, Fricton J, Schulte J. Temporomandibular joint (TMJ) iontophoresis: A double-blinded
randomized clinical trial. J Orofac Pain 1997;11(2):182-3.
2. Kim YK, Chung SC, Kim YJ, Kim YW. Short-Term Effect of Laser Therapy on Temporomandibular Disorders. J Orofac Pain
1998(Abstract no.19).
3. DuPont JS, Jr., Graham R, Tidwell JB. Trigger point identification and treatment with microcurrent. Cranio 1999;17(4):293-6.
4. Pinheiro AL, Cavalcanti ET, Pinheiro TI, Alves MJ, Manzi CT. Low-level laser therapy in the management of disorders of the
maxillofacial region. J Clin Laser Med Surg 1997;15(4):181-3.
5. Grieder A, Vinton PW, Cinotti WR, Kangur TT. An evaluation of ultrasonic therapy for temporomandibular joint dysfunction.
Oral Surg Oral Med Oral Pathol 1971;31(1):25-31.
6. Mannheimer JS. Overview of physical therapy modalities and procedures. In: Pertes RA, Gross SG, editors. Clinical
management of temporomandibular disorders and orofacial pain. Chicago: Quintessence; 1995. p. 227-44.
7. Kraus SL. Physical therapy management of TMD. In: Kraus SL, editor. Temporomandibular Disorders. 2nd ed. New York:
Churchill Livingstone Inc.; 1994. p. 161-215.
8. Okeson JP. Management of Temporomandibular Disorders and Occlusion. 4th ed. St. Louis: CV Mosby Co; 1998. p. 377-80;
464-5.
9. Rocabado M, Iglarsh ZA. Musculoskeletal Approach to Maxillofacial pain. New York: Lippincott; 1991.
10. Dunn J. Physical therapy. In: Kaplan AS, Assael LA, editors. Temporomandibular Disorders: Diagnosis and Treatment.
Philadelphia: Saunders; 1991. p. 455-500.
11. Simons DG, Travell JG, Simons LS. Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual. 2nd ed.
Baltimore: Williams & Wilkins; 1999.
12. Komiyama O, Kawara M, Arai M, Asano T, Kobayashi K. Posture correction as part of behavioural therapy in treatment of
myofascial pain with limited opening. Journal of Oral Rehabilitation. 1999;26(5):428-35.
13. Dall Arancio D, Fricton J. Randomized controlled study of exercises for masticatory myofascial pain. J. Orofac. Pain
1993;7(1):117.
14. Magnusson T, Syren M. Therapeutic jaw exercises and interocclusal appliance therapy. A comparison between two common
treatments of temporomandibular disorders. Swedish Dental Journal 1999;23(1):27-37.
15. Shata R, Mehta NR, Forgione AG. Active resistance exercise for TMD related tension pain. J Dent Res 2000;79(special
issue):abstract 3541.
16. Wright EF, Domenech MA, Fischer JR, Jr. Usefulness of posture training for patients with temporomandibular disorders.
Journal of the American Dental Association 2000;131(2):202-10.
17. Burgess J, Sommers E, Truelove E, Dworkin S. Short-term effect of two therapeutic methods on myofascial pain and
dysfunction of the masticatory system. J Prosthet. Dent 1988;60(5):606-10.
18. Carlson CR, Okeson JP, Falace DA, Nitz AJ, Anderson D. Stretch-based relaxation and the reduction of EMG activity among
masticatory muscle pain patients. J Craniomandib Disord 1991;5(3):205-12.
19. Au AR, Klineberg IJ. Isokinetic exercise management of temporomandibular joint clicking in young adults. J Prosthet Dent
1993;70(1):33-9.
20. Simons DG, Travell JG, Simons LS. Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual. 2nd ed.
Baltimore: Williams & Wilkins; 1999.
21. Lentell G, Hetherington T, Eagan J, Morgan M. The use of thermal agents to influence the effectiveness of a low-load prolong
stretch. J Orthop Sports Phys Ther 1992;16(5):200-07.
22. Austin DG. Special considerations in orofacial pain and headache. Dent Clin North Am 1997;41(2):325-39.
23. Fricton JR. Etiology and management of masticatory myofascial pain. J Musculoske Pain 1999;7(1/2):143-60.
24. Murphy GJ. Physical medicine modalities and trigger point injections in the management of temporomandibular disorders and
assessing treatment outcome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83(1):118-22.
25. Decker KL, Bromaghim CA. Utilizing physical therapy in the treatment of temporomandibular disorders. In: Hardin JF, editor.
Clark's Clinical Dentistry. Philadelphia: J.B. Lippincott Co; 1994. p. 1-14.
26. Munting E. Ultrasonic therapy for painful shoulders. Physiotherapy 1978;64(6):180-1.
27. Nwuga VC. Ultrasound in treatment of back pain resulting from prolapsed intervertebral disc. Arch Phys Med Rehabil
1983;64(2):88-9.
28. Talaat AM, el-Dibany MM, el-Garf A. Physical therapy in the management of myofacial pain dysfunction syndrome. Ann Otol
Rhinol Laryngol 1986;95(3 Pt 1):225-8.
29. Lehmann JF, Masock AJ, Warren CG, Koblanski JN. Effect of therapeutic temperatures on tendon extensibility. Arch Phys
Med Rehabil 1970;51(8):481-7.
30. Lehmann JF, DeLateur BJ, Warren CG, Stonebridge JB. Heating of joint structures by ultrasound. Arch Phys Med Rehabil
1968;49(1):28-30.
31. Lehmann JF, Delateur BJ, Stonebridge JB, Warren CG. Therapeutic temperature distribution produced by ultrasound as
modified by dosage and volume of tissue exposed. Arch Phys Med Rehabil 1967;48(12):662-6.
32. Waide FL, Montana J, Bade DM, Dimitroll M. Tolerance of ultrasound over the temporomandibular joint. J Orthop Sports Phys
Ther 1992;5(15):206-8.
33. Erickson RI. Ultrasound-A useful adjunct in temporomandibular joint therapy. Oral Surg 1964;18:176-9.
34. Esposito CJ, Veal SJ, Farman AG. Alleviation of myofascial pain with ultrasonic therapy. J Prosthet Dent 1984;51(1):106-8.
35. Fischer AA. New approaches in treatment of myofascial pain. Physical Medicine and Rehabilitation Clinics of North America
1997;8(1):153-69.

286
36. Freund B, Schwartz M. The use of botulinum toxin for the treatment of temporomandibular disorder. Oral Health
1998;88(2):32-7.
37. Simons DG, Travell JG, Simons LS. Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual. 2nd ed.
Baltimore: Williams & Wilkins; 1999.
38. Mahowald ML, Dkstra D. Rehabilitation of patients with rheumatic disease. In: Klippel JH, Weyand CM, Wortmann RL, editors.
Primer on the Rheumatic Disease. Atlanta: Arthritis Foundation; 1997. p. 407-12.
39. Kamyszek G, Ketcham R, Radke J. Electromyographic data at rest before and after TENS applied to cranial nerves. J Dent
Res 2000;79(special issue):abstract 1143.
40. Wessberg GA, Carroll WL, Dinham R, Wolford LM. Transcutaneous electrical stimulation as an adjunct in the management of
myofascial pain-dysfunction syndrome. J Prosthet Dent 1981;45(3):307-14.
41. Moystad A, Krogstad BS, Larheim TA. Transcutaneous nerve stimulation in a group of patients with rheumatic disease
involving the temporomandibular joint. J Prosthet Dent 1990;64(5):596-600.
42. Lapeer GL. High-intensity transcutaneous nerve stimulation at the Hoku acupuncture point for relief of muscular headache
pain. Literature review and clinical trial. Cranio 1986;4(2):164-71.
43. Black RR. Use of transcutaneous electrical nerve stimulation in dentistry. J Am Dent Assoc 1986;113(4):649-52.
44. Castaneda R. Occlusal Adjustment. In: Kaplan AS, Assael LA, editors. Temporomandibular Disorders: Diagnosis and
Treatment. Philadelphia: Saunders; 1991. p. 549-58.
45. Linde C, Isacsson G, Jonsson BG. Outcome of 6-week treatment with transcutaneous electric nerve stimulation compared with
splint on symptomatic temporomandibular joint disk displacement without reduction. Acta Odontologica Scandinavica
1995;53(2):92-8.
46. Kruger LR, van der Linden WJ, Cleaton-Jones PE. Transcutaneous electrical nerve stimulation in the treatment of myofascial
pain dysfunction. South African Journal of Surgery 1998;36(1):35-8.
47. Treacy K. Awareness/relaxation training and transcutaneous electrical neural stimulation in the treatment of bruxism. Journal
of Oral Rehabilitation 1999;26(4):280-7.
48. Kraus SL. Physical therapy management of TMD. In: Kraus SL, editor. Temporomandibular Disorders. 2nd ed. New York:
Churchill Livingstone Inc.; 1994. p. 291-2.
49. Vallbona C, Richards T. Evolution of magnetic therapy from alternative to traditional medicine. Phys Med Rehabil Clin N Am
1999;10(3):729-54.
50. Schindler M. Boost your pain-fighting power with magnets. Prevention 1999;51(3):112-7, 71.
51. Vallbona C, Hazlewood CF, Jurida G. Response of pain to static magnetic fields in postpolio patients: a double-blind pilot
study. Arch Phys Med Rehabil 1997;78(11):1200-3.
52. Foley-Nolan D, Barry C, Coughlan RJ, O'Connor P, Roden D. Pulsed high frequency (27MHz) electromagnetic therapy for
persistent neck pain. A double blind, placebo-controlled study of 20 patients. Orthopedics 1990;13(4):445-51.
53. Sherman RA, Robson L, Marden LA. Initial exploration of pulsing electromagnetic fields for treatment of migraine. Headache
1998;38(3):208-13.
54. Smania N, Corato E, Fiaschi A, Pietropoli P, Aglioti SM, Tinazzi M. Repetitive magnetic stimulation: a novel therapeutic
approach for myofascial pain syndrome. Journal of Neurology 2005;252(3):307-14.
55. Peroz I, Chun Y-H, Karageorgi G, Schwerin C, Bernhardt O, Roulet J-F, et al. A multicenter clinical trial on the use of pulsed
electromagnetic fields in the treatment of temporomandibular disorders. Journal of Prosthetic Dentistry 2004;91(2):180-7.
56. Conti PC. Low level laser therapy in the treatment of temporomandibular disorders (TMD): a double-blind pilot study. Cranio
1997;15(2):144-9.
57. FDA. Biostimulation lasers: Available at: "http://www.fda.gov/cdrh/consumer/laserfacts.html"; 2000.
58. Martin D, Willis ML, Ashley Mullinax, L, Clarke, NL, Jay A. Homburger, JA, Berger, IH Pulsed Radiofrequency Application in
the Treatment of Chronic Pain Pain Practice 2007; 7 (1):31–35.
59. Paramore LC. Use of alternative therapies: estimates from the 1994 Robert Wood Johnson Foundation National Access to
Care Survey. J Pain Symptom Manage 1997;13(2):83-9.
60. Kaptchuk TJ, Eisenberg DM. Chiropractic: origins, controversies, and contributions. Arch Intern Med 1998;158(20):2215-24.
61. Boline PD, Kassak K, Bronfort G, Nelson C, Anderson AV. Spinal manipulation vs. amitriptyline for the treatment of chronic
tension-type headaches: a randomized clinical trial. J Manipulative Physiol Ther 1995;18(3):148-54.
62. Nilsson N, Christensen HW, Hartvigsen J. The effect of spinal manipulation in the treatment of cervicogenic headache. J
Manipulative Physiol Ther 1997;20(5):326-30.
63. Prudden B. Myotherapy: Bonnie Prudden's complete guide to pain free living. New York: Dial Press; 1984.
64. Travell JG, Simons LS. Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual, The upper Extremities.
Baltimore: Williams & Wilkins; 1983.
65. Verhoef MJ, Page SA. Physicians' perspectives on massage therapy. Can Fam Physician 1998;44:1018-20, 23-4.
66. Ernst E. Massage therapy for low back pain: a systematic review. J Pain Symptom Manage 1999;17(1):65-9.
67. Hsieh CY, Phillips RB, Adams AH, Pope MH. Functional outcomes of low back pain: comparison of four treatment groups in a
randomized controlled trial. J Manipulative Physiol Ther 1992;15(1):4-9.
68. Konrad K, Tatrai T, Hunka A, Vereckei E, Korondi I. Controlled trial of balneotherapy in treatment of low back pain. Ann
Rheum Dis 1992;51(6):820-2.
69. Hoehler FK, Tobis JS, Buerger AA. Spinal manipulation for low back pain. Jama 1981;245(18):1835-8.
70. Godfrey CM, Morgan PP, Schatzker J. A randomized trial of manipulation for low-back pain in a medical setting. Spine
1984;9(3):301-4.

287
71. Puustjarvi K, Airaksinen O, Pontinen PJ. The effects of massage in patients with chronic tension headache. Acupunct
Electrother Res 1990;15(2):159-62.
72. Simons DG, Travell JG, Simons LS. Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual. 2nd ed.
Baltimore: Williams & Wilkins; 1999.
73. Braverman DL, Schulman RA. Massage techniques in rehabilitation medicine. Phys Med Rehabil Clin N Am 1999;10(3):631-
49, ix.
74. Starlanyl DJ, Copeland ME. Fibromyalgia & Chronic Myofascial Pain Syndrome. Oakland: New Harbinger Publishing Inc;
1996.
75. Okeson JP. Management of Temporomandibular Disorders and Occlusion. 4th ed. St. Louis: CV Mosby Co; 1998. p. 376-7.
76. Barnes JF. Myofascial release for craniomandibular pain and dysfunction. Int J Orofacial Myology 1996;22:20-2.
77. Ehrett SL. Craniosacral therapy and myofascial release in entry-level physical therapy curricula. Phys Ther 1988;68(4):534-40.
78. Hanten WP, Chandler SD. Effects of myofascial release leg pull and sagittal plane isometric contract-relax techniques on
passive straight-leg raise angle. J Orthop Sports Phys Ther 1994;20(3):138-44.
79. Moher D CD, Eastwood S, Olkin I, Rennie D, Stroup DF et al. Improving the quality of reports of meta-analyses of randomized
controlled trials: the Quorom Statement. The Lancet 2003;354:1896-900.
80. Fricton JN, Nixdorf DR, Schiffman EL, Ouyang W, Velly AM, Look JO. Critical Appraisal of Methods used in Randomized
Controlled Trials of Treatments for Temporomandibular Disorders. J. Orofacial Pain 2007;(submitted).
81. Al-Hasson HK, Ismail AI, Jr. Ash MM. Concerns of patients seeking treatment for TMJ dysfunction. J Prosthet Dent
1986;56:217-21.
82. Dworkin SF, Huggins KH, Wilson L, Mancl L, Turner J, Massoth D, et al. A randomized clinical trial using research diagnostic
criteria for temporomandibular disorders-axis II to target clinic cases for a tailored self-care TMD treatment program. J Orofac
Pain 2002;16(6):48-63.
83. Ioannidis J E, SJ, Gotzsche, PC, O'Neill, RT, Altman, DG, Schulz, K, Moher, D. CONSORT Group. Better reporting of harms in
randomized trials: an extension of the CONSORT statement. Ann Intern Med 2004;141(10):781-8.
84. Forssell H, Kalso E. Application of Principles of Evidence-Based Medicine to Occlusal Treatment of Temporomandibular
Disorders: Are there lessons to be learned? J. Orofacial Pain 2004(18):9-22.
85. Higgins JP, Green S. 6. Assessment of Study Quality Cochrane Handbook for Systematic Reviews of Interventions 4.2.5
(updated May 2005). ; 2005.
86. Kalso E, Edwards J, McQuay HJ, Moore RA. Five easy pieces of evidence-based medicine (3). Eur J Pain 2001;5:227-30.
87. Higgins JP, Green S. Cochrane Handbook for Systematic Reviews of Interventions 4.2.5 (updated May 2005). Appendix 8b;
2005.
88. Chatellier G, Zapletal E, Lemaitre D, Menard J, Degoulet P. The number needed to treat: a clinically useful nomogram in its
proper context. BMJ 1996;312:426-29.
89. Kleinbaum DG, Kupper LL, Morgenstern H. Epidemiological Research: Principles and Quantative Methods. New York: Van
Nostrand Reinhold Company; 1982.
90. Chinn S. A simple method for converting odds ratio to effect size for use in meta-analysis. Stat Med 2000;19:3127-31.
91. Higgins JPT, Green S. editors. Combining dichotomous and continuous outcomes. Cochrane Handbook for Systematic
Reviews of Interventions 4.2.5 (updated May 2005). Section 8.6.5; 2005.
92. Torelli P, Jensen R, Olesen J. Physiotherapy for tension-type headache: a controlled study. Cephalalgia 2004;24(1):29-36.
93. Buchbinder D, Currivan RB, Kaplan AJ, Urken ML. Mobilization regimens for the prevention of jaw hypomobility in the radiated
patient: a comparison of three techniques. Journal of Oral and & Maxillofacial Surgery 1993;51(8):863-7.
94. Maloney GE, Mehta N, Forgione AG, Zawawi KH, Al-Badawi EA, Driscoll SE. Effect of a Passive Jaw Motion Device on Pain
and Range of Motion in TMD patients not responding to flat plane intraoral appliances. J. Cranio. Prac. 2002;20(1):55-65.
95. Grace EG, Sarlani D, Read B. The use of an oral exercise device in the treatment of muscular TMD. J. Cranio. Practice
2002;July;20(3):204-8.
96. Yoda R, Sakamoto I, Imai H, Honma Y, Shinjo Y, Takano A, et al. A randomized controlled trial of therpeutic exercise for
clicking due to disk anterior displacement with reduction in the temporomandibular joint. Cranio 2003;21(1):10-16.
97. Michellotti A, Steenks MH, Farella M, Parisiani F, Cimino R, Martina R. The additional value of a home physical therapy
regimen versus patient education only for treatment of myofascial pain of the jaw muscles: short-term results of a randomized
clinical trial. J. Orofacial Pain 2004;18(2):114-25.
98. Ceccherelli F, Altafini L, Lo Castro G, Avila A, Ambrosio F, Giron GP. Diode laser in cervical myofascial pain: a double-blind
study versus placebo. Clinical Journal of Pain 1989;5(4):301-4.
99. Bertolucci LE, Grey T. Clinical analysis of mid-laser versus placebo treatment of arthralgic TMJ degenerative joints. Cranio
1995;13(1):26-9.
100. Kulekcioglu S, Sivriolglu K, Ozcan O, Parlak M. Effectiveness of low-level laser therapy in temporomandibular disorders.
Scand. J Rheumatol 2003(32):114-8.
101. Ilbuldu E, Cakmak A, Disci R, Aydin R. Comparison of laser, dry needling, and placebo laser treatments in myofascial pain
syndrome. Photomedicine and Laser Surgery 2004;22(4):306-11.
102. Gur A, Sarac AJ, Cevik R, Altindag O, Sarac S. Efficacy of 904 nm gallium arsenide low level laser therapy in the management
of chronic myofascial pain in the neck: a double-blind and randomize-controlled trial. Lasers in Surgery & Medicine
2004;35(3):229-35.
103. Ceylan Y, Hizmetli S, Silig Y. The effects of infrared laser and medical treatments on pain and serotonin degradation products
in patients with myofascial pain syndrome. A controlled trial. Rheumatology International 2004;24(5):260-3.

288
104. Altan L, Bingol U, Aykac M. Investigation of the effect of GaAs laser therapy on cervical myofascial pain syndrome.
Rheumatology International 2005;25(1):23-7.
105. Hansson P, Ekblom A. Transcutaneous electrical nerve stimulation (TENS) as compared to placebo TENS for the relief of
acute oro-facial pain. Pain 1983;15(2):157-65.
106. Bertolucci LE, Grey T. Clinical comparative study of microcurrent electrical stimulation to mid-laser and placebo treatment in
degenerative joint disease of the temporomandibular joint. Cranio 1995;13(2):116-20.
107. Farina S, Casarotto M, Benelle M, Tinazzi M, Fiaschi A, Goldoni M, et al. A randomized controlled study on the effect of two
different treatments (FREMS and TENS) in myofacial pain sydrome. Eur Med Phys 2004(40):293-301.
108. Reich BA. Non-invasive treatment of vascular and muscle contraction headache: a comparative longitudinal clinical study.
Headache 1989;29(1):34-41.
109. Gray RJ, Quayle AA, Hall CA, Schofield MA. Physiotherapy in the treatment of temporomandibular joint disorders: a
comparative study of four treatment methods. British Dental Journal 1994;176(7):257-61.
110. Shin SM, Choi JK. Effect of indomethacin phonophoresis on the relief of temporomandibular joint pain. Cranio 1997;15(4):345-
8.
111. Schiffman EL, Braun BL, Lindgren BR. Temporomandibular joint iontophoresis: a double-blind randomized clinical trial. Journal
of Orofacial Pain 1996;10(2):157-65.
112. Reid KI, Dionne RA, Sicard-Rosenbaum L, Lord D, Dubner RA. Evaluation of iontophoretically applied dexamethasone for
painful pathologic temporomandibular joints. Oral Surgery, Oral Medicine, Oral Pathology 1994;77(6):605-9.
113. Al-Badawi EA, Mehta N, Forgione AG, Lobo SL, Zawawi KH. Efficacy of pulsed radio frequency energy therapy in
temporomandibular joint pain and dysfunction. Cranio. 2004;Jan;22(1):10-20.
114. Crockett DJ, Foreman ME, Alden L, Blasberg B. A comparison of treatment modes in the management of myofascial pain
dysfunction syndrome. Biofeedback & Self Regulation 1986;11(4):279-91.
115. Schiffman EL, Look JO, Fricton JR, Hodges JS, Swift JQ, Decker KL, et al. A Randomized Clinical Trial Evaluating Four
Treatment Strategies for Patients with Temporomandibular Joint Disc Displacement without Reduction with Limited Mouth
Opening. (in review) 2005.
116. De Laat A, Stappaerts K, Papy S. Counseling and Physical Therapy as Treatment for Myofascial Pain of the Masticatory
System. J Orofac Pain 2003;Winter;17(1):42-49.
117. Dworkin SF, LeResche L. Research diagnostic criteria for temporomandibular disorders: review, criteria, examinations and
specifications, critique. (Review). Journal of Craniomandibular Disorders 1992;6(4):301-55.
118. Gam AN, Thorsen J, Lonnberg F. The effect of low-level laser therapy on musculoskeletal pain: a meta-anlysis. Pain
1993(52):63-66.
119. Health CfDaR. Laser Facts. Washington D.C.: United States Food and Drug Administration (FDA); Feb. 2008.

Therapeutic Injections

1. McMillan AS, Nolan A. The efficacy of procaine in the treatment of myofascial pain in the jaw muscles. J Orofac Pain
1996;10(2):187.
2. McMillan AS, Nolan A, Kelly PJ. The efficacy of dry needling and procaine in the treatment of myofascial pain in the jaw
muscles. Journal of Orofacial Pain 1997;11(4):307-14.
3. Salim M. Myofascial pain--trigger point injection vs transcutaneous electrical nerve stimulation (TENS). J Pak Med Assoc
1992;42(10):244.
4. Okeson JP. Management of Temporomandibular Disorders and Occlusion. 4th ed. St. Louis: CV Mosby Co; 1998. p. 475.
5. Cifala J. Myofascial (trigger point pain) injection: theory and treatment. Osteopath. Med. 1979:31-36.
6. Jaeger B, Skootsky, SA. Double Blind, Controlled Study of Different Myofascial Trigger Point Injection Techniques. Pain
1987;4 (Supp):S292.
7. Lewit K. The needle effect in the relief of myofascial pain. Pain 1979;6(1):83-90.
8. Simons D. Electrogenic nature of palpable bands and "jump sign" associated with myofascial trigger points. In: JJ B, editor.
Advances in pain research and therapy. New York: Raven Press; 1976. p. 913-8.
9. Simons DG, Travell JG, Simons LS. Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual. 2nd ed.
Baltimore: Williams & Wilkins; 1999.
10. Fricton JR. Etiology and management of masticatory myofascial pain. J Musculoske Pain 1999;7(1/2):143-60.
11. Hong CZ. Lidocaine injection versus dry needling to myofascial trigger point. The importance of the local twitch response.
American Journal of Physical Medicine & Rehabilitation 1994;73(4):256-63.
12. Tschopp KP, Gysin C. Local injection therapy in 107 patients with myofascial pain syndrome of the head and neck. Orl;
Journal of Oto-Rhino-Laryngology & its Related Specialties 1996;58(6):306-10.
13. Freund B, Schwartz M. The use of botulinum toxin for the treatment of temporomandibular disorder. Oral Health
1998;88(2):32-7.
14. Tan EK. Treating severe bruxism with botulinum toxin. J Am Dent Assoc 2000;131(2):211-6.
15. Cheshire WP, Abashian SW, Mann JD. Botulinum toxin in the treatment of myofascial pain syndrome. Pain 1994;59(1):65-9.
16. Rollnik JD, Tanneberger O, Schubert M, Schneider U, Dengler R. Treatment of tension-type headache with botulinum toxin
type A: a double-blind, placebo-controlled study. Headache 2000;40(4):300-5.
17. Schmitt WJ, Slowey E, Fravi N, Weber S, Burgunder JM. Effect of botulinum toxin A injections in the treatment of chronic
tension-type headache: a double-blind, placebo-controlled trial. Headache 2001;2001 Jul-Aug;41(7):658-64.

289
18. Kamanli A, Kaya A, Ardicoglu O, Ozgocmen S, Zengin FO, Bayik Y. Comparison of lidocaine injection, botulinum toxin
injection, and dry needling to trigger points in myofascial pain syndrome. Rheumatology International 2005;25(8):604-11.
19. Botulinum toxin and intractable trigeminal neuralgia. Clinical Neuropharmacology 2005;28(4):161-2.
20. Silberstein SD, Stark SR, Lucas SM, Christie SN, DeGryse RE, Turkel CC, et al. Botulinum toxin type A for the prophylactic
treatment of chronic daily headache: a randomized, double-blind, placebo-controlled trial.(see comment). Mayo Clinic
Proceedings 2005;80(9):1126-37.
21. Ferrante FM, Bearn L, Rothrock R, King L. Evidence against trigger point injection technique for the treatment of
cervicothoracic myofascial pain with botulinum toxin type A.(see comment). Anesthesiology 2005;103(2):377-83.
22. Botulinum toxin type a for the prophylaxis of chronic daily headache: subgroup analysis of patients not receiving other
prophylactic medications: a randomized double-blind, placebo-controlled study. Headache 2005;45(4):315-24.
23. Mathew NT, Frishberg BM, Gawel M, Dimitrova R, Gibson J, Turkel C, et al. Botulinum toxin type A (BOTOX) for the
prophylactic treatment of chronic daily headache: a randomized, double-blind, placebo-controlled trial. Headache
2005;45(4):293-307.
24. Evaluating the effects of ice application on the pain felt during botulinum toxin type-a injections: a prospective, randomized,
single-blind controlled trial. Annals of Plastic Surgery 2004;53(6):543-6.
25. Padberg M, Bruijn Sd, Haan Rd, Tavy D. Treatment of chronic tension-type headache with botulinum toxin: a double-blind,
placebo-controlled clinical trial. Cephalalgia 2004;24(8):675-80.
26. Schulte-Mattler WJ, Krack P, BoNTTH. Treatment of chronic tension-type headache with botulinum toxin A: a randomized,
double-blind, placebo-controlled multicenter study.(see comment). Pain 2004;109(1-2):110-4.
27. Relja M, Telarovic S. Botulinum toxin in tension-type headache. Journal of Neurology 2004;251 Suppl 1:I12-4.
28. Ondo WG, Vuong KD, Derman HS. Botulinum toxin A for chronic daily headache: a randomized, placebo-controlled, parallel
design study. Cephalalgia 2004;24(1):60-5.
29. Kokoska MS, Glaser DA, Burch CM, Hollenbeak CS. Botulinum toxin injections for the treatment of frontal tension headache. J
Headache Pain 2004;5:103-09.
30. von Lindern JJ, Niederhagen D, Berge S, T Appel T. Type A botulinum toxin in the treatment of chronic facial pain associated
with masticatory hyperactivity. J Oral Maxillofac Surg 2003;Jul;61(7):774-8.
31. Nixdorf DR, Heo G, Major PW. Randomized controlled trial of botulinum toxin A for chronic myogenous orofacial pain. Pain
2002;Oct;99(3):465-73.
32. Bertolami CN, Gay T, Clark GT, Rendell J, Shetty V, Liu C, et al. Use of sodium hyaluronate in treating temporomandibular
joint disorders: a randomized, double-blind, placebo-controlled clinical trial. Journal of Oral & Maxillofacial Surgery
1993;51(3):232-42.
33. Ferrante FM, Kaufman AG, Dunbar SA, Cain CF, Cherukuri S. Sphenopalatine ganglion block for the treatment of myofascial
pain of the head, neck, and shoulders. Regional Anesthesia & Pain Medicine 1998;23(1):30-6.
34. Janzen VD, Scudds R. Sphenopalatine blocks in the treatment of pain in fibromyalgia and myofascial pain syndrome.
Laryngoscope 1997;107(10):1420-2.
35. Loitman JE. Pain management: beyond pharmacology to acupuncture and hypnosis. Jama 2000;283(1):118-9.
36. Berman BM, Singh BK, Lao L, Singh BB, Ferentz KS, Hartnoll SM. Physicians' attitudes toward complementary or alternative
medicine: a regional survey. J Am Board Fam Pract 1995;8(5):361-6.
37. Wright EF, Schiffman EL. Treatment alternatives for patients with masticatory myofascial pain. J Am Dent Assoc
1995;126(7):1030-9.
38. Cheng RS, Pomeranz B. A combined treatment with D-amino acids and electroacupuncture produces a greater analgesia than
either treatment alone; naloxone reverses these effects. Pain 1980;8(2):231-6.
39. Pert A, Dionne R, Ng L, Bragin E, Moody TW, Pert CB. Alterations in rat central nervous system endorphins following
transauricular electroacupuncture. Brain Res 1981;224(1):83-93.
40. Pomeranz B, Bibic L. Electroacupuncture suppresses a nociceptive reflex: naltrexone prevents but does not reverse this
effect. Brain Res 1988;452(1-2):227-31.
41. Pomeranz B, Warma N. Electroacupuncture suppression of a nociceptive reflex is potentiated by two repeated
electroacupuncture treatments: the first opioid effect potentiates a second non-opioid effect. Brain Res 1988;452(1-2):232-6.
42. Fricton JR, Nixdorf DR, Schiffman EL, Look JO, Ouyang W. Critical Appraisal of Methods in Randomized Controlled Trials for
Temporomandibular Disorders. 2006.
43. Al-Hasson HK, Ismail AI, Jr. Ash MM. Concerns of patients seeking treatment for TMJ dysfunction. J Prosthet Dent
1986;56:217-21.
44. Fricton J LJ, Wright E, Alencar F, Chen H, Lang, M, Ouyang, W, Velly, A. Systematic Review of Intraoral Orthopedic
Appliance and Occlusal Treatment for Temporomandibular Disorders: 51 RCTs reviewed. J Orofacial Pain 2007;(In review).
45. Chinn S. A simple method for converting odds ratio to effect size for use in meta-analysis. Stat Med 2000;19:3127-31.
46. Higgins JP, Green S. Cochrane Handbook for Systematic Reviews of Interventions 4.2.5 (updated May 2005). Appendix 8b;
2005.
47. Muller W, Stratz T. Local treatment of tendinopathies and myofascial pain syndromes with the 5-HT3 receptor antagonist
tropisetron. Scandinavian Journal of Rheumatology - Supplement 2004(119):44-8.
48. Hameroff SR, Crago BR, Blitt CD, Womble J, Kanel J. Comparison of bupivacaine, etidocaine, and saline for trigger-point
therapy. Anesth Analg 1981;60(10):752-5.
49. Simons DG, Travell JG, Simons LS. Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual. 2nd ed.
Baltimore: Williams & Wilkins; 1999.
50. Okeson JP. Management of Temporomandibular Disorders and Occlusion. 4th ed. St. Louis: CV Mosby Co; 1998. p. 399-400.
290
51. Kopp S, Wenneberg B, Haraldson T, Carlsson GE. The short-term effect of intra-articular injections of sodium hyaluronate and
corticosteroid on temporomandibular joint pain and dysfunction. Journal of Oral & Maxillofacial Surgery 1985;43(6):429-35.
52. Kopp S, Carlsson GE, Haraldson T, Wenneberg B. Long-term effect of intra-articular injections of sodium hyaluronate and
corticosteroid on temporomandibular joint arthritis. Journal of Oral & Maxillofacial Surgery 1987;45(11):929-35.
53. Kopp S, Akerman S, Nilner M. Short-term effects of intra-articular sodium hyaluronate, glucocorticoid, and saline injections on
rheumatoid arthritis of the temporomandibular joint. Journal of Craniomandibular Disorders 1991;5(4):231-8.
54. Bryant CJ, Harrison SD, Hopper C, Harris M. Use of intra-articular morphine for postoperative analgesia following TMJ
arthroscopy. British Journal of Oral & Maxillofacial Surgery 1999;37(5):391-6.
55. Karst M, Rollnik JD, Fink M, Reinhard M, Piepenbrock S. Pressure pain threshold and needle acupuncture in chronic tension-
type headache--a double-blind placebo-controlled study. Pain 2000;88(2):199-203.
56. Vincent CA. The treatment of tension headache by acupuncture: a controlled single case design with time series analysis.
Journal of Psychosomatic Research 1990;34(5):553-61.
57. White AR, Resch KL, Chan JC, Norris CD, Modi SK, Patel JN, et al. Acupuncture for episodic tension-type headache: a
multicentre randomized controlled trial. Cephalalgia 2000;20(7):632-7.
58. Melchart D, Streng A, Hoppe A, Brinkhaus B, Witt C, Wagenpfeil S, et al. Acupuncture in patients with tension-type headache:
randomised controlled trial. BMJ 2005;331(7513):376-82.
59. Johansson A, Wenneberg B, Wagersten C, Haraldson T. Acupuncture in treatment of facial muscular pain. Acta Odontologica
Scandinavica 1991;49(3):153-8.
60. List T, Helkimo M, Karlsson R. Pressure pain thresholds in patients with craniomandibular disorders before and after treatment
with acupuncture and occlusal splint therapy: a controlled clinical study. Journal of Orofacial Pain 1993;7(3):275-82.
61. Carlsson J, Fahlcrantz A, Augustinsson LE. Muscle tenderness in tension headache treated with acupuncture or
physiotherapy. Cephalalgia 1990;10(3):131-41.
62. List T, Helkimo M. Acupuncture and occlusal splint therapy in the treatment of craniomandibular disorders. II. A 1-year follow-
up study. Acta Odontol Scand 1992;50(6):375-85.
63. Raustia AM. Diagnosis and treatment of temporomandibular joint dysfunction. Advantages of computed tomography diagnosis.
Stomatognathic treatment and acupuncture--a randomized trial. Proceedings of the Finnish Dental Society 1986;82(Suppl 9-
10):1-41.
64. Goddard G, Karibe H, McNeill C, Villafuerte E. Acupuncture and sham acupuncture reduce muscle pain in myofascial pain
patients. J Orofac Pain 2002;Winter;16(1):71-6.
65. Xue CCL, Dong L, Polus B, English RA, Zheng Z, Costa CD, et al. Electroacupuncture for tension-type headache on distal
acupoints only: a randomized, controlled, crossover trial. Headache 2004;44(4):333-41.
66. Ebneshahidi NS, Heshmatipour M, Moghaddami A, Eghtesadi-Araghi P. The effects of laser acupuncture on chronic tension
headache--a randomised controlled trial. Acupuncture in Medicine 2005;23(1):13-8.
67. Elsharkawy TM, Ali NM. Evaluation of acupuncture and occlusal splint therapy in the treatment of temporomandibular joint
disorders. Egyptian Dental Journal 1995;41(3):1227-32.
68. List T, Helkimo M, Andersson S, Carlsson GE. Acupuncture and occlusal splint therapy in the treatment of craniomandibular
disorders. Part I. A comparative study. Swed Dent J 1992;16(4):125-41.

Orthopedic and Oral Appliances

291
1. Dao TT, Lavigne GJ. Oral splints: the crutches for temporomandibular disorders and bruxism? Crit Rev Oral Biol Med
1998;9(3):345-61.
2. Okeson JP. Management of Temporomandibular Disorders and Occlusion. 4th ed. St. Louis: CV Mosby Co; 1998. p. 475.
3. Singh BP, Berry DC. Occlusal changes following use of soft occlusal splints. J Prosthet Dent 1985;54(5):711-5.
4. Wright E, Anderson G, Schulte J. A randomized clinical trial of intraoral soft splints and palliative treatment for masticatory
muscle pain. J Orofacial Pain 1995;9(2):192-99.
5. Brayer L, Erlich J. The night guard: its uses and dangers of abuse. J Oral Rehabil 1976;3(2):181-4.
6. Clark GT. Treatment of jaw clicking with temporomandibular repositioning: analysis of 25 cases. J Craniomandibular Pract
1984;2(3):263-70.
7. List T, Helkimo M. Adverse events of acupuncture and occlusal splint therapy in the treatment of craniomandibular disorders.
Cranio 1992;10(4):318-24; discussion 24-6.
8. Bush RM, Abbott FM, Butler JH, Harrington WG. Oral orthotics: design, indications, efficacy and care. In: Hardin JF, editor.
Clark's Clinical Dentistry. Philadelphia: J.B. Lippincott Co; 1998. p. 1-33.
9. Widmalm SE. Use and abuse of bite splints. Compend Contin Educ Dent 1999;20(3):249-54, 56, 58-9; quiz 60.
10. Joondeph DR. Long-term stability of mandibular orthopedic repositioning. Angle Orthod 1999;69(3):201-9.
11. Okeson JP. Long-term treatment of disk-interference disorders of the temporomandibular joint with anterior repositioning
occlusal splints. J Prosthet Dent 1988;60(5):611-6.
12. Abbott DM, Bush FM. Occlusions altered by removable appliances. J Am Dent Assoc 1991;122(2):79-81.
13. Brown DT, Gaudet EL, Jr., Phillips C. Changes in vertical tooth position and face height related to long term anterior
repositioning splint therapy. Cranio 1994;12(1):19-22.
14. Douglass JB, Smith PJ. Loss of control of the vertical dimension of occlusion during interocclusal acrylic resin splint therapy: a
clinical report. J Prosthet Dent 1992;67(1):1-4.
15. Dawson PE. Evaluation, diagnosis and treatment of occlusal problems. 2nd ed. St. Louis: CV Mosby Co; 1989. p. 183-205.
16. Okeson JP. Management of Temporomandibular Disorders and Occlusion. 4th ed. St. Louis: CV Mosby Co; 1998. p. 474.
17. Attanasio R. Intraoral orthotic therapy. Dent Clin North Am 1997;41(2):309-24.
18. Nelson SJ. Principles of stabilization bite splint therapy. Dent Clin North Am 1995;39(2):403-21.
19. Boero RP. The physiology of splint therapy: a literature review. Angle Orthod 1989;59(3):165-80.
20. Christensen GJ. Abnormal occlusal conditions: a forgotten part of dentistry. J Am Dent Assoc 1995;126(12):1667-8.
21. Pavone BW. Bruxism and its effect on the natural teeth. J Prosthet Dent 1985;53(5):692-6.
22. Okeson JP. The effects of hard and soft occlusal splints on nocturnal bruxism. J Am Dent Assoc 1987;114(6):788-91.
23. Greco PM, Vanarsdall RL, Jr., Levrini M, Read R. An evaluation of anterior temporal and masseter muscle activity in appliance
therapy. Angle Orthod 1999;69(2):141-6.
24. Sheikholeslam A, Holmgren K, Riise C. A clinical and electromyographic study of the long-term effects of an occlusal splint on
the temporal and masseter muscles in patients with functional disorders and nocturnal bruxism. J Oral Rehabil
1986;13(2):137-45.
25. Solberg WK, Clark GT, Rugh JD. Nocturnal electromyographic evaluation of bruxism patients undergoing short term splint
therapy. J Oral Rehabil 1975;2(3):215-23.
26. Sheikholeslam A, Moller E, Lous I. Postural and maximal activity in elevators of mandible before and after treatment of
functional disorders. Scand J Dent Res 1982;90(1):37-46.
27. Carlsson GE, Ingervall B, Kocak G. Effect of increasing vertical dimension on the masticatory system in subjects with natural
teeth. J Prosthet Dent 1979;41(3):284-9.
28. Holmgren K, Sheikholeslam A, Riise C. An electromyographic study of the immediate effect of an occlusal splint on the
postural activity of the anterior temporal and masseter muscles in different body positions with and without visual input. J Oral
Rehabil 1985;12(6):483-90.
29. Visser A, McCarroll RS, Naeije M. Masticatory muscle activity in different jaw relations during submaximal clenching efforts. J
Dent Res 1992;71(2):372-9.
30. Clark GT, Beemsterboer PL, Rugh JD. Nocturnal masseter muscle activity and the symptoms of masticatory dysfunction. J
Oral Rehabil 1981;8(3):279-86.
31. Kutsuki M, Yamaguchi Y, Yoshitake K, Tsutsumi S. 3-D stress distribution in temporomandibular joint during clenching. J Dent
Res 2000;79(special issue):592, abstract 3585.
32. dos Santos JD, Jr., de Rijk WG. Vectorial analysis of the equilibrium of forces transmitted to TMJ and occlusal biteplane
splints. J Oral Rehabil 1995;22(4):301-10.
33. dos Santos J, Suzuki H, Ash MM. Mechanical analysis of the equilibrium of occlusal splints. J Prosthet Dent 1988;59(3):346-
52.
34. Hatcher DC, Faulkner MG, Hay A. Development of mechanical and mathematic models to study temporomandibular joint
loading. J Prosthet Dent 1986;55(3):377-84.
35. Ito T, Gibbs CH, Marguelles-Bonnet R, Lupkiewicz SM, Young HM, Lundeen HC, et al. Loading on the temporomandibular
joints with five occlusal conditions. J Prosthet Dent 1986;56(4):478-84.
36. Edwards SE, Sindelar BJ, Herring SW. Intra-oral appliances and collagen fiber anisotropy in the TMJ disc. J Dent Res
2000;79(special issue):526, abstract 3059.
37. Pertes RA. Occlual Appliance Therapy. In: Pertes RA, Gross SG, editors. Clinical management of temporomandibular
disorders and orofacial pain. Chicago: Quintessence; 1995. p. 197-209.
38. Colt JS. Occlusal splint therapy in the treatment of temporomandibular disorders: A historical perspective. Cranio Clin Int
1991;1(2):1-12.
292
39. Messing SG. Splint therapy. In: Kaplan AS, Assael LA, editors. Temporomandibular Disorders: Diagnosis and Treatment.
Philadelphia: Saunders; 1991. p. 395-454.
40. Elsharkawy TM, Ali NM. Evaluation of acupuncture and occlusal splint therapy in the treatment of temporomandibular joint
disorders. Egyptian Dental Journal
1995;41(3):1227-32.
41. Carmeli E, Sheklow SL, Bloomenfeld I. Comparative study of repositioning splint therapy and passive range of motion
techniques lot anterior displaced temporomandibular discs with unstable excursive reduction. Physiotherapy 2001;87:26-36.
42. Okeson JP. Management of Temporomandibular Disorders and Occlusion. 4th ed. St. Louis: CV Mosby Co; 1998. p. 488-94.
43. Anderson GC, Schulte JK, Goodkind RJ. Comparative study of two treatment methods for internal derangement of the
temporomandibular joint. J Prosthet Dent 1985;53(3):392-7.
44. Clark GT. The TMJ repositioning appliance: a technique for construction, insertion, and adjustment. Cranio 1986;4(1):37-46.
45. Hersek N, Uzun G, Cindas A, Canay S, Kutsal YG. Effect of anterior repositioning splints on the electromyographic activities of
masseter and anterior temporalis muscles. Cranio 1998;16(1):11-6.
46. Summer JD, Westesson PL. Mandibular repositioning can be effective in treatment of reducing TMJ disk displacement. A long-
term clinical and MR imaging follow-up. Cranio 1997;15(2):107-20.
47. Williamson EH, Rosenzweig BJ. The treatment of temporomandibular disorders through repositioning splint therapy: a follow-
up study. Cranio 1998;16(4):222-5.
48. Tallents RH, Katzberg RW, Macher DJ, Roberts CA. Use of protrusive splint therapy in anterior disk displacement of the
temporomandibular joint: a 1- to 3-year follow-up. J Prosthet Dent 1990;63(3):336-41.
49. Williamson EH, Sheffield JW. The non-surgical treatment of internal derangement of the temporomandibular joint: a survey of
300 cases. Facial Orthop Temporomandibular Arthrol 1985;2(10):18-21.
50. Sato H, Fujii T, Uetani M, Kitamori H. Anterior mandibular repositioning in a patient with temporomandibular disorders: a
clinical and tomographic follow-up case report. Cranio 1997;15(1):84-8.
51. Williamson EH, Navarro EZ, Zwemer JD. A comparison of electromyographic activity between anterior repositioning splint
therapy and a centric relation splint. Cranio 1993;11(3):178-83.
52. Austin DG. Special considerations in orofacial pain and headache. Dent Clin North Am 1997;41(2):325-39.
53. Lundh H, Westesson PL, Jisander S, Eriksson L. Disk-repositioning onlays in the treatment of temporomandibular joint disk
displacement: comparison with a flat occlusal splint and with no treatment. Oral Surg Oral Med Oral Pathol 1988;66(2):155-62.
54. Tallents RH, Katzberg RW, Miller TL, Manzione J, Macher DJ, Roberts C. Arthrographically assisted splint therapy: painful
clicking with a nonreducing meniscus. Oral Surg Oral Med Oral Pathol 1986;61(1):2-4.
55. Davies SJ, Gray RJ. The pattern of splint usage in the management of two common temporomandibular disorders. Part I: The
anterior repositioning splint in the treatment of disc displacement with reduction. Br Dent J 1997;183(6):199-203.
56. Shankland WE, 2nd. Migraine and tension-type headache reduction through pericranial muscular suppression: a preliminary
report. Cranio 2001;Oct;19(4):269-78.
57. Dahlstrom L, Haraldson T. Bite plates and stabilization splints in mandibular dysfunction. A clinical and electromyographic
comparison. Acta Odontol Scand 1985;43(2):109-14.
58. Magnusson T, Adiels AM, Nilsson HL, Helkimo M. Treatment effect on signs and symptoms of temporomandibular disorders--
comparison between stabilisation splint and a new type of splint (NTI). A pilot study. Swed Dent J 2004;28(1):11-20.
59. Karppinen K, Eklund S, Suoninen E, Eskelin M, Kirveskari P. Adjustment of dental occlusion in treatment of chronic
cervicobrachial pain and headache. J Oral Rehabil 1999;26(9):715-21.
60. Moher D CD, Eastwood S, Olkin I, Rennie D, Stroup DF et al. Improving the quality of reports of meta-analyses of randomized
controlled trials: the Quorom Statement. The Lancet 2003;354:1896-900.
61. Fricton JN, Nixdorf DR, Schiffman EL, Ouyang W, Velly AM, Look JO. Critical Appraisal of Methods used in Randomized
Controlled Trials of Treatments for Temporomandibular Disorders. J. Orofacial Pain 2007;(submitted).
62. Al-Hasson HK, Ismail AI, Jr. Ash MM. Concerns of patients seeking treatment for TMJ dysfunction. J Prosthet Dent
1986;56:217-21.
63. Dworkin SF, Huggins KH, Wilson L, Mancl L, Turner J, Massoth D, et al. A randomized clinical trial using research diagnostic
criteria for temporomandibular disorders-axis II to target clinic cases for a tailored self-care TMD treatment program. J Orofac
Pain 2002;16(6):48-63.
64. Egger M JnP, Bartlett C,Holenstein F,Sterne J How important are comprehensive literature searches and the assessment of
trial quality in systematic reviews? Empirical study. Health Technol. Assess. 2003;7(1).
65. Ioannidis J E, SJ, Gotzsche, PC, O'Neill, RT, Altman, DG, Schulz, K, Moher, D. CONSORT Group. Better reporting of harms in
randomized trials: an extension of the CONSORT statement. Ann Intern Med 2004;141(10):781-8.
66. Forssell H, Kalso E. Application of Principles of Evidence-Based Medicine to Occlusal Treatment of Temporomandibular
Disorders: Are there lessons to be learned? J. Orofacial Pain 2004(18):9-22.
67. Higgins JP, Green S. 6. Assessment of Study Quality Cochrane Handbook for Systematic Reviews of Interventions 4.2.5
(updated May 2005). ; 2005.
68. Kalso E, Edwards J, McQuay HJ, Moore RA. Five easy pieces of evidence-based medicine (3). Eur J Pain 2001;5:227-30.
69. Higgins JP, Green S. Cochrane Handbook for Systematic Reviews of Interventions 4.2.5 (updated May 2005). Appendix 8b;
2005.
70. Chatellier G, Zapletal E, Lemaitre D, Menard J, Degoulet P. The number needed to treat: a clinically useful nomogram in its
proper context. BMJ 1996;312:426-29.
71. Kleinbaum DG, Kupper LL, Morgenstern H. Epidemiological Research: Principles and Quantative Methods. New York: Van
Nostrand Reinhold Company; 1982.
293
72. Chinn S. A simple method for converting odds ratio to effect size for use in meta-analysis. Stat Med 2000;19:3127-31.
73. Higgins JPT, Green S. editors. Combining dichotomous and continuous outcomes. Cochrane Handbook for Systematic
Reviews of Interventions 4.2.5 (updated May 2005). Section 8.6.5; 2005.
74. Forssell H, Kirveskari P, Kangasniemi P. Effect of occlusal adjustment on mandibular dysfunction. A double-blind study. Acta
Odontol Scand 1986;44(2):63-9.
75. Tsolka P, Morris RW, Preiskel HW. Occlusal adjustment therapy for craniomandibular disorders: a clinical assessment by a
double-blind method. J Prosthet Dent 1992;68(6):957-64.
76. Vallon D, Ekberg E, Nilner M, Kopp S. Occlusal adjustment in patients with craniomandibular disorders including headaches. A
3- and 6-month follow-up. Acta Odontol Scand 1995;53(1):55-9.
77. Vallon D, Nilner M, Soderfeldt B. Treatment outcome in patients with craniomandibular disorders of muscular origin: a 7-year
follow-up. J Orofac Pain 1998;12(3):210-8.
78. Kirveskari P, Le Bell Y, Salonen M, Forssell H, Grans L. Effect of elimination of occlusal interferences on signs and symptoms
of craniomandibular disorder in young adults. J Oral Rehabil 1989;16(1):21-6.
79. Kirveskari P, Jamsa T, Alanen P. Occlusal adjustment and the incidence of demand for temporomandibular disorder
treatment. J Prosthet Dent 1998;79(4):433-8.
80. Wenneberg B, Nystrom T, Carlsson GE. Occlusal equilibration and other stomatognathic treatment in patients with mandibular
dysfunction and headache. J Prosthet Dent 1988;59(4):478-83.
81. Ekberg EC, Sabet ME, Petersson A, Nilner M. Occlusal appliance therapy in a short-term perspective in patients with
temporomandibular disorders correlated to condyle position. Int J Prosthodont 1998;11(3):263-8.
82. Ekberg EC, Vallon D, Nilner M. Occlusal appliance therapy in patients with temporomandibular disorders. A double-blind
controlled study in a short-term perspective. Acta Odontol Scand 1998;56(2):122-8.
83. Ekberg E, Nilner M. The influence of stabilisation appliance therapy and other factors on the treatment outcome in patients
with temporomandibular disorders of arthrogeneous origin. Swed Dent J 1999;23(1):39-47.
84. Ekberg E, Vallon D, Nilner M. The efficacy of appliance therapy in patients with temporomandibular disorders of mainly
myogenous origin. A randomized, controlled, short-term trial. J Orofac Pain 2003 Spring;17(2):133-9.
85. Dao TT, Lavigne GJ, Charbonneau A, Feine JS, Lund JP. The efficacy of oral splints in the treatment of myofascial pain of the
jaw muscles: a controlled clinical trial. Pain 1994;56(1):85-94.
86. Rubinoff MS, Gross A, McCall WD, Jr. Conventional and nonoccluding splint therapy compared for patients with myofascial
pain dysfunction syndrome. Gen Dent 1987 Nov-Dec;35(6):502-6.
87. Wassell RW, Adams N, Kelly PJ. Treatment of temporomandibular disorders by stabilising splints in general dental practice:
results after initial treatment. British Dental Journal 2004;197:35-41.
88. Raphael KG, Marbach JJ. Widespread pain and the effectiveness of oral splints in myofascial face pain. J Am Dent Assoc
2001;132(3):305-16.
89. Davies SJ, Gray RJ. The pattern of splint usage in the management of two common temporomandibular disorders. Part II: The
stabilisation splint in the treatment of pain dysfunction syndrome. Br Dent J 1997;183(7):247-51.
90. Johansson A, Wenneberg B, Wagersten C, Haraldson T. Acupuncture in treatment of facial muscular pain. Acta Odontologica
Scandinavica 1991;49(3):153-8.
91. List T, Helkimo M, Andersson S, Carlsson GE. Acupuncture and occlusal splint therapy in the treatment of craniomandibular
disorders. Part I. A comparative study. Swed Dent J 1992;16(4):125-41.
92. List T, Helkimo M, Karlsson R. Pressure pain thresholds in patients with craniomandibular disorders before and after treatment
with acupuncture and occlusal splint therapy: a controlled clinical study. Journal of Orofacial Pain 1993;7(3):275-82.
93. Lundh H, Westesson PL, Eriksson L, Brooks SL. Temporomandibular joint disk displacement without reduction. Treatment
with flat occlusal splint versus no treatment. Oral Surg Oral Med Oral Pathol 1992;73(6):655-8.
94. Raustia AM. Diagnosis and treatment of temporomandibular joint dysfunction. Advantages of computed tomography diagnosis.
Stomatognathic treatment and acupuncture--a randomized trial. Proceedings of the Finnish Dental Society 1986;82(Suppl 9-
10):1-41.
95. List T, Helkimo M. Acupuncture and occlusal splint therapy in the treatment of craniomandibular disorders. II. A 1-year follow-
up study. Acta Odontol Scand 1992;50(6):375-85.
96. Tsolka P, Preiskel HW. Kinesiographic and electromyographic assessment of the effects of occlusal adjustment therapy on
craniomandibular disorders by a double-blind method. J Prosthet Dent 1993;69(1):85-92.
97. Dahlstrom L, Carlsson GE, Carlsson SG. Comparison of effects of electromyographic biofeedback and occlusal splint therapy
on mandibular dysfunction. Scand J Dent Res 1982;90(2):151-6.
98. Dahlstrom L, Carlsson SG. Treatment of mandibular dysfunction: the clinical usefulness of biofeedback in relation to splint
therapy. J Oral Rehabil 1984;11(3):277-84.
99. Crockett DJ, Foreman ME, Alden L, Blasberg B. A comparison of treatment modes in the management of myofascial pain
dysfunction syndrome. Biofeedback & Self Regulation 1986;11(4):279-91.
100. Wahlund K, List T, Larsson B. Treatment of temporomandibular disorders among adolescents: a comparison between occlusal
appliance, relaxation training, and brief information. Acta Odontol Scand 2003;61;Aug(4):203-11.
101. Turk DC, Zaki HS, Rudy TE. Effects of intraoral appliance and biofeedback/stress management alone and in combination in
treating pain and depression in patients with temporomandibular disorders. J Prosthet Dent 1993;Aug;70(2):158-64.
102. Carlson CR, Bertrand PM, Ehrlich AD, Maxwell AW, Burton RG. Physical self-regulation training for the management of
temporomandibular disorders. J Orofac Pain 2001;15(1):47-55.

294
103. Linde C, Isacsson G, Jonsson BG. Outcome of 6-week treatment with transcutaneous electric nerve stimulation compared with
splint on symptomatic temporomandibular joint disk displacement without reduction. Acta Odontologica Scandinavica
1995;53(2):92-8.
104. Magnusson T, Syren M. Therapeutic jaw exercises and interocclusal appliance therapy. A comparison between two common
treatments of temporomandibular disorders. Swedish Dental Journal 1999;23(1):27-37.
105. Schokker RP, Hansson TL, Ansink BJ. The result of treatment of the masticatory system of chronic headache patients. J
Craniomandib Disord 1990;4(2):126-30.
106. Manns A, Miralles R, Santander H, Valdivia J. Influence of the vertical dimension in the treatment of myofascial pain-
dysfunction syndrome. J Prosthet Dent 1983;50(5):700-9.
107. Manns A, Miralles R, Cumsille F. Influence of vertical dimension on masseter muscle electromyographic activity in patients
with mandibular dysfunction. J Prosthet Dent 1985;53(2):243-7.
108. Gray RJ, Davies SJ, Quayle AA, Wastell DG. A comparison of two splints in the treatment of TMJ pain dysfunction syndrome.
Can occlusal analysis be used to predict success of splint therapy? Br Dent J 1991;170(2):55-8.
109. Jokstad A, Mo A, Krogstad NS. Clinical comparison between two different splint designs for temporomandibular disorder
therapy. Acta Odontologica Scandinavica 2005;63(4):218-26.
110. Egermark I, Ronnerman A. Temporomandibular disorders in the active phase of orthodontic treatment. J Oral Rehabil
1995;22(8):613-8.
111. Okeson JP. Management of Temporomandibular Disorders and Occlusion. 4th ed. St. Louis: CV Mosby Co; 1998. p. 207-8.
112. Imai T, Okamoto T, Kaneko T, Umeda K, Yamamoto T, Nakamura S. Long-term follow-up of clinical symptoms in TMD
patients who underwent occlusal reconstruction by orthodontic treatment. Eur J Orthod 2000;22(1):61-7.
113. Greene CS. Orthodontics and temporomandibular disorders. Dent Clin North Am 1988;32(3):529-38.
114. Luther F. Orthodontics and the temporomandibular joint: where are we now? Part 2. Functional occlusion, malocclusion, and
TMD. Angle Orthod 1998;68(4):305-18.
115. Turk DC, Rudy TE, Kubinski JA, Zaki HS, Greco CM. Dysfunctional patients with temporomandibular disorders: evaluating the
efficacy of a tailored treatment protocol. J Consult Clin Psychol 1996;64(1):139-46.
116. Lagerstrom L, Egermark I, Carlsson GE. Signs and symptoms of temporomandibular disorders in 19-year-old individuals who
have undergone orthodontic treatment. Swed Dent J 1998;22(5-6):177-86.
117. McNamara JA, Jr. Orthodontic treatment and temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 1997;83(1):107-17.
118. Management of temporomandibular disorders. National Institutes of Health Technology Assessment Conference Statement. J
Am Dent Assoc 1996;127(11):1595-606.
119. Hirata RH, Heft MW, Hernandez B, King GJ. Longitudinal study of signs of temporomandibular disorders (TMD) in
orthodontically treated and nontreated groups. Am J Orthod Dentofacial Orthop 1992;101(1):35-40.
120. Henrikson T. Temporomandibular disorders and mandibular function in relation to Class II malocclusion and orthodontic
treatment. A controlled, prospective and longitudinal study. Swed Dent J Suppl 1999;134:1-144.
121. Turp JC, McNamara JA, Jr. Orthodontic treatment and temporomandibular disorder: is there a relationship? Part 2: Clinical
implications. J Orofac Orthop 1997;58(3):136-43.
122. McNamara JA, Jr., Turp JC. Orthodontic treatment and temporomandibular disorders: is there a relationship? Part 1: Clinical
studies. J Orofac Orthop 1997;58(2):74-89.
123. Henrikson T, Nilner M, Kurol J. Signs of temporomandibular disorders in girls receiving orthodontic treatment. A prospective
and longitudinal comparison with untreated Class II malocclusions and normal occlusion subjects. Eur J Orthod
2000;22(3):271-81.
124. Egermark I, Thilander B. Craniomandibular disorders with special reference to orthodontic treatment: an evaluation from
childhood to adulthood. Am J Orthod Dentofacial Orthop 1992;101(1):28-34.
125. Olsson M, Lindqvist B. Mandibular function before and after orthodontic treatment. Eur J Orthod 1995;17(3):205-14.
126. Egger M JP, Bartlett C, Holenstein F, Sterne J. How important are comprehensive literature searches and the assessment of
trial quality in systematic reviews? Empirical study. Health Technol Assess. 2003;7(1):1-76.
127. Kreiner M, Betancor E, Clark GT. Occlusal stabilization appliances. Evidence of their efficacy. J Am Dent Assoc
2001;132(6):770-7.
128. Dworkin SF, LeResche L. Research diagnostic criteria for temporomandibular disorders: review, criteria, examinations and
specifications, critique. (Review). Journal of Craniomandibular Disorders 1992;6(4):301-55.
129. Turk DC, Dworkin RH, Allen RR, Bellamy N, Brandeburg N, Carr DB, et al. Core outcome domains for chronic pain clinical
trials: IMMPACT recommendations. Pain 2003;106:337-45.
130. Dworkin RH, Turk DC, Farrar JT, Haythornthwaite JA, Jensen MP, Katz NP, et al. Core outcome measures for chronic pain
clinical trials: IMMPACT recommendations. Pain 2005;113:9-19.
131. Forssell H, Kalso E, Koskela P, Vehmanen R, Puukka P, Alanen P. Occlusal treatments in temporomandibular disorders: a
qualitative systematic review of randomized controlled trials. Pain 1999;83(3):549-60.
132. Al-Ani Z, Gray RJ, Davies SJ, Sloan P, Glenny AM. Stabilization splint therapy for the treatment of temporomandibular
myofascial pain: a systematic review. J Dent Educ 2005 Nov;69(11):1242-50.
133. Raustia AM, Pohjola RT, Virtanen KK. Acupuncture compared with stomatognathic treatment for TMJ dysfunction. Part I: A
randomized study. J Prosthet Dent 1985;Oct;54(4):581-5.

Pharmacologic therapy
295
1. Management of temporomandibular disorders. National Institutes of Health Technology Assessment Conference Statement. J
Am Dent Assoc 1996;127(11):1595-606.
2. Dionne RA. Pharmacologic treatments for temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
1997;83(1):134-42.
3. Denucci DJ, Dionne RA, Dubner R. Identifying a neurobiologic basis for drug therapy in TMDs. J Am Dent Assoc
1996;127(5):581-93.
4. Onghena P, Van Houdenhove B. Antidepressant-induced analgesia in chronic non-malignant pain: a meta-analysis of 39
placebo-controlled studies. Pain 1992;49(2):205-19.
5. Dao TT, Lavigne GJ. Oral splints: the crutches for temporomandibular disorders and bruxism? Crit Rev Oral Biol Med
1998;9(3):345-61.
6. Pascucci RA. COX-2-specific inhibition: implications for clinical practice. J Am Osteopath Assoc 1999;99(11 Suppl):S18-22.
7. Schuna AA, Megeff C. New drugs for the treatment of rheumatoid arthritis. Am J Health Syst Pharm 2000;57(3):225-34.
8. Wynn RL. The new COX-2 inhibitors: rofecoxib (Vioxx) and celecoxib (Celebrex). Gen Dent 2000;48(1):16-20.
9. Brooks P, Day RO. Nonsteroidal anti-inflammatory drugs: Differences and similarities. N Engl J Med 1991;324(24):1716-25.
10. Carson J, Strom BL, Soper KA, et al. The association of nonsteroidal anti-inflammatory drugs with upper gastrointestinal
bleeding. Arch Intern Med 1987;147(1):85-88.
11. Langman M, Weil J, Wainsright P, et al. Risks of bleeding peptic ulcer associated with individual nonsteroidal anti-
inflammatory drugs. Lancet 1994;343(8905):1075-8.
12. Paulus HE, Bulpitt KJ. Nonsteroidal anti-inflammatory drugs. In: Klippel JH, Weyand CM, Wortmann RL, editors. Primer on the
Rheumatic Disease. Atlanta: Arthritis Foundation; 1997. p. 422-6.
13. Steiner TJ, Lange R. Ketoprofen (25 mg) in the symptomatic treatment of episodic tension- type headache: double-blind
placebo-controlled comparison with acetaminophen (1000 mg). Cephalalgia 1998;18(1):38-43.
14. Mehlisch DR, Weaver M, Fladung B. Ketoprofen, acetaminophen, and placebo in the treatment of tension headache.
Headache 1998;38(8):579-89.
15. Lange R, Lentz R. Comparison ketoprofen, ibuprofen and naproxen sodium in the treatment of tension-type headache. Drugs
Exp Clin Res 1995;21(3):89-96.
16. Packman B, Packman E, Doyle G, Cooper S, Ashraf E, Koronkiewicz K, et al. Solubilized ibuprofen: evaluation of onset, relief,
and safety of a novel formulation in the treatment of episodic tension-type headache. Headache 2000;40(7):561-7.
17. Diamond S, Balm TK, Freitag FG. Ibuprofen plus caffeine in the treatment of tension-type headache. Clin Pharmacol Ther
2000;68(3):312-9.
18. Cerbo R CV, Grazioli I, Tavolato B, Trenti T, Uslenghi C, Sternieri E. Efficacy of a fixed combination of indomethacin,
prochlorperazine, and caffeine in the treatment of episodic tension-type headache: a double-blind, randomized, nimesulide-
controlled, parallel group, multicentre trial. Eur J Neurol. 2005;12(10):759-67.
19. Schachtel BP, Furey SA, Thoden WR. Nonprescription ibuprofen and acetaminophen in the treatment of tension-type
headache. Journal of Clinical Pharmacology 1996;36(12):1120-5.
20. Mongini F, Bona G, Garnero M, Gioria A. Efficacy of meclofenamate sodium versus placebo in headache and craniofacial
pain. Headache 1993;33(1):22-8.
21. Ekberg EC, Kopp S, Akerman S. Diclofenac sodium as an alternative treatment of temporomandibular joint pain. Acta
Odontologica Scandinavica 1996;54(3):154-9.
22. Minakuchi H, Kuboki T, Maekawa K, Matsuka Y, H HY. Self-reported remission, difficulty, and satisfaction with nonsurgical
therapy used to treat anterior disc displacement without reduction. Oral Surgery Oral Medicine Oral Pathology Oral Radiology
& Endodontics 2004;98(4):435-40.
23. Svensson P, Houe L, Arendt-Nielsen L. Effect of systemic versus topical nonsteroidal anti-inflammatory drugs on postexercise
jaw-muscle soreness: a placebo-controlled study. J Orofac Pain 1997;Fall;11(4):353-62.
24. Di Rienzo Businco L, Di Rienzo Businco A, D'Emilia M, Lauriello M, Coen Tirelli G. Topical versus systemic diclofenac in the
treatment of temporo-mandibular joint dysfunction symptoms. Acta Otorhinolaryngologica Italica 2004;24(5):279-83.
25. Ta LE, Dionne RA. Treatment of painful temporomandibular joints with a cyclooxygenase-2 inhibitor: a randomized placebo-
controlled comparison of celecoxib to naproxen. Pain 2004;111(1-2):13-21.
26. Ganzberg S, Quek SYP. Pharmacotherapy. In: Pertes RA, Gross SG, editors. Clinical management of temporomandibular
disorders and orofacial pain. Chicago: Quintessence; 1995. p. 211-26.
27. Okeson JP. Management of Temporomandibular Disorders and Occlusion. 4th ed. St. Louis: CV Mosby Co; 1998. p. 372.
28. Pettengill CA, Reisner-Keller L. The use of tricyclic antidepressants for the control of chronic orofacial pain. Cranio
1997;15(1):53-6.
29. Kreisberg MK. Tricyclic antidepressants: analgesic effect and indications in orofacial pain. J Craniomandib Disord
1988;2(4):171-7.
30. Watson CP. Antidepressant drugs as adjuvant analgesics. J Pain Symptom Manage 1994;9(6):392-405.
31. Brazeau GA, Gremillion HA, Widmer CG, Mahan PE, Benson MB, Mauderli AP, et al. The role of pharmacy in the
management of patients with temporomandibular disorders and orofacial pain. J Am Pharm Assoc (Wash) 1998;38(3):354-61;
quiz 62-3.
32. Kreisberg MK. Headache as a symptom of craniomandibular disorders. II: Management. Cranio 1986;4(3):219-28.
33. Sindrup SH, Jensen TS. Efficacy of pharmacological treatments of neuropathic pain: an update and effect related to
mechanism of drug action. Pain 1999;83(3):389-400.

296
34. Freundlich B, Leventhal L. Diffuse Pain Syndromes. In: Klippel JH, Weyand CM, Wortmann RL, editors. Primer on the
Rheumatic Disease. Atlanta: Arthritis Foundation; 1997. p. 123-7.
35. Atack J. Anxioselective compounds acting at the GABA(A) receptor benzodiazepine binding site. CNS & Neurological
Disorders - Drug Targets 2003;2(4):213-23.
36. Hansen HC. Treatment of chronic pain with antiepileptic drugs: a new era. South Med J 1999;92(7):642-9.
37. Okeson JP. Management of Temporomandibular Disorders and Occlusion. 4th ed. St. Louis: CV Mosby Co; 1998. p. 371.
38. Friedman AP, Boyles WF, Elkind AH, Fillingim J, Ford RG, Gallagher RM, et al. Fiorinal with codeine in the treatment of
tension headache--the contribution of components to the combination drug. Clin Ther 1988;10(3):303-15.
39. Friedman AP, DiSerio FJ. Symptomatic treatment of chronically recurring tension headache: a placebo-controlled, multicenter
investigation of Fioricet and acetaminophen with codeine. Clinical Therapeutics 1987;10(1):69-81.
40. Tepper S, Rapoport AM. The Triptans - A Summary. CNS Drugs 1999;12(5):403-17.
41. Dao TT, Lund JP, Remillard G, Lavigne GJ. Is myofascial pain of the temporal muscles relieved by oral sumatriptan? A cross-
over pilot study. Pain 1995;62(2):241-4.
42. Brennum J, Kjeldsen M, Olesen J. The 5-HT1-like agonist sumatriptan has a significant effect in chronic tension-type
headache. Cephalalgia 1992;12(6):375-9.
43. Leeb BF, Schweitzer H, Montag K, Smolen JS. A metaanalysis of chondroitin sulfate in the treatment of osteoarthritis. J
Rheumatol 2000;27(1):205-11.
44. McAlindon TE, Gulin J, Felson DT. Glucosamine and chondroitin treatment for osteoarthritis of the knee or hip: Meta-analysis
and quality assessment of clinical trials. Arthritis Rheum 1998;41:S198, abstract 994.
45. Towheed TE. Glucosamine sulphate in osteoarthritis: A systematic review. Arthritis Rheum 1998;41:S198, abstract 995.
46. Qiu GX, Gao SN, Giacovelli G, Rovati L, Setnikar I. Efficacy and safety of glucosamine sulfate versus ibuprofen in patients
with knee osteoarthritis. Arzneimittelforschung 1998;48(5):469-74.
47. Drovanti A, Bignamini AA, Rovati AL. Therapeutic activity of oral glucosamine sulfate in osteoarthrosis: a placebo-controlled
double-blind investigation. Clin Ther 1980;3(4):260-72.
48. Clegg D, Reda, DJ, Harris, CL, Klein, MA, O'Dell, JR, Hooper, MM, Bradley, JD, Bingham, CO 3rd, Weisman, MH, Jackson,
CG, Lane, NE, Cush, JJ, Moreland, LW, Schumacher, HR Jr, Oddis, CV, Wolfe, F, Molitor, JA, Yocum, DE, Schnitzer, TJ,
Furst, DE, Sawitzke, AD, Shi, H, Brandt, KD, Moskowitz, RW, Williams, HJ. Glucosamine, chondroitin sulfate, and the two in
combination for painful knee osteoarthritis. New Engl J Med 2006;354(8):795-808.
49. Lobo SL, Mehta N, Forgione AG, Melis M, Al-Badawi E, Ceneviz C, et al. Use of Theraflex-TMJ topical cream for the treatment
of temporomandibular joint and muscle pain. Cranio 2004;22(2):137-44.
50. Winocur E, Gavish A, Halachmi M, Eli I, Gazit E. Topical application of capsaicin for the treatment of localized pain in the
temporomandibular joint area. J Orofac Pain 2000;14(1):31-6.
51. Perry R. Focus on Nicotine and Caffeine. . New York: Troll Associates; 1990.
52. Migliardi JR, Armellino JJ, Friedman M, Gillings DB, Beaver WT. Caffeine as an analgesic adjuvant in tension headache. Clin
Pharmacol Ther 1994;56(5):576-86.
53. Hofer I, Battig K. Cardiovascular, behavioral, and subjective effects of caffeine under field conditions. Pharmacology,
Biochemistry & Behavior 1994;48(4):899-908.
54. White B, Lincoln CA, Pearce NW. Anxiety and muscle tension as consequences of caffeine withdrawal. Science
1980;209:1547-48.
55. Padilla M, Clark GT, Merrill RL. Topical medications for orofacial neuropathic pain: a review. J Am Dent Assoc
2000;131(2):184-95.
56. Quek S. Treating masseter trigger points with a peripheral nerve block: a novel idea worth considering. AAOP News
1999;5(1):12-3.
57. Ashina M, Lassen LH, Bendtsen L, Jensen R, Olesen J. Effect of inhibition of nitric oxide synthase on chronic tension-type
headache: a randomised crossover trial. Lancet 1999;353(9149):287-9.
58. Ribeiro CA. L-5-Hydroxytryptophan in the prophylaxis of chronic tension-type headache: a double-blind, randomized, placebo-
controlled study. For the Portuguese Head Society. Headache 2000;40(6):451-6.
59. Fricton J, Look, JO, Wright, E, Alencar, F, Chen, H, Lang, M, Ouyang, W, Velly, AM. Systematic Review of Intraoral
Orthopedic Appliances and Occlusal Treatment for Temporomandibular Disorders: 55 RCTs reviewed. J Orofacial Pain
2007;in review.
60. Fricton J N, DR, Schiffman, EL, Ouyang, W, Velly, AM, Look, JO. Critical Appraisal of Methods used in Randomized
Controlled Trials of Treatments for Temporomandibular Disorders. J. Orofacial Pain 2007;(In Review).
61. Al-Hasson HK, Ismail AI, Jr. Ash MM. Concerns of patients seeking treatment for TMJ dysfunction. J Prosthet Dent
1986;56:217-21.
62. Dworkin SF, Huggins KH, Wilson L, Mancl L, Turner J, Massoth D, et al. A randomized clinical trial using research diagnostic
criteria for temporomandibular disorders-axis II to target clinic cases for a tailored self-care TMD treatment program. J Orofac
Pain 2002;16(6):48-63.
63. Fricton J, Look J, Wright E, Niederman R, Alencar F, Chen H, et al. Systematic Review of Intraoral Orthopedic Appliance and
Occlusal Treatment for Temporomandibular Disorders: 51 RCTs reviewed. 2006.
64. Chinn S. A simple method for converting odds ratio to effect size for use in meta-analysis. Stat Med 2000;19:3127-31.
65. Higgins JP, Green S. Cochrane Handbook for Systematic Reviews of Interventions 4.2.5 (updated May 2005). Appendix 8b;
2005.
66. Jager RG, Absi EG. A comparison of naproxen and placebo in the treatment of temporomandibular joint dysfunction. J Orofac
Pain 1995;9(1):105.
297
67. Reisner-Keller LA. Pharmacotherapeutics in the management of orofacial pain. Dent Clin North Am 1997;41(2):259-78.
68. Bendtsen L, Jensen R, Olesen J. A non-selective (amitriptyline), but not a selective (citalopram), serotonin reuptake inhibitor is
effective in the prophylactic treatment of chronic tension-type headache. J Neurol Neurosurg Psychiatry 1996;61(3):285-90.
69. Gobel H, Hamouz V, Hansen C, Heininger K, Hirsch S, Lindner V, et al. Chronic tension-type headache: amitriptyline reduces
clinical headache-duration and experimental pain sensitivity but does not alter pericranial muscle activity readings. Pain
1994;59(2):241-9.
70. Holroyd KA, Nash JM, Pingel JD, Cordingley GE, Jerome A. A comparison of pharmacological (amitriptyline HCL) and
nonpharmacological (cognitive-behavioral) therapies for chronic tension headaches. J Consult Clin Psychol 1991;59(3):387-
93.
71. Holroyd KA, O'Donnell FJ, Stensland M, Lipchik GL, Cordingley GE, Carlson BW. Management of chronic tension-type
headache with tricyclic antidepressant medication, stress management therapy, and their combination: a randomized
controlled trial. J. American Medical Association 2001;285(17):2208-15.
72. Langemark M, Loldrup D, Bech P, Olesen J. Clomipramine and mianserin in the treatment of chronic tension headache. A
double-blind, controlled study. Headache 1990;30(3):118-21.
73. Pfaffenrath V, Diener HC, Isler H, Meyer C, Scholz E, Taneri Z, et al. Efficacy and tolerability of amitriptylinoxide in the
treatment of chronic tension-type headache: a multi-centre controlled study. Cephalalgia 1994;14(2):149-55.
74. Sharav Y, Singer E, Schmidt E, Dionne RA, Dubner R. The analgesic effect of amitriptyline on chronic facial pain. Pain
1987;31(2):199-209.
75. Rizzatti-Barbosa CM, Nogueira MT, de Andrade ED, Ambrosano GM, de Barbosa JR. Clinical evaluation of amitriptyline for
the control of chronic pain caused by temporomandibular joint disorders. Cranio. 2003;Jul;21(3):221-5.
76. Boline PD, Kassak K, Bronfort G, Nelson C, Anderson AV. Spinal manipulation vs. amitriptyline for the treatment of chronic
tension-type headaches: a randomized clinical trial. J Manipulative Physiol Ther 1995;18(3):148-54.
77. Bendtsen L, Jensen R. Mirtazapine is effective in the prophylactic treatment of chronic tension-type headache. Neurology
2004;62(10):1706-11.
78. Saper JR, Silberstein SD, Lake AE, 3rd, Winters ME. Double-blind trial of fluoxetine: chronic daily headache and migraine.
Headache 1994;34(9):497-502.
79. Manna V, Bolino F, Di Cicco L. Chronic tension-type headache, mood depression and serotonin: therapeutic effects of
fluvoxamine and mianserine. Headache 1994;34(1):44-9.
80. Mitsikostas DD, Gatzonis S, Thomas A, Ilias A. Buspirone vs amitriptyline in the treatment of chronic tension-type headache.
Acta Neurol Scand 1997;96(4):247-51.
81. Nappi G, Sandrini G, Granella F, Ruiz L, Cerutti G, Facchinetti F, et al. A new 5-HT2 antagonist (ritanserin) in the treatment of
chronic headache with depression. A double-blind study vs amitriptyline. Headache 1990;30(7):439-44.
82. Harkins S, Linford J, Cohen J, Kramer T, Cueva L. Administration of clonazepam in the treatment of TMD and associated
myofascial pain: a double-blind pilot study. J Craniomandib Disord 1991;5(3):179-86.
83. DeNucci DJ, Sobiski C, Dionne RA. Triazolam improves sleep but fails to alter pain in TMD patients. J Orofac Pain
1998;12(2):116-23.
84. Herman CR, Schiffman EL, Look JO, Rindal DB. The effectiveness of adding pharmacologic treatment with clonazepam or
cyclobenzaprine to patient education and self-care for the treatment of jaw pain upon awakening: a randomized clinical trial. J
Orofac Pain 2002;16(1):64-70.
85. Singer E, Dionne R. A controlled evaluation of ibuprofen and diazepam for chronic orofacial muscle pain. J Orofac Pain
1997;11(2):139-46.
86. Rizzatti-Barbosa CM, Martinelli DA, Ambrosano GM, de Albergaria-Barbosa JR. Therapeutic response of benzodiazepine,
orphenadrine citrate and occlusal splint association in TMD pain. Cranio 2003;Apr;21(2):116-20.
87. Fogelholm R, Murros K. Tizanidine in chronic tension-type headache: a placebo controlled double-blind cross-over study.
Headache 1992;32:509-13.
88. Murros K, Kataja M, Hedman C, Havanka H, Sako E, Farkkila M, et al. Modified-release formulation of tizanidine in chronic
tension-type headache. Headache 2000;40:633-37.
89. Nguyen P, Mohamed SE, Gardiner D, Salinas T. A randomized double-blind clinical trial of the effect of chondroitin sulfate and
glucosamine hydrochloride on temporomandibular joint disorders: a pilot study. Cranio 2001;19(2):130-9.
90. Thie NM, Prasad NG, Major PW. Evaluation of glucosamine sulfate compared to ibuprofen for the treatment of
temporomandibular joint osteoarthritis: a randomized double blind controlled 3 month clinical trial. J Rheumatol.
2001;28(6):1347-55.
91. Clegg DO, Reda DJ, Harris CL, Klein MA, O'Dell JR, Hooper MM, et al. Glucosamine, chondroitin sulfate, and the two in
combination for painful knee osteoarthritis. N Engl J Med. 2006;354(8):795-808.
92. Zitman FG, Linssen ACG, Edelbroek PM, Stijnen T. Low dose amitriptyline in chronic pain: the gain is modest. Pain
1990;42:35-42.
93. Fricton JN, Nixdorf DR, Schiffman EL, Ouyang W, Velly AM, Look JO. Critical Appraisal of Methods used in Randomized
Controlled Trials of Treatments for Temporomandibular Disorders. J. Orofacial Pain 2007;(submitted).
94. Forssell H, Tasmuth T, Tenovuo O, Hampf G, Kalso E. Venlafaxine in the treatment of atypical facial pain: a randomized
controlled trial. Journal of Orofacial Pain 2004;18(2):131-7.
95. Talaat AM, El-Dibany MM, A. E-G. Physical therapy in the management of myofacial pain dysfunction syndrome. Ann Otol
Rhinol Laryngol 1986;95(3 Pt 1):225-8.

298
 Cognitive-behavioral/ psychological therapy
1. Management of temporomandibular disorders. National Institutes of Health Technology Assessment Conference Statement. J
Am Dent Assoc 1996;127(11):1595-606.
2. Carrobles JA, Cardona A, Santacreu J. Shaping and generalization procedures in the EMG-biofeedback treatment of tension
headaches. Br J Clin Psychol 1981;20(Pt 1):49-56.
3. Arena JG, Bruno GM, Hannah SL, Meador KJ. A comparison of frontal electromyographic biofeedback training, trapezius
electromyographic biofeedback training, and progressive muscle relaxation therapy in the treatment of tension headache.
Headache 1995;35(7):411-9.
4. Loew TH, Sohn R, Martus P, Tritt K, Rechlin T. Functional relaxation as a somatopsychotherapeutic intervention: a
prospective controlled study. Alternative Therapies in Health & Medicine. 2000;6(6):70-5.
5. Larsson B, Carlsson J, Fichtel A, Melin L. Relaxation treatment of adolescent headache sufferers: results from a school-based
replication series. Headache 2005;45(6):692-704.
6. Larsson B, Melin L, Doberl A. Recurrent tension headache in adolescents treated with self-help relaxation training and a
muscle relaxant drug. Headache 1990;30(10):665-71.
7. Blanchard EB, Appelbaum KA, Radnitz CL, Michultka D, Morrill B, Kirsch C, et al. Placebo-controlled evaluation of abbreviated
progressive muscle relaxation and of relaxation combined with cognitive therapy in the treatment of tension headache. J
Consult Clin Psychol 1990;58(2):210-5.
8. Komiyama O, Kawara M, Arai M, Asano T, Kobayashi K. Posture correction as part of behavioural therapy in treatment of
myofascial pain with limited opening. Journal of Oral Rehabilitation. 1999;26(5):428-35.
9. Turk DC, Rudy TE, Kubinski JA, Zaki HS, Greco CM. Dysfunctional patients with temporomandibular disorders: evaluating the
efficacy of a tailored treatment protocol. J Consult Clin Psychol 1996;64(1):139-46.
10. Dworkin SF, Huggins KH, Wilson L, Mancl L, Turner J, Massoth D, et al. A randomized clinical trial using research diagnostic
criteria for temporomandibular disorders-axis II to target clinic cases for a tailored self-care TMD treatment program. J Orofac
Pain 2002;16(6):48-63.
11. Turner JA, Mancl L, Aaron LA. Brief cognitive-behavioral therapy for temporomandibular disorder pain: effects on daily
electronic outcome and process measures. Pain 2005;117(3):377-87.
12. Flor H, Birbaumer N. Comparison of the efficacy of electromyographic biofeedback, cognitive-behavioral therapy, and
conservative medical interventions in the treatment of chronic musculoskeletal pain. J Consult Clin Psychol 1993;61(4):653-8.
13. Devineni T, Blanchard EB. A randomized controlled trial of an internet-based treatment for chronic headache. Behaviour
Research & Therapy 2005;43(3):277-92.
14. Holroyd KA, Nash JM, Pingel JD, Cordingley GE, Jerome A. A comparison of pharmacological (amitriptyline HCL) and
nonpharmacological (cognitive-behavioral) therapies for chronic tension headaches. J Consult Clin Psychol 1991;59(3):387-
93.
15. Foster KA, Liskin J, Cen S, Abbott A, Armisen V, Globe D, et al. The Trager approach in the treatment of chronic headache: a
pilot study. Alternative Therapies in Health & Medicine 2004;10(5):40-6.
16. Fricton J N, DR, Schiffman, EL, Ouyang, W, Velly, AM, Look, JO. Critical Appraisal of Methods used in Randomized
Controlled Trials of Treatments for Temporomandibular Disorders. J. Orofacial Pain 2007;(In Review).
17. Al-Hasson HK, Ismail AI, Jr. Ash MM. Concerns of patients seeking treatment for TMJ dysfunction. J Prosthet Dent
1986;56:217-21.
18. Fricton J, Look J, Wright E, Niederman R, Alencar F, Chen H, et al. Systematic Review of Intraoral Orthopedic Appliance and
Occlusal Treatment for Temporomandibular Disorders: 51 RCTs reviewed. 2006.
19. Chinn S. A simple method for converting odds ratio to effect size for use in meta-analysis. Stat Med 2000;19:3127-31.
20. Higgins JP, Green S. Cochrane Handbook for Systematic Reviews of Interventions 4.2.5 (updated May 2005). Appendix 8b;
2005.
21. Rokicki LA, Holroyd KA, France CR, Lipchik GL, France JL, Kvaal SA. Change mechanisms associated with combined
relaxation/EMG biofeedback training for chronic tension headache. Applied Psychophysiology & Biofeedback. 1997;22(1):21-
41.
22. Bussone G, Grazzi L, D'Amico D, Leone M, Andrasik F. Biofeedback-assisted relaxation training for young adolescents with
tension-type headache: a controlled study. Cephalalgia 1998;18(7):463-7.
23. Gale EN, Funch DP. Factors associated with successful outcome from behavioral therapy for chronic temporomandibular joint
(TMJ) pain. Journal of Psychosomatic Research 1984;28(6):441-8.
24. Erlandsson SI, Rubinstein B, Carlsson SG. Tinnitus: evaluation of biofeedback and stomatognathic treatment. Br J Audiol
1991;25(3):151-61.
25. Turk DC, Zaki HS, Rudy TE. Effects of intraoral appliance and biofeedback/stress management alone and in combination in
treating pain and depression in patients with temporomandibular disorders. J Prosthet Dent 1993;Aug;70(2):158-64.
26. Bruhn P, Olesen J, Melgaard B. Controlled trial of EMG feedback in muscle contraction headache. Ann Neurol 1979;6(1):34-6.
27. Wahlund K, List T, Larsson B. Treatment of temporomandibular disorders among adolescents: a comparison between occlusal
appliance, relaxation training, and brief information. Acta Odontol Scand 2003;61;Aug(4):203-11.
28. VanDyck R, Zitman FG, Linssen AC, Spinhoven P. Autogenic training and future oriented hypnotic imagery in the treatment of
tension headache: outcome and process. Int J Clin Exp Hypn 1991;39(1):6-23.
29. Fichtel A, Larsson B. Relaxation treatment administered by school nurses to adolescents with recurrent headaches. Headache
2004;44(6):545-54.

299
30. Wylie KR, Jackson C, Crawford PM. Does psychological testing help to predict the response to acupuncture or
massage/relaxation therapy in patients presenting to a general neurology clinic with headache? Journal of Traditional Chinese
Medicine. 1997;17(2):130-9.
31. Elliot NG, Donna PF. Factors associated with successful outcome from behavioral therapy for chronic temporomandibular joint
(TMJ) pain. Journal of Psychosomatic Research 1984;28(6):441-8.

Temporomandibular joint surgery

1. Fricton JR, Nixdorf DR, Schiffman EL, Look JO, Ouyang W. Critical Appraisal of Methods in Randomized Controlled Trials for
Temporomandibular Disorders. 2006.
2. Al-Hasson HK, Ismail AI, Jr. Ash MM. Concerns of patients seeking treatment for TMJ dysfunction. J Prosthet Dent
1986;56:217-21.
3. Fricton J, Look, JO, Wright, E, Alencar, F, Chen, H, Lang, M, Ouyang, W, Velly, AM. Systematic Review of Intraoral
Orthopedic Appliances and Occlusal Treatment for Temporomandibular Disorders: 55 RCTs reviewed. J Orofacial Pain
2007;in review.
4. Chinn S. A simple method for converting odds ratio to effect size for use in meta-analysis. Stat Med 2000;19:3127-31.
5. Higgins JP, Green S. Cochrane Handbook for Systematic Reviews of Interventions 4.2.5 (updated May 2005). Appendix 8b;
2005.
6. Management of temporomandibular disorders. National Institutes of Health Technology Assessment Conference Statement. J
Am Dent Assoc 1996;127(11):1595-606.
7. Okeson J. Orofacial Pain: Guidelines for Assessment, Diagnosis, and Management: Quintessence Publishing; 1996.
8. Fridrich KL, Wise JM, Zeitler DL. Prospective comparison of arthroscopy and arthrocentesis for temporomandibular joint
disorders. J Oral Maxillofac Surg 1996;54(7):816-20; discussion 21.
9. Petersson A, Eriksson L, Lundh H. No short-term difference in outcome after temporomandibular joint arthrography alone or
with immediate lavage. Oral Surg Oral Med Oral Pathol 1994;77(4):322-6.
10. Stegenga B, de Bont LG, Dijkstra PU, Boering G. Short-term outcome of arthroscopic surgery of temporomandibular joint
osteoarthrosis and internal derangement: a randomized controlled clinical trial. Br J Oral Maxillofac Surg 1993;31(1):3-14.
11. McNamara DC, Rosenberg I, Jackson PA, Hogben J. Efficacy of arthroscopic surgery and midlaser treatments for chronic
temporomandibular joint articular disc derangement following motor vehicle accident. Aust Dent J 1996;41(6):377-87.
12. Miyamoto H, Sakashita H, Miyata M, Goss AN. Arthroscopic surgery of the temporomandibular joint: comparison of two
successful techniques. Br J Oral Maxillofac Surg 1999;37(5):397-400.
13. Holmlund AB, Axelsson S, Gynther GW. A comparison of discectomy and arthroscopic lysis and lavage for the treatment of
chronic closed lock of the temporomandibular joint: a randomized outcome study. Journal of Oral & Maxillofacial Surgery
2001;59(9):972-7; discussion 77-8.
14. Schiffman EL, Look JO, Fricton JR, Hodges JS, Swift JQ, Decker KL, et al. A Randomized Clinical Trial Evaluating Four
Treatment Strategies for Patients with Temporomandibular Joint Disc Displacement without Reduction with Limited Mouth
Opening. (in review) 2005.
15. Kuwahara T, Bessette RW, Maruyama T. A retrospective study on the clinical results of temporomandibular joint surgery.
Cranio 1994;Jul;12(3):179-83.
16. FDA. FDA Safety Alert: Serious Problems with PROPLAST-Coated TMJ Implant. Rockville, MD: Department of Health &
Human Services; 1992.
17. TMJ implant advisory. Journal of Oral & Maxillofacial Surgery 1992;50(10):1148-9.
18. Burgess J, Sommers E, Truelove E, Dworkin S. Short-term effect of two therapeutic methods on myofascial pain and
dysfunction of the masticatory system. J Prosthet. Dent 1988;60(5):606-10.
19. Dall Arancio D, Fricton J. Randomized controlled study of exercises for masticatory myofascial pain. J. Orofac. Pain
1993;7(1):117.
20. Minakuchi H, Kuboki T, Maekawa K, Matsuka Y, H HY. Self-reported remission, difficulty, and satisfaction with nonsurgical
therapy used to treat anterior disc displacement without reduction. Oral Surgery Oral Medicine Oral Pathology Oral Radiology
& Endodontics 2004;98(4):435-40.
21. Shata R, Mehta NR, Forgione AG. Active resistance exercise for TMD related tension pain. J Dent Res 2000;79(special
issue):abstract 3541.
22. Torelli P, Jensen R, Olesen J. Physiotherapy for tension-type headache: a controlled study. Cephalalgia 2004;24(1):29-36.
23. Wright EF, Domenech MA, Fischer JR, Jr. Usefulness of posture training for patients with temporomandibular disorders.
Journal of the American Dental Association 2000;131(2):202-10.
24. Buchbinder D, Currivan RB, Kaplan AJ, Urken ML. Mobilization regimens for the prevention of jaw hypomobility in the radiated
patient: a comparison of three techniques. Journal of Oral and & Maxillofacial Surgery 1993;51(8):863-7.
25. Grace EG, Sarlani D, Read B. The use of an oral exercise device in the treatment of muscular TMD. J. Cranio. Practice
2002;July;20(3):204-8.
26. Komiyama O, Kawara M, Arai M, Asano T, Kobayashi K. Posture correction as part of behavioural therapy in treatment of
myofascial pain with limited opening. Journal of Oral Rehabilitation. 1999;26(5):428-35.
27. Magnusson T, Syren M. Therapeutic jaw exercises and interocclusal appliance therapy. A comparison between two common
treatments of temporomandibular disorders. Swedish Dental Journal 1999;23(1):27-37.
28. Maloney GE, Mehta N, Forgione AG, Zawawi KH, Al-Badawi EA, Driscoll SE. Effect of a Passive Jaw Motion Device on Pain
and Range of Motion in TMD patients not responding to flat plane intraoral appliances. J. Cranio. Prac. 2002;20(1):55-65.
300
29. Michellotti A, Steenks MH, Farella M, Parisiani F, Cimino R, Martina R. The additional value of a home physical therapy
regimen versus patient education only for treatment of myofascial pain of the jaw muscles: short-term results of a randomized
clinical trial. J. Orofacial Pain 2004;18(2):114-25.
30. Yoda R, Sakamoto I, Imai H, Honma Y, Shinjo Y, Takano A, et al. A randomized controlled trial of therpeutic exercise for
clicking due to disk anterior displacement with reduction in the temporomandibular joint. Cranio 2003;21(1):10-16.
31. Cheshire WP, Abashian SW, Mann JD. Botulinum toxin in the treatment of myofascial pain syndrome. Pain 1994;59(1):65-9.
32. Ferrante FM, Bearn L, Rothrock R, King L. Evidence against trigger point injection technique for the treatment of
cervicothoracic myofascial pain with botulinum toxin type A.(see comment). Anesthesiology 2005;103(2):377-83.
33. Kamanli A, Kaya A, Ardicoglu O, Ozgocmen S, Zengin FO, Bayik Y. Comparison of lidocaine injection, botulinum toxin
injection, and dry needling to trigger points in myofascial pain syndrome. Rheumatology International 2005;25(8):604-11.
34. Kokoska MS, Glaser DA, Burch CM, Hollenbeak CS. Botulinum toxin injections for the treatment of frontal tension headache. J
Headache Pain 2004;5:103-09.
35. Mathew NT, Frishberg BM, Gawel M, Dimitrova R, Gibson J, Turkel C, et al. Botulinum toxin type A (BOTOX) for the
prophylactic treatment of chronic daily headache: a randomized, double-blind, placebo-controlled trial. Headache
2005;45(4):293-307.
36. Nixdorf DR, Heo G, Major PW. Randomized controlled trial of botulinum toxin A for chronic myogenous orofacial pain. Pain
2002;Oct;99(3):465-73.
37. Ondo WG, Vuong KD, Derman HS. Botulinum toxin A for chronic daily headache: a randomized, placebo-controlled, parallel
design study. Cephalalgia 2004;24(1):60-5.
38. Padberg M, Bruijn Sd, Haan Rd, Tavy D. Treatment of chronic tension-type headache with botulinum toxin: a double-blind,
placebo-controlled clinical trial. Cephalalgia 2004;24(8):675-80.
39. Relja M, Telarovic S. Botulinum toxin in tension-type headache. Journal of Neurology 2004;251 Suppl 1:I12-4.
40. Rollnik JD, Tanneberger O, Schubert M, Schneider U, Dengler R. Treatment of tension-type headache with botulinum toxin
type A: a double-blind, placebo-controlled study. Headache 2000;40(4):300-5.
41. Schmitt WJ, Slowey E, Fravi N, Weber S, Burgunder JM. Effect of botulinum toxin A injections in the treatment of chronic
tension-type headache: a double-blind, placebo-controlled trial. Headache 2001;2001 Jul-Aug;41(7):658-64.
42. Schulte-Mattler WJ, Krack P, BoNTTH. Treatment of chronic tension-type headache with botulinum toxin A: a randomized,
double-blind, placebo-controlled multicenter study.(see comment). Pain 2004;109(1-2):110-4.
43. Silberstein SD, Stark SR, Lucas SM, Christie SN, DeGryse RE, Turkel CC, et al. Botulinum toxin type A for the prophylactic
treatment of chronic daily headache: a randomized, double-blind, placebo-controlled trial.(see comment). Mayo Clinic
Proceedings 2005;80(9):1126-37.
44. von Lindern JJ, Niederhagen D, Berge S, T Appel T. Type A botulinum toxin in the treatment of chronic facial pain associated
with masticatory hyperactivity. J Oral Maxillofac Surg 2003;Jul;61(7):774-8.
45. Hong CZ. Lidocaine injection versus dry needling to myofascial trigger point. The importance of the local twitch response.
American Journal of Physical Medicine & Rehabilitation 1994;73(4):256-63.
46. McMillan AS, Nolan A, Kelly PJ. The efficacy of dry needling and procaine in the treatment of myofascial pain in the jaw
muscles. Journal of Orofacial Pain 1997;11(4):307-14.
47. Muller W, Stratz T. Local treatment of tendinopathies and myofascial pain syndromes with the 5-HT3 receptor antagonist
tropisetron. Scandinavian Journal of Rheumatology - Supplement 2004(119):44-8.
48. Tschopp KP, Gysin C. Local injection therapy in 107 patients with myofascial pain syndrome of the head and neck. Orl;
Journal of Oto-Rhino-Laryngology & its Related Specialties 1996;58(6):306-10.
49. Bertolami CN, Gay T, Clark GT, Rendell J, Shetty V, Liu C, et al. Use of sodium hyaluronate in treating temporomandibular
joint disorders: a randomized, double-blind, placebo-controlled clinical trial. Journal of Oral & Maxillofacial Surgery
1993;51(3):232-42.
50. Bryant CJ, Harrison SD, Hopper C, Harris M. Use of intra-articular morphine for postoperative analgesia following TMJ
arthroscopy. British Journal of Oral & Maxillofacial Surgery 1999;37(5):391-6.
51. Kopp S, Wenneberg B, Haraldson T, Carlsson GE. The short-term effect of intra-articular injections of sodium hyaluronate and
corticosteroid on temporomandibular joint pain and dysfunction. Journal of Oral & Maxillofacial Surgery 1985;43(6):429-35.
52. Kopp S, Carlsson GE, Haraldson T, Wenneberg B. Long-term effect of intra-articular injections of sodium hyaluronate and
corticosteroid on temporomandibular joint arthritis. Journal of Oral & Maxillofacial Surgery 1987;45(11):929-35.
53. Kopp S, Akerman S, Nilner M. Short-term effects of intra-articular sodium hyaluronate, glucocorticoid, and saline injections on
rheumatoid arthritis of the temporomandibular joint. Journal of Craniomandibular Disorders 1991;5(4):231-8.
54. Gray RJ, Quayle AA, Hall CA, Schofield MA. Physiotherapy in the treatment of temporomandibular joint disorders: a
comparative study of four treatment methods. British Dental Journal 1994;176(7):257-61.
55. Karkow M, Schiffman EL, Decker K, Fricton J, Schulte J. Temporomandibular joint (TMJ) iontophoresis: A double-blinded
randomized clinical trial. J Orofac Pain 1997;11(2):182-3.
56. Reid KI, Dionne RA, Sicard-Rosenbaum L, Lord D, Dubner RA. Evaluation of iontophoretically applied dexamethasone for
painful pathologic temporomandibular joints. Oral Surgery, Oral Medicine, Oral Pathology 1994;77(6):605-9.
57. Schiffman EL, Braun BL, Lindgren BR. Temporomandibular joint iontophoresis: a double-blind randomized clinical trial. Journal
of Orofacial Pain 1996;10(2):157-65.
58. Shin SM, Choi JK. Effect of indomethacin phonophoresis on the relief of temporomandibular joint pain. Cranio 1997;15(4):345-
8.
59. Ahmed HE, White PF, Craig WF, Hamza MA, Ghoname ES, Gajraj NM. Use of percutaneous electrical nerve stimulation
(PENS) in the short-term management of headache. Headache 2000;40(4):311-5.
301
60. Bertolucci LE, Grey T. Clinical comparative study of microcurrent electrical stimulation to mid-laser and placebo treatment in
degenerative joint disease of the temporomandibular joint. Cranio 1995;13(2):116-20.
61. Farina S, Casarotto M, Benelle M, Tinazzi M, Fiaschi A, Goldoni M, et al. A randomized controlled study on the effect of two
different treatments (FREMS and TENS) in myofacial pain sydrome. Eur Med Phys 2004(40):293-301.
62. Hansson P, Ekblom A. Transcutaneous electrical nerve stimulation (TENS) as compared to placebo TENS for the relief of
acute oro-facial pain. Pain 1983;15(2):157-65.
63. Kruger LR, van der Linden WJ, Cleaton-Jones PE. Transcutaneous electrical nerve stimulation in the treatment of myofascial
pain dysfunction. South African Journal of Surgery 1998;36(1):35-8.
64. Linde C, Isacsson G, Jonsson BG. Outcome of 6-week treatment with transcutaneous electric nerve stimulation compared with
splint on symptomatic temporomandibular joint disk displacement without reduction. Acta Odontologica Scandinavica
1995;53(2):92-8.
65. Peroz I, Chun Y-H, Karageorgi G, Schwerin C, Bernhardt O, Roulet J-F, et al. A multicenter clinical trial on the use of pulsed
electromagnetic fields in the treatment of temporomandibular disorders. Journal of Prosthetic Dentistry 2004;91(2):180-7.
66. Reich BA. Non-invasive treatment of vascular and muscle contraction headache: a comparative longitudinal clinical study.
Headache 1989;29(1):34-41.
67. Smania N, Corato E, Fiaschi A, Pietropoli P, Aglioti SM, Tinazzi M. Repetitive magnetic stimulation: a novel therapeutic
approach for myofascial pain syndrome. Journal of Neurology 2005;252(3):307-14.
68. Treacy K. Awareness/relaxation training and transcutaneous electrical neural stimulation in the treatment of bruxism. Journal
of Oral Rehabilitation 1999;26(4):280-7.
69. Altan L, Bingol U, Aykac M. Investigation of the effect of GaAs laser therapy on cervical myofascial pain syndrome.
Rheumatology International 2005;25(1):23-7.
70. Bertolucci LE, Grey T. Clinical analysis of mid-laser versus placebo treatment of arthralgic TMJ degenerative joints. Cranio
1995;13(1):26-9.
71. Ceccherelli F, Altafini L, Lo Castro G, Avila A, Ambrosio F, Giron GP. Diode laser in cervical myofascial pain: a double-blind
study versus placebo. Clinical Journal of Pain 1989;5(4):301-4.
72. Ceylan Y, Hizmetli S, Silig Y. The effects of infrared laser and medical treatments on pain and serotonin degradation products
in patients with myofascial pain syndrome. A controlled trial. Rheumatology International 2004;24(5):260-3.
73. Conti PC. Low level laser therapy in the treatment of temporomandibular disorders (TMD): a double-blind pilot study. Cranio
1997;15(2):144-9.
74. Gur A, Sarac AJ, Cevik R, Altindag O, Sarac S. Efficacy of 904 nm gallium arsenide low level laser therapy in the management
of chronic myofascial pain in the neck: a double-blind and randomize-controlled trial. Lasers in Surgery & Medicine
2004;35(3):229-35.
75. Kim YK, Chung SC, Kim YJ, Kim YW. Short-Term Effect of Laser Therapy on Temporomandibular Disorders. J Orofac Pain
1998(Abstract no.19).
76. Kulekcioglu S, Sivriolglu K, Ozcan O, Parlak M. Effectiveness of low-level laser therapy in temporomandibular disorders.
Scand. J Rheumatol 2003(32):114-8.
77. Ilbuldu E, Cakmak A, Disci R, Aydin R. Comparison of laser, dry needling, and placebo laser treatments in myofascial pain
syndrome. Photomedicine and Laser Surgery 2004;22(4):306-11.
78. Wenneberg B, Wennegberg A. Effects of Low Level Laser Therapy in Facial Muscular Pain. Journal of Dental Research
1998;77(Special Issue B):749.
79. Carlsson J, Fahlcrantz A, Augustinsson LE. Muscle tenderness in tension headache treated with acupuncture or
physiotherapy. Cephalalgia 1990;10(3):131-41.
80. Ebneshahidi NS, Heshmatipour M, Moghaddami A, Eghtesadi-Araghi P. The effects of laser acupuncture on chronic tension
headache--a randomised controlled trial. Acupuncture in Medicine 2005;23(1):13-8.
81. Elsharkawy TM, Ali NM. Evaluation of acupuncture and occlusal splint therapy in the treatment of temporomandibular joint
disorders. Egyptian Dental Journal 1995;41(3):1227-32.
82. Goddard G, Karibe H, McNeill C, Villafuerte E. Acupuncture and sham acupuncture reduce muscle pain in myofascial pain
patients. J Orofac Pain 2002;Winter;16(1):71-6.
83. Johansson A, Wenneberg B, Wagersten C, Haraldson T. Acupuncture in treatment of facial muscular pain. Acta Odontologica
Scandinavica 1991;49(3):153-8.
84. Karst M, Rollnik JD, Fink M, Reinhard M, Piepenbrock S. Pressure pain threshold and needle acupuncture in chronic tension-
type headache--a double-blind placebo-controlled study. Pain 2000;88(2):199-203.
85. List T, Helkimo M, Karlsson R. Pressure pain thresholds in patients with craniomandibular disorders before and after treatment
with acupuncture and occlusal splint therapy: a controlled clinical study. Journal of Orofacial Pain 1993;7(3):275-82.
86. Melchart D, Streng A, Hoppe A, Brinkhaus B, Witt C, Wagenpfeil S, et al. Acupuncture in patients with tension-type headache:
randomised controlled trial. BMJ 2005;331(7513):376-82.
87. Raustia AM. Diagnosis and treatment of temporomandibular joint dysfunction. Advantages of computed tomography diagnosis.
Stomatognathic treatment and acupuncture--a randomized trial. Proceedings of the Finnish Dental Society 1986;82(Suppl 9-
10):1-41.
88. Ritenbaugh C, Mist S, Hammerschlag R. Traditional Chinese medicine for tempromandibular dysfunction: a phase II whole
system RCT. Focus on Alternative and Complementary Therapies 2005(10(supplement 1)):45.
89. Vincent CA. The treatment of tension headache by acupuncture: a controlled single case design with time series analysis.
Journal of Psychosomatic Research 1990;34(5):553-61.

302
90. White AR, Resch KL, Chan JC, Norris CD, Modi SK, Patel JN, et al. Acupuncture for episodic tension-type headache: a
multicentre randomized controlled trial. Cephalalgia 2000;20(7):632-7.
91. Xue CCL, Dong L, Polus B, English RA, Zheng Z, Costa CD, et al. Electroacupuncture for tension-type headache on distal
acupoints only: a randomized, controlled, crossover trial. Headache 2004;44(4):333-41.
92. Ferrante FM, Kaufman AG, Dunbar SA, Cain CF, Cherukuri S. Sphenopalatine ganglion block for the treatment of myofascial
pain of the head, neck, and shoulders. Regional Anesthesia & Pain Medicine 1998;23(1):30-6.
93. Janzen VD, Scudds R. Sphenopalatine blocks in the treatment of pain in fibromyalgia and myofascial pain syndrome.
Laryngoscope 1997;107(10):1420-2.
94. Crockett DJ, Foreman ME, Alden L, Blasberg B. A comparison of treatment modes in the management of myofascial pain
dysfunction syndrome. Biofeedback & Self Regulation 1986;11(4):279-91.
95. De Laat A, Stappaerts K, Papy S. Counseling and Physical Therapy as Treatment for Myofascial Pain of the Masticatory
System. J Orofac Pain 2003;Winter;17(1):42-49.

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 Appendix IVc. A Response to:

2019 Committee on Temporomandibular Disorders (TMD):

From Research Discoveries to Clinical Treatment

Gary M. Heir, DMD

Rutgers School of Dental Medicine
Newark, New Jersey
USA

 Review and estimate the public health significance of TMDs, including prevalence, incidence,
burden and costs; and review challenges to data collection and reliability.

According to the United States National Institutes of Health (NIH)/National Institute of Dental and Craniofacial
Research, the prevalence of temporomandibular joint and muscle disorders ranges from 5% to 12%.i The NIH
observed that the prevalence for temporomandibular disorders was three times that in women compared to
men and were more likely to seek treatment. It was also observed that a younger population of patients are
seeking treatment which is unusual for chronic pain conditions.

In the United States, temporomandibular disorders represent a significant public health problem affecting up to
15% of the adult population and 7% of adolescents.ii According to some data, temporomandibular disorders
represent a significant disabling musculoskeletal disorder, second only to chronic low back pain.iii Despite this,
only 50 to 65% of patients seek treatment.

Data indicates the occurrence of temporomandibular disorders is three times more prevalent in females than
males and typically affects patients in the age groups of 20 to 30 years of age.iv,v

Approximately 15-18% reportedly go on to chronic orofacial pain and temporomandibular disorders. In a study
performed in 2002, “18% of subjects received TMJD treatment over 20 years with a success rate of 85%.”vi

According to the NIH, the cost for management of temporomandibular disorders in the United States per
annum, not including imaging has reached $4 billion.

 Evaluate the evidence base for assessment, diagnosis, treatment, and management of acute and
chronic TMD. Recognizing that TMDs are diverse and multifactorial conditions influenced by
genetics, sex and gender, environmental, physiological, and psychological factors.

Assessment and diagnosis of temporomandibular disorders has been and remains problematic. The term
temporomandibular disorder, or TMD is often confused with the anatomical term TMJ, even among
professionals. The lack of inclusion of standardized orofacial pain topics in the undergraduate curriculum of
dental schools results in the graduation of new dentists, some with no knowledge of facial pain disorders, and
others with a misconception of the problems. Many dentists inappropriately assume that all orofacial pain is of
odontogenic origin or “clicking TMJs” and look for mechanistic remedies, occasionally with devastating results
for the patient.

A common error in taxonomy is the bidirectional interchange of the terms TMD and TMJ as if they were
synonymous. Even when reviewing articles submitted for publication, many authors will perform studies based
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on subjects citing cohorts of “TMD” patients based only on the presence of orofacial pain and not a specific
diagnosis. The orofacial pain community has taken the lead in rectifying this situation through efforts such as
refining the research diagnostic criteria for temporomandibular disorders and the new diagnostic criteria for
TMD where classification of various forms of temporomandibular disorders is possible both for research and
clinical purposes. However, until a standardized classification is agreed upon and taught at the undergraduate
level, confusion will continue. Fortunately, the Commission on Dental Accreditation of the American dental
Association now recognizes orofacial pain as an accredited area of advanced dental education in the United
States with many states now recognizing orofacial pain as a specialty.

In response to the question in this section regarding an evidence basis for assessment, diagnosis, treatment
and management of acute and chronic TMD, it has already been noted that the term TMD is unacceptable as a
diagnostic term. We require a specific diagnosis in order to formulate an effective treatment. This now brings to
light the need for specialty in order to address the details of this multifactorial problem.

The need for a specialty in the multifactorial problem of orofacial pain in the United States is evident. General
dentists and other dental specialists require information regarding recognition of pain problems that are
unresponsive to routine dental care. For example, many patients are inadvertently harmed when suffering
from neuropathic pain. Healthcare providers often perform well-intentioned but needless procedures because
they do not have the required special training or expertise to address these often highly complex problems. All
too often our patients are seen for iatrogenic disorders that could have been avoided had they been directed to
a specialist in orofacial pain. The most difficult problem for these patients is the initial complaint compounded
by the iatrogenic disorder secondary to misguided treatment. Therefore, in response to the first part of this
question, evidence-based diagnosis, treatment and management of acute and chronic TMD, the response is
as follows:

Acute dental pain is not within the purview of the orofacial pain dentist. This typically represents dental
emergencies, odontogenic pain, infections or trauma. The source of acute pain is easily identified and
adequately treated by the general dentist or dental specialist in the field of the problem, e.g. endodontics,
periodontics and oral surgery.

Chronic pain is within the expertise of the orofacial pain dentist. Orofacial pain is pain perceived in the face
and/or oral cavity. It is caused by diseases or disorders of regional structures, by dysfunction of the nervous
system, or through referral from distant sources.vii Orofacial pain often mimics non-dental pain disorders in the
orofacial region. Orofacial Pain dentistry is concerned with the prevention, evaluation, diagnosis and
management of chronic orofacial pain disorders.

The orofacial pain dentist must have knowledge and multifactorial skills beyond those taught in the standard
undergraduate curriculum leading to the DDS or DMD degree. The orofacial pain dentist must demonstrate
knowledge, diagnostic skills, and treatment expertise in areas including musculoskeletal, neurovascular, and
neuropathic pain disorders; sleep disorders related to orofacial pain; orofacial movement disorders; intraoral,
intracranial, extracranial, and systemic disorders that cause orofacial pain and/or dysfunction.

The orofacial pain dentist must understand pain mechanisms and assume the responsibility to diagnose and
treat patients in pain that is often chronic, multifactorial, and complex. It is the responsibility of the orofacial
pain dentist to accurately diagnose the cause(s) of the pain and decide if treatment should be dentally,
medically, or psychologically managed, and be capable of optimizing management when multispecialty
management is required.

Management may consist of a number of interdisciplinary modalities including, e.g., physical medicine,
behavioral medicine, and pharmacotherapy or, in rare instances, surgical interventions. Among the essential
armamentarium is the knowledge and proper use of adjunctive diagnostic testing and pharmacologic agents.

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Regarding the second part of this question, is the influenced of genetics, sex and gender, environmental,
physiological, and psychological factors.

Numerous studies have been published not only on gender differences in response to pain, but also in gender
differences in the response to analgesic medications. They are too numerous to even attempt to list in this brief
response.viii,ix The role of genetics, genetic predisposition, environmental factors and epigenetics has raised
new awareness in the field of orofacial pain. Significant research in identifying phenotypical expression of pain
disorders secondary to environmental factors including physical and emotional stress are gaining relevancy
when evaluating our patients.x However, this is not taught at an undergraduate level, and are topics found in
Masters level programs at postgraduate levels of orofacial pain training. The need to support this type of
research and the programs at the universities with accredited programs is evident.

One of the early theories of temporomandibular disorders was that it was a psychological condition brought on
by stress. This theory still stigmatizes many patients who have organic problems related to the stomatognathic
system. While pain in any part of the body can result in an increase in the activity of the stress response and
hypothalamus-pituitary-interrenal axis (HPI axis) and immune response, this is an often overlooked component
when treating patients with chronic pain. xiCombined with genetic predisposition, sensitization of an individual
secondary to a chronic pain often results in a pro-nociceptive individual who becomes more and more difficult
to treat secondary to a growing inefficiency of the pain inhibitory system. The failure to recognize a systemic
condition, that pain is the disease not the symptom, results and focused and ineffective treatments limited to
frustration for both the clinician and the patient. If not recognized the disability and frustration that evolves
becomes not only a psychosocial problem but a financial issue on the community as individuals may become
more and more disabled leaving the workforce and depending on social services.

It is rare that we see true system somatoform disorders an orofacial pain practice, but not uncommon to see a
patient whose chronic pain is embellished by the emotional overlay resulting from untreated pain and failed
promises of success.xii,xiii,xiv

 Identify barriers to appropriate patient-centered TMD care, in the presence and absence of an
evidence base, and strategies to reduce these barriers along the continuum of TMD pain.

The most obvious barrier for patients in seeking treatment is access to care. This is the result of several
factors:

1. Diversity and disparity in care paths and protocols in treatment.

Commentary: At this time the only standardized curriculum in orofacial pain and temporomandibular
disorders is that which has been adopted by the postgraduate programs in orofacial pain which was
published by the American Academy of Orofacial Pain (AAOP) several years ago. There is no
standardized protocol for treatment nor curriculum recommended at the undergraduate or postgraduate
level which has been universally adopted By the American Dental Association or dental schools
throughout the United States. Therefore, depending upon the school from which an individual’s dentist
has graduated, they may or may not receive the same level of understanding of their problem or
treatment. Many dentists perceive pain in the faces of odontogenic origin only, and therefore their
diagnostic evaluation includes only the dentition and supporting structures. The lack of understanding
of pain mechanisms and areas from which pain may refer to the oral cavity and perioral structures is a
significant limitation in diagnosis and treatment.

2. Lack of a specialty
Commentary: In order to find specialized treatment for complex orofacial pain problems patients and
professionals must first have an awareness that such a specialty exists. The fact that there is no
recognized specialty in this field in the United States, despite the fact that a few states within the United
States have recognized orofacial pain as a specialty, is of limited value when the American Dental
306
 Association fails to recognize the need for this specialty. Countless numbers of patients, some with dire
diagnoses such as intracranial neoplasms manifesting as dental or facial pain, have received dental
extractions and endodontic procedures which were unnecessary and delayed an appropriate diagnosis
which might have been lifesaving in many cases. There are numerous cases of cerebellar pontine
angle tumors causing trigeminal pain in the distribution of the oral cavity and face which have been
misdiagnosed as dental pain. Countless numbers of teeth have been extracted or treated
endodontically for various forms of headache disorders. Patients with complaints based on symptom
somatoform disorders have been subjected to unnecessary multiple procedures resulting in disastrous
outcomes. The list goes on. Had the patients in these cases been referred by their healthcare providers
to an orofacial pain specialist, the outcomes of these cases would surely be different. However, all too
often the patient and the provider does not know that such a specialized field exists. Orofacial pain as a
specialty spans the gap where general dental training ends and medicine begins. The failure to provide
such a specialty does not serve the public and is a significant barrier the general health of orofacial
pain.

3. At this time, insurance carriers can choose to deny coverage to individuals requiring treatment for facial
pain disorders arbitrarily based on the absence of a recognized specialty. This is another barrier to
treatment that can readily be solved .

 Review the state of science for TMD and provide an overview of basic, translational, and clinical
research for TMD.

The area of pain is the most underfunded of all health-related issues. Despite that, research in pain continues.
There are numerous peer-reviewed journals dedicated specifically to pain and many to research and orofacial
pain. The Journal of Orofacial Pain and Headache of the AAOP along with its sister academies in Europe,
Asia, South America and Australia-New Zealand has a high impact and is dedicated to research in orofacial
pain. The international Association for the Study of Pain (IASP) sponsors the premier journal of pain with
numerous articles relevant to facial pain published annually. Worldwide, universities perform research at
centers in the US, Sweden, Japan, South America, the Netherlands and centers worldwide dedicated to the
relief of pain and suffering of the orofacial pain patient. Masters and PhD programs in the US and around the
world published volumes of literature annually. This research is not always in the laboratory, but clinical
research as well. The specific work done in Germany on neuropathic pain is remarkable, molecular biology
from Japan and research on muscle disorders from the Netherlands and pain mechanisms from Israel make
the community of pain researchers and clinicians a very unique family sharing information from the laboratory
to the clinic on a regular basis. There are numerous students who vie four positions to study with these
researchers or to learn at the chair side from world-class clinicians. The science and evidence available. The
researchers are willing, and the students are able. Scientific meetings such as those held annually by AAOP
and every two years by IASP bring the worlds pain community together where the translation from research to
clinic becomes second nature.

 Identify opportunities and challenges for development, dissemination, and clinical

implementation of safe and effective clinical treatments for TMD.

This is the easiest of all the questions to answer; standardized undergraduate and postgraduate curricula are
necessary. Standardization of care paths and the recognition of a specialty is needed.

 Identify scientific and clinical disciplines needed to advance TMD science and the development,
dissemination, and implementation of safe and effective treatments; as well as strategies to
enhance education and training in these disciplines.

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The Commission on Dental Accreditation of the American Dental Association has published standards in
education as a requirement for accreditation of an orofacial pain postgraduate program. The curriculum must
include the following topics:

Biomedical Sciences

Formal instruction must be provided in each of the following:

a. Gross and functional anatomy and physiology including the musculoskeletal and articular
system of the orofacial, head, and cervical structures;
b. Growth, development, and aging of the masticatory system;
c. Head and neck pathology and pathophysiology with an emphasis on pain;
d. Applied rheumatology with emphasis on the temporomandibular joint (TMJ) and related
structures;
e. Sleep physiology and dysfunction;
f. Oromotor disorders including dystonias, dyskinesias, and bruxism;
g. Epidemiology of orofacial pain disorders;
h. Pharmacology and pharmacotherapeutics; and
i. Principals of biostatistics, research design and methodology, scientific writing, and critique of
literature.

The program must provide a strong foundation of basic and applied pain sciences to develop knowledge in
functional neuroanatomy and neurophysiology of pain including:

a. The neurobiology of pain transmission and pain mechanisms in the central and peripheral
nervous systems;
b. Mechanisms associated with pain referral to and from the orofacial region;
c. Pharmacotherapeutic principles related to sites of neuronal receptor specific action pain;
d. Pain classification systems;
e. Psychoneuroimmunology and its relation to chronic pain syndromes;
f. Primary and secondary headache mechanisms;
g. Pain of odontogenic origin and pain that mimics odontogenic pain; and
h. The contribution and interpretation of orofacial structural variation (occlusal and skeletal) to
orofacial pain, headache, and dysfunction.

Behavioral Sciences

Formal instruction must be provided in behavioral science as it relates to orofacial pain disorders and pain
behavior including:

a. cognitive-behavioral therapies including habit reversal for oral habits, stress management, sleep
problems, muscle tension habits and other behavioral factors;
b. the recognition of pain behavior and secondary gain behavior;
c. psychologic disorders including depression, anxiety, somatization and others as they relate to
orofacial pain, sleep disorders, and sleep medicine; and
d. conducting and applying the results of psychometric tests.

Clinical Sciences

A majority of the total program time must be devoted to providing orofacial pain patient services, including
direct patient care and clinical rotations.

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The program must provide instruction and clinical training for the clinical assessment and diagnosis of complex
orofacial pain disorders to ensure that upon completion of the program the resident is able to:

a. Conduct a comprehensive pain history interview;

b. Collect, organize, analyze, and interpret data from medical, dental, behavioral, and psychosocial
histories and clinical evaluation to determine their relationship to the patient’s orofacial pain
and/or sleep disorder complaints;
c. Perform clinical examinations and tests and interpret the significance of the data;
d. Function effectively within interdisciplinary health care teams, including the recognition for the
need of additional tests or consultation and referral; and
e. Establish a differential diagnosis and a prioritized problem list.

The program must provide instruction and clinical training in multidisciplinary pain management for the
orofacial pain patient to ensure that upon completion of the program the resident is able to:

a. Develop an appropriate treatment plan addressing each diagnostic component on the problem
list with consideration of cost/risk benefits;
b. Incorporate risk assessment of psychosocial and medical factors into the development of the
individualized plan of care;
c. Obtain informed consent;
d. Establish a verbal or written agreement, as appropriate, with the patient emphasizing the
patient’s treatment responsibilities;
e. Have primary responsibility for the management of a broad spectrum of orofacial pain patients
in a multidisciplinary orofacial pain clinic setting, or interdisciplinary associated services.
Responsibilities should include:
1. intraoral appliance therapy;
2. physical medicine modalities;
3. sleep-related breathing disorder intraoral appliances;
4. non-surgical management of orofacial trauma;
5. behavioral therapies beneficial to orofacial pain; and
6. pharmacotherapeutic treatment of orofacial pain including systemic and topical
medications and diagnostic/therapeutic injections.

Residents must :
1. Participate in clinical experiences in other healthcare services
2. Residents must gain experience in teaching orofacial pain.
3. The program must provide instruction in the principles of practice management.
4. Formal patient care conferences must be held at least ten (10) times per year.

 Identify multidisciplinary/interdisciplinary research approaches necessary in the short- and long-

term to advance basic, translational, and clinical TMD research and improve the assessment,
diagnosis, treatment, and management of TMDs.

The best way to respond to this question is by example. In order to expeditiously respond to this request, I
attach a bibliography of some of the topics performed at one US based university by its residents after
graduations and / or faculty.

References
Heir GM, Continuing education : Caveat emptor, The Journal of the American Dental Association Volume 148, Issue 4, April 2017,
Pages 201–203

309
Edmonds S, Enriquez C, Milner M, Nasri-Heir C, Heir, GM; Is there an association between fear avoidance beliefs, and pain and
disappointment in patients with orofacial pain? Journal of Oral Rehabilitation · March 2017

Liu J, Mendelson ZS, Velagala J, Heir GM; Pain-Free Outcomes and Durability of Surgical Intervention for Trigeminal Neuralgia: A
Comparison of Gamma Knife and Microvascular Decompression, World Neurosurgery, (in press)

Kalladka M, Nasri-Heir C, Eliav E, Ananthan S, Vishwanath A, Heir G; Continuous Neuropathic Pain Secondary to Endoscopic
Procedures: Report of Two Cases and Review of the Literature; Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology; Oral
Surgery, Oral Medicine, Oral Pathology and Oral Radiology, Vol 122, 2 pp 55-59, August 2016

Heir GM. Park RCW, Singer S, Orofacial pain due to rare interosseous hemangioma first diagnosed as secondary to trauma,
Quintessence International, 2016;47(8):699-704.

Nasri-Heir C, Khan J, Benoliel R, Feng C, Yarnitsky D, Kuo F, Hirschberg C, Hartwell G, Huang C, Heir G, Korczeniewska O, Diehl S,
Eliav E; Altered Pain Modulation in Patients with Persistent Post-Endodontic Pain. 2015 Oct; 156(10):2032-41. PMID: 26098442

Khan J, Anwer, HMM, Eliav, E, Heir G: Oromandibular dystonia Differential diagnosis and management, JADA September 2015
Volume 146, Issue 9, Pages 690–693, DOI: http://dx.doi.org/10.1016/j.adaj2014.09.001

Heir, GM, Masterson M, Case Report: Bilateral glossopharyngeal neuropathy following chemo and radiation therapy for a primitive
neuroectodermal tumor, Journal of Oral Rehabilitation, Accepted Aug 19, 2015, in press

Liu JK, Mendelson Z, Sheikh AB, Heir GM. Retractorless Microvascular Decompression for Trigeminal Neuralgia: Technical Nuances
and Results in 25 Cases, J Neurol Surg B 2015; 76 - A147

Guarda-Nardini Luca GN, Manfredini D, Mion Marta, Heir G, Marchese-Ragona R, Anatomically Based Outcome Predictors of
Treatment for Obstructive Sleep Apnea with Intraoral Splint Devices: A Systematic Review of Cephalometric Studies. J Clin Sleep Med
2015 Apr 10. Epub 2015 Apr 10.

Heir GM, Jaeger B, Schwartz A, Application of psychometric testing for validation in the field of orofacial pain, Journal of Oral & Facial
Pain and Headache, 01/2015; 28(4):369-73

Balasundaram A, Heir GM, Villegas FP, Ahmad M, Taher F, In vitro correlation of the level of inferior alveolar canal with CBCT imaging.
Surg Radiol Anat 2014 Dec 4. Epub 2014 Dec

Yatani H, Komiyama O, Matsuka Y, Wajima K, Muraoka W, Ikawa M, Sakamoto E, De Laat A, Heir GM., Systematic review and
recommendations for nonodontogenic toothache. J Oral Rehabil. 2014 Jul 10. doi: 10.1111/joor.12208.

Kalladka M, Quek S, Heir G, Eliav E, Mupparapu M, Viswanath A, Temporomandibular Joint Osteoarthritis: Diagnosis and Long-Term
Conservative Management: A Topic Review, J Indian Prosthodont Soc, Sept. 2013, DOI 10.1007/s13191-013-0321-3

Haribabu PK, Eliav E, Heir G; Authors’ response, JADA August 2013 144(8): 877-878

Sampaio FA, Sunagawa Y, Cunha CO, Puchimada B, Sood R, Ananthan S, Heir GM; Differential Diagnosis of Chronic Paroxysmal
Hemicrania. After Unsuccessful Microvascular Decompression, Abstracts of the 2013 International Headache Congress, Cephalagia,
Volume 33, Number 8 (Supplement) pp. 150, June 2013

Heir GM, The Emerging Specialty of Orofacial Pain, Journal: The Journal of Indian Prosthodontic Society DOI: 10.1007/s13191-013-
0295-1, June 2013

Januzzi E, Nasri-Heir C, Grossmann E, Leite FMG, Heir GM, Melnik TM; Nasri-Heir C, Khan J, Heir GM, Combined Palliative and Anti-
Inflammatory Medications as Treatment of Temporomandibular Joint Disc Displacement Without Reduction: A Systematic Review, The
Journal of Craniomandibular& Sleep Practice, July 2013, VOL. 31, NO. 3

Konatham P, Eliav E, Heir GM: Topical Medications for the Effective Management of Neuropathic Orofacial Pain; The Journal of the
American Dental Association, JADA 144(6) http://jada.ada.org June 2013 pp 594-601

Heir GM, Nasri-Heir C, Thomas D, Puchimada BP, Khan J, Eliav E, Benoliel R, Complex regional pain syndrome following trigeminal
nerve injury: report of 2 cases, Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 2012 Dec;114(6): pp 733-9.

Plaza-Villegas F, Heir GM, Markman S, Khan J, Noma N, Benoliel R, Patel J, Eliav E, Topical pregabalin and diclofenac for the
treatment of neuropathic orofacial pain in rats, Oral Surg Oral Med Oral Pathol Oral Radiol, Vol. 114 No. 4Oct 2012, pp 114:449-456,

Heir, GM, de la Hoz J, Orofacial Dyskinesias, textbook chapter in press

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Heir GM, Assessment of the TMJ Patient, in Oral and Maxillofacial Surgery by Fonseca RJ, Turvey TA, Marciani RD; Elsevier Health
Sciences, new edition in press

Heir GM, Postherpetic Trigeminal Neuropathy, Clinical Cases in Orofacial Pain, Eds. Malin Ernberg, Per Alstergren, pp. 181-187, May
2017, Wiley-Blackwell

Heir GM, Post Herpetic Neuralgia, Orofacial Disorders, ed Ferreira, Springer Publishing, textbook chapter, in press

Nitzan D, Benoliel R, Heir GM, Dolwick F; Pain and Dysfunction of the Temporomandibular Joint; Chpt 9 in Orofacial Pain & Headache
2nd Edition, Ed. Shariv and Benoliel, Mosby/Elsevier, 2015

Benoliel R, Heir GM, Eliav E; Neuropathic Orofacial Pain; Chpt 12 in Orofacial Pain & Headache 2nd Edition, Ed. Shariv and Benoliel,
Mosby/Elsevier, 2015

Heir GM, Nasri C, Yoshinari NH, Lyme Disease and Pain (Doença de Lyme e Dor); Chpt 38 in Orofacial Pain Diagnosis and Treatment
(Dores Orofaciais Diagnóstico e Tratamento); Eds. De Siqueira JDT, Teixeira MJ, Artes Médicas, São Paulo, Brazil, 2012

Abstracts and Audio-Visual Programs

Kabaria A, Heir G, Sowmya Ananthan S; Trigeminal Neuropathy Following Needle-Stick Injury; Balboa Day, Rutgers University,
University wide research and clinical abstract presentations, 2017, First Place Winner

Ahmed Raddad A, Mohammed M Ahmed MM, Heir GM; Eagle Syndrome: Case Report; Balboa Day, Rutgers University, University
wide research and clinical abstract presentations, 2017, Second Place Winner

First Bite Syndrome: Case Report, Ahmed MM, Wise S, Heir G; Balboa Day, Rutgers University, University wide research and clinical
abstract presentations, 2017

Qawi AA, Ananthan S, Heir GM; A Rare Case Of Carbon Monoxide (CO) Poisoning Mimicking Dental Pain; Balboa Day, Rutgers
University, University wide research and clinical abstract presentations, 2017

Alhomrany Y, Nair A, Markman S, Heir G, Diagnosis and Treatment of Painful Post Traumatic Trigeminal Neuropathy with topical
medications; Balboa Day, Rutgers University, University wide research and clinical abstract presentations, 2017

Ziegler J, Spivack E, Heir G, Rigassio-Radler D, Touger-Decker R; Interprofessional Clinical Training of Nutrition and Dental
Students/Residents: Examining Drug-Nutrient/Dietary Supplement Interactions and their Impact on Diet/Nutrition and Oral Health;
Annual National Conference (ANC), San Antonio, Texas, July 2016

Carla Enriquez C, Heir G, Nasri-Heir C, Edmond S. Is there an association between the fear avoidance beliefs; and pain and disability
outcomes in patients with orofacial pain?" APTA Combined Sections Meeting 2016, Anaheim, CA, February 17-20, 2016

Microvascular Decompression for Trigeminal Neuralgia: Technical Nuances and Results in 25 Cases, 25th Annual Meeting North
American Skull Base Society, Tampa Marriott Waterside Hotel & Marina, Tampa, Florida, 20–25 February 2015

Anosike N, Dalwai S, Nasri-Heir C, Thomas D, Kaufman A, Heir G, Complex regional pain syndrome of the orofacial region after a
dental procedure: a case report, Balboa Day, New Jersey Dental School, Newark, NJ, USA, March 2015 (second place)

Heir GM, Cohen HV, Kim S, Radzam D, Eliav E, Nasri-Heir C, Sensory Alterations in the Maxillofacial regions following concomitant
Chemo-Radiation Therapy for Squamous Cell Carcinoma of Head and Neck ,the 15th World Congress on Pain is organized by the
International Association for the Study of Pain, Buenos Aires, Argentina, October 6 - 11, 2014.

Ziegler J, Rigassio Radler D, Heir G, Cohen H,Touger-Decker R, Interprofessional collaboration between the dietetic interns and dental
students enhances learning outcomes of the students and provide interdisciplinary care to the clinic population. Academy of Nutrition
and Dietetics, Houston, 2013

Sampaio FA, Sunagawa Y, Cunha CO, Puchimada B, Sood R, Ananthan S, Heir GM; Differential Diagnosis of Chronic Paroxysmal
Hemicrania. After Unsuccessful Microvascular Decompression, International Headache Society and American Headache Society 27–30
June 2013, Boston, MA

Ananthan S, Zagury JG, Eliav E, Heir GM, Sensory Assessment of Post-Dental Implant Neuropathy, IASP NeuroSig Congress,
Toronto, May 2013

311
Alnaas D, Mugri M, Sabeh A, Ramadan K, Alamir A, Markman S, Heir G; Case report: Therapeutic Use of Botulinum Neurotoxin for
Oromandibular Dyskinesia; American Academy of Orofacial Pain, Orlando, April 2013

Sabeh A, Ramadan K, Mugri M, Sampaio FA, Alnaas D, Singer S, Heir G; Polypoid Lesion Resulting In Sensory Disturbances: A Case
Report; Balboa Day, New Jersey Dental School, Newark, NJ, USA, March 2013

Sabeh A.; Alnaas D.; Heir G, .Differential Diagnosis of Lyme Disease in Orofacial Pain, Mugri M.; Ramadan K.; Balboa Day, New
Jersey Dental School, Newark, NJ, USA, March 2013

Aldam A, Shigdar D, Hassun H, Nasri-Heir C, Heir G; Case report of: Burning mouth syndrome; Balboa Day, New Jersey Dental
School, Newark, NJ, USA, March 2013

Nasri-Heir C, Khan J, Heir GM, Kuo F, Korczeniewska OA, Huang C, Diehl S.R. Yarnitsky D, Eliav E, Atypical Pain Modulation Profile in
Patients with Atypical Odontalgia, International Association for the Study of Pain (IASP) meeting Milan, Italy 2012

Fengshen Kuo F, Korczeniewska FO, Khan J, Nasri-Heir C, Heir GM, Hirschberg C, Hartwell GR, Yarnitsky D, Huang CY, Eliav E,
Diehl SR; Atypical Odontalgia is Associated with a GTP cyclohydrolase 1 (GCH1) high risk haplotype in Caucasians, Hispanics and
African Americans; International Association for the Study of Pain (IASP) meeting Milan, Italy 2012

Nasri-Heir C, Shigdar D, Alnaas D, Korckeniweks O, Eliav R. Heir G. Primary BMS: Literature review and preliminary findings
suggesting possible association to pain modulation. Quintessence International. 30:49-60, 2017.

Edmond SL, Enriquez CS, Miller, MH, Nasri-Heir C, Heir GM. Is there an association between avoidance beliefs and pain and disability
in patients with orofacial pain? J Oral Rehabil. 44(6): 426-433, 2017.

Kalladka M, Nasri- Heir C, Eliav E, Ananthan S , Viswanath S, Heir G; Continuous Neuropathic Pain Secondary to Endoscopic
Procedures: Report of Two Cases and Review of the Literature; Oral Surg Oral Med Oral Pathol Oral Radiol. 122(2):e55-9, 2016.

Nasri-Heir, Cibele; Epstein, Joel B.; Touger-Decker, Riva, Benoliel, Rafael; What should we tell patients with painful temporomandibular
disorders about what to eat? Journal of the American Dental Association (JADA), Aug 2016; 147(8): 667-671. 5p.

Nasri-Heir C. Zagury J, Thomas D, Ananthan S; Burning Mouth Syndrome: Current Concepts; J Indian Prosthodont Soc.,15(4):300-7,
2015.

Nasri-Heir C, Khan J, Benoliel R, Feng C, Yarnitsky D, Kuo F, Hirschberg C, Hartwell G, Huang CY, Heir G, Korczeniewska O, Diehl
SR, Eliav E; Altered Pain Modulation in Patients with Persistent Post-Endodontic Pain; Pain, 156(10):2032-41, 2015.

Ceusters W, Nasri-Heir C, Alnaas D, Cairns BE, Michelotti A, Ohrbach R; Perspectives on next steps in classification of orofacial pain -
Part 3: biomarkers of chronic oro-facial pain - from research to clinic; J Oral Rehabil., 42(12):956-66, 2015.

Nasri-Heir, Cibele; Benoliel, Rafael; Touger-Decker, Riva; Epstein, Joel B.; Eliav, Eli; Orofacial Pain. Nutrition & Oral Medicine
(9781607614890) , 2014, p313-331, 19p. Publisher: Springer Science & Business Media B.V.

Nasri-Heir C, Khan J, Heir GM; Topical Medications as Treatment for Neuropathic Orofacial Pain; Dent Clin North Am, 57(3): 541-53,
2013.

Januzzi E, Nasri-Heir C, Grossmann E, Leite FMG, Heir GM, Melnik TM; Combined Palliative and Anti-Inflammatory Medications as
Treatment of Temporomandibular Joint Disc Displacement Without Reduction: A Systematic Review; Journal of Craniomandibular
Practice, 31(3):1-15, 2013.

Nasri-Heir C; Burning Mouth Syndrome.; Alpha Omegan,105(3-4):76-81, 2012.

Markowitz, Kenneth; Fairlie, Karen; Ferrandiz, Javier; Nasri-Heir, Cibele; Fine, Daniel H.; A longitudinal study of occlusal caries in
Newark New Jersey school children: Relationship between initial dental finding and the development of new lesions; Archives of Oral
Biology. November 2012 57(11):1482-1490

Heir GM, Nasri-Heir C, Thomas D, Puchimada BP, Khan J, Eliav E, Benoliel R; Complex Regional Pain Syndrome Following Trigeminal
Nerve Injury: report of 2 cases; Oral Surg Oral Med Oral Pathol Oral Radiol., 114(6):733-9, 2012.

Nasri-Heir C, Gomes J, Ananthan S, Teich S, Benoliel, R, Heir GM, Eliav E; The Role of Sensory Input of the Chorda Tympani Nerve
and the Number of Fungiform Papillae in Burning Mouth Syndrome; Oral Surg Oral Med Oral Pathol Oral Radiol Endod., 112(1):65-72,
2011.

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Zagury JG, Eliav E, Nasri-Heir C, Ananthan S, Pertes R, Sharav Y, Benoliel R.; Prolonged Gingival Cold Allodynia: A Novel Finding in
Patient with Atypical Odontalgia; Oral Surg Oral Med Oral Radiol Endod., 111(3):312-9, 2011.

Eliav E, Nasri-Heir C; Critical Commentary 2: Steroid Dysregulation and Stomatodynia (burning mouth syndrome); J Orofac Pain,
23(3):214-5, 2009.

Heir G, Karolchek S, Kalladka M, Vishwanath A, Gomes J, Khatri R, Nasri C., Eliav E, Ananthan S; Use of Topical Medication in
Orofacial Neuropathic Pain: a Retrospective Study; Oral Surg Oral Med Oral Pathol Oral Radiol Endod.,105(4):466-9, 2008.

Kalladka M., Ananthan S., Eliav E, Nasri-Heir C, Khan J, Heir G.M.

Orbital psuedotumor presenting as a temporomandibular disorder: A case report and review of literature.

Journal of the American Dental Association. 2018 July 24, pii: S0002-8177 (18)30347-7.

Kanti V, Ananthan S, Subramanian G, Quek SYP. Efficacy of the twin block, a peripheral nerve block for the management of
chronic masticatory myofascial pain: A case series.

Quintessence Int. 2017 Oct 6:725-729. doi: 10.3290/j.qi.a39094.

Kalladka M., Nasri-Heir C., Eliav E. , Ananthan S., Vishwanath A., Heir G. Continuous neuropathic pain secondary to endoscopic
procedures: report of two cases and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Volume#: August
2016: 122 (2), e55-e59.

Nasri-Heir C, Zagury J, Thomas D, Ananthan S. Burning mouth syndrome: current concepts. Journal of the Indian Prosthodontic
Society, October- December 15 (4): 300-307, 2015

Quek SY, Subramanian G, Patel J, Ananthan S, Zagury JG, Khan J Efficacy of regional nerve block in management of myofascial pain
of masseteric origin. Cranio. Sep 14:2151090314Y0000000026, 2014.

Nasri-Heir C, Gomes J, Heir GM, Ananthan S, Benoliel R, Teich S, Eliav E. The role of sensory input of the chorda tympani nerve
and the number of fungiform papillae in burning mouth syndrome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
Jul;112(1):65-72, 2011.

Zagury JG, Eliav E, Heir GM, Nasri-Heir C, Ananthan S, Pertes R, Sharav Y, Benoliel R Prolonged gingival cold allodynia: a novel
finding in patients with atypical odontalgia. Oral Surg Oral Med Oral Pathol Oral Radiol Endol, Mar: 111(3): 312-9, 2011.

Raphael KG, Janal MN, Ananthan S, Cook DB, Staud R. Temporal summation of heat pain in temporomandibular disorder patients. J
Orofac Pain. Winter;23(1):54-64, 2009.

Heir G, Karolchek S, Kalladka M, Vishwanath A, Gomes J, Khatri R, Nasri C, Eliav E, Ananthan S. Use of topical medication in
orofacial neuropathic pain: a retrospective study. Ora Surg Oral Med Oral Pathol Oral Radiol Endod. Apr;105(4):466-9, 2008.

Books, Monographs and Chapters

Ananthan S., Khan J., Ziccardi V.B., Benoliel R. Post-Traumatic Trigeminal Neuropathy. In: Clinical Cases in Orofacial Pain. Editors:
Malin Ernberg & Per Alstergren. John Wiley & Sons, Inc, Hoboken, NJ (2017).

Benoliel R., Ananthan S., Gomes Zagury J., Khan J., Eliav E.: Chapter 12: Orofacial Pain. In: Burket’s Oral
Medicine 12th Edition. Editor: Michael Glick. People's Medical Publishing House- USA, Shelton, CT. (2015), Pages: 309-321.

Noboru Noma; Kohei Shimizu; Kosuke Watanabe; Young, Andrew; Yoshiki Imamura; Junad Khan; Cracked tooth syndrome mimicking
trigeminal autonomic cephalalgia: A report of four cases. Quintessence International, Apr 2017; 48(4): 329-337. 9p.

Khan, Junad; Noboru, Noma; Young, Andrew; Thomas, Davis; Pro and anti-inflammatory cytokine levels (TNF-α, IL-1β, IL-6 and IL-10)
in rat model of neuroma; Pathophysiology. Dec 2016 Language: English. DOI: 10.1016/j.pathophys.2017.04.001,

In Reply. Khan, Junad; Alghamdi, Hamed; Anwer, Muhammad Moin; Ziccardi, Vincent; Eliav, Eli; In: Journal of Oral & Maxillofacial
Surgery (02782391); Nov 2016; v.74. n.11, 2113-2113. 1p. (letter

Khan, Junad; Alghamdi, Hamed; Anwer, Muhammad Moin; Eliav, Eli; Ziccardi, Vincent; Role of Collagen Conduit With Duloxetine
and/or Pregabalin in the Management of Partial Peripheral Nerve Injury; Journal of Oral & Maxillofacial Surgery (02782391), Jun 2016;
74(6): 1120-1130. 11p.
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Khan J; Creanga AG; Singer S; Joseph S; Markman S; Obscured Pain in the Presence of a Temporomandibular Disorder; Journal Of
The New Jersey Dental Association (J N J Dent Assoc), ISSN: 0093-7347, 2015 Fall; Vol. 86 (4), pp. 33-6;

Khan, Junad; Neuropathic pain; Journal of Indian Prosthodontic Society , Apr-Jun2016, Vol. 16 Issue 2, p114-115, 2p.

Khan, Junad; Ramadan, Khaled; Korczeniewska, Olga; Anwer, Muhammad Moin; Benoliel, Rafael; Eliav, Eli; In Research article:
Interleukin-10 levels in rat models of nerve damage and neuropathic pain; Neuroscience Letters. 10 April 2015 592:99-106 Language

Khan, Junad; Benavent, Vanessa; Korczeniewska, Olga A; Benoliel, Rafael; Eliav, Eli; Exercise-induced hypoalgesia profile in rats
predicts neuropathic pain intensity induced by sciatic nerve constriction injury.
Journal of Pain, Nov2014; 15(11): 1179-1189. 11p.

Shanti, Rabie M; Khan, Junad; Eliav, Eli; Ziccardi, Vincent B; Is there a role for a collagen conduit and anti-inflammatory agent in the
management of partial peripheral nerve injuries? Journal of Oral & Maxillofacial Surgery (02782391), Jun 2013; 71(6): 1119-1125. 7p

Chen, I.-Fang; Khan, Junad; Noma, Noboru; Hadlaq, Emad; Teich, Sorin; Benoliel, Rafael; Eliav, Eli ;Anti-nociceptive effect of IL-12p40
in a rat model of neuropathic pain; Cytokine. June 2013 62(3):401-406 (Masters Publication)

Noma, Noboru; Kamo, Hiroshi; Nakaya, Yuka; Dezawa, Ko; Young, Andrew; Khan, Junad; Imamura, Yoshiki; Stellate Ganglion Block
as an Early Intervention in Sympathetically Maintained Headache and Orofacial Pain Caused by Temporal Arteritis. Pain Medicine, Mar
2013; 14(3): 392-397. 6p

He, Shuyang; Khan, Junad; Gleason, Joseph; Eliav, Eli; Fik-Rymarkiewicz, Ewa; Herzberg, Uri; Albert, Vivian; Hariri, Robert; Placenta-
derived adherent cells attenuate hyperalgesia and neuroinflammatory response associated with perineural inflammation in rats; Brain
Behavior and Immunity. January 2013 27:185-192

Markman, S. Referred pain; Journal of the New Jersey Dental Association, 2014 Spring, 85(2):26-29

Thomas, D.; Markman, S.; Sofferman, B.;.Sleep basics and sleep-pain interrelations for orofacial pain dentists; The Alpha Omegan,
2013 Spring-Summer, 106(1-2):29-33

Prashanth Konatham Haribabu

Haribabu, Prashanth Konatham; Raja, Krishna Kumar; Iyer, Shankar; Safe Sinus Lift: Use of Acrylic Stone Trimmer to Avoid Sinus
Lining Perforation.
Journal of Oral Implantology; Jun2014, Vol. 40 Issue 3, p281-284, 4p. Publisher: Allen Press Publishing Services Inc

Iyer, Shankar; Haribabu, Prashanth Konatham; Yi Xing; Part II Minimizing Alveolar Bone Loss During and After Extractions. Protocol
and Techniques for Alveolar Bone Preservation; Alpha Omegan , Spring 2014, Vol. 107 Issue 1, p14-25, 12p

Kanti V, Aparna MK.; Obstructive sleep apnea in a patient with orofacial pain secondary to cervical fixation. Journal of American Dental
Association; 2017 Mar 148(3):185-189.

Kalladka M, Viswanath A, Gomes J, Eliav E, Pertes R, Heir G.Cranio. 2007 Apr;25(2):138-43.

Heir G, Karolchek S, Kalladka M, Vishwanath A, Gomes J, Khatri R, Nasri C, Eliav E, Ananthan S.study. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod. 2008 Apr;105(4):466-9

Kalladka M, Proter N, Benoliel R, Czerninski R, Eliav E.changes. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008
Sep;106(3):364-70.
Eliav E, Benoliel R, Herzberg U, Kalladka M, Tal M. The Brain Behav Immun. 2009 May;23(4):474-84.

Kalladka M, Quek S, Heir G, Eliav E, Mupparapu M, Viswanath A. Temporomandibular Joint Osteoarthritis: Diagnosis and Long-Term
Conservative Management: A Topic Review J Indian Prosthodont Soc (Jan-Mar 2014) 14(1):6–15

Kalladka M, Greenberg BL, Padmashree SM, Venkateshaiah NT, Yalsangi S, Raghunandan BN, Glick M. Screening for coronary heart
disease and diabetes risk in a dental setting.Int J Public Health. 2014 Jun;59(3):485-92. doi: 10.1007/s00038-013-0530-x. Epub 2013
Dec 19.
\
Kalladka M, Heir G, Ananthan S, Eliav E, Viswanath A. Neuropathic Pain Secondary to Intubation and Endoscopy: Report of Two
Cases and Review of Literature. 2017. Oral Surg Oral Med Oral Pathol Oral Radiol Endod

314
Quek SYP, Kalladka M, Kanti V, Subramanian G.technique. J Indian Prosthodont Soc. 2018 Apr-Jun;18(2):181-185. doi:
10.4103/jips.jips_293_17.

levels. Young A, Kalladka M, Viswanath A, Zusman T, Khan J.Pathophysiology. 2018 Mar 19. pii: S0928-4680(18)30028-2. doi:
10.1016/j.pathophys.2018.03.001. (Epub ahead of print) No abstract available.

effects. Young A, Viswanath A, Kalladka M, Khan J, Eliav E, Diehl SR. Neurosci Lett. 2018 Mar 15;675:110-115. doi:
10.1016/j.neulet.2018.03.022. (Epub ahead of print)

Age and gender differences in mechanically induced intraoral temporal summation and conditioned pain modulation in healthy subjects.
Khan J, Korczeniewska O, Benoliel R, Kalladka M, Eliav E, Nasri-Heir C. Oral Surg Oral Med Oral Pathol Oral Radiol. 2018 Apr 13. pii:
S2212-4403(18)30890-3. doi: 10.1016/j.oooo.2018.03.021

Orbital Pseudotumor Presenting as a Temporomandibular disorder: A Case Report and Review of Literature. Mythili Kalladka, Sowmya
Ananthan, Eli Eliav, Cibele Nasri Heir, Junad Khan, , Gary Heir. J Am Dent Assoc. 2018 Nov;149(11):983-988. doi:
10.1016/j.adaj.2018.05.016. Epub 2018 Jul 25.

Presentation of cysticercosis of the lateral pterygoid muscle as temporomandibular disorder: A diagnostic and therapeutic
challenge.Kalladka M, Navaneetham A, Eliav E, Khan J, Heir G, Mupparapu M.J Indian Prosthodont Soc. 2018 Oct-Dec;18(4):377-383.
doi: 10.4103/jips.jips_129_18.

Maloth S, Padmashree S, Rema J, Yalsangi S, Ramadoss T, Kalladka M. Diagnosis of Crouzons Syndrome. Hong Kong Dental
Journal. 2010; 7: 95-100

Yalsangi S, Padmashree S, Rema J, Maloth S, Ramadoss T, Kalladka M. Rhabdomyoma of Orofacial Region-A rare case report. 2011;
Hong Kong Dental Journal

Young, A., “Orofacial Pain Overview: Getting Rid of the Riddles,” Journal of the California Dental Association, (In Press)

“Mouse Model Demonstrates Genetic Differences in Susceptibility to Opioid Side Effects.” Study completed, Currently being prepared
for publication

"Enhancement of Analgesia by Combining Duloxetine and Pregabalin Administration." Currently being prepared for publication.

"Pain and sensory changes in HIV+ patients, as well as PTSD, depression, and nutritional correlations."
Currently being prepared for publication.

"Role of the opioid system in interleukin modulation of pain." Study completed. Currently being prepared for publication.

"Role of IL-2, IL-4, TNFa in neuropathic pain" Currently being prepared for publication.

“Changes in Evidence-Based Dentistry Knowledge, Attitudes, Access, and Confidence Through a Blended Learning Curriculum.” IRB
approved, ongoing study.

“Comparison of conservative TMD treatment and neuromuscular treatment.” IRB approved, study in initial stages.

“Dementia predictors in gingival crevicular fluid.” Study in initial stages.

“Acidic diet aggravates dental wear.” Study in initial stages.

“Methamphetamine use correlates with dental horizontal fracture.” Study in initial stages.

All of the following are products of, or associated with the orofacial pain program at UMDNJ/RSDM

Quek, S.Y.P.; Subramanian, G.; Patel, J.; Ananthan, S.; Zagury, J.G.; Khan, J.; Efficacy of regional nerve block in management of
myofascial pain of masseteric
origin; Cranio - Journal of Craniomandibular Practice, October 2015, 33(4):286-291

Nasri-Heir, Cibele; Zagury, Julyana Gomes; Thomas, Davis; Ananthan, Sowmya. Burning mouth syndrome: Current concepts; Journal
of Indian Prosthodontic Society, Oct-Dec 2015, Vol. 15 Issue 4, p300-307, 8p

Paolino C, Fahey R, Viswanth A, Natto ZS, Papageorge MB, Gilmore WC; Prevalence of surgical treatment of deep fascial space
infection from third--molars, Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology. February 2017 123(2):e24

315
Decoteau C, Paolino CR. Vyas H, Finkelman M, Papageorge MB, Viswanath A, Assessment of preemptive analgesic effects of
Caldolar vs Ofirmev on third molar Surgery: A prospective, Randomized, double-blinded pilot study. Oral Surgery, Oral Medicine, Oral
Pathology & Oral Radiology, Feb 2017; 123(2): e25-e25. 1p. (Article) ISSN: 2212-4403

Johnson, Robert E 3rd; Eckert, Pasquale P; Gilmore, William; Viswanath, Archana; Finkelman, Matthew; Rosenberg, Morton B, Most
American Association of Oral and Maxillofacial Surgeons Members Have Not Adopted the American Society of Anesthesiologists-
Recommended Nil Per Os Guidelines; Journal of Oral & Maxillofacial Surgery (02782391), Oct 2016; 74(10): 1926-1931

English, III, Ray; Ashrafi, Alireza; Sabooree, Sepideh; Boulos, Mina; Viswanath, Archana, Postdischarge nausea and vomiting following
third molar extractions under ambulatory anesthesia, Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology. May 2015
119(5):e254-e255

Ashrafi, Alireza; Sabooree, Sepideh; Papageorge, Maria; Rosenberg, Morton; Schumann, Roman; Viswanath, Archana, The evaluation
of a noninvasive respiratory volume monitor in patients undergoing dental extractions during moderate sedation. Oral Surgery, Oral
Medicine, Oral Pathology & Oral Radiology , May 2014, Vol. 117 Issue 5, pe330-e330,

Viswanath, Archana; Kerns, Timothy J.; Sorkin, John D.; Dwyer, Diane M.; Groves, Carmela; Steinberger, Eileen K.,. Self-reported oral
cancer screening by smoking status in Maryland: trends over time. Journal of Public Health Dentistry, Fall2013, Vol. 73 Issue 4, p261-
270, 10p. Publisher: Wiley-Blackwell.,

Cunha, C.O.; Pinto, L. M. S.; Sampaio, F. A.; Co PC. Is aerobic exercise useful to manage chronic pain? Revista Dor, v. 17, p. 61-64,
2016.

Costa, Y. M. ; Morita-Neto, O. ; Araujo-Junior, E. N. S. ; Sampaio, F. A. ; Conti, P. C. R. ; Bonjardim, L. R. . Test-retest reliability of

quantitative sensory testing for mechanical somatosensory and pain modulation assessment of masticatory structures. Journal of Oral
Rehabilitation (Print), p. 197-204, 2016.

Furquim B. D ; Pinto-Fiamengui L. M. S; Conti P. C. R. . DTM e dor crônica: uma visão atual. Dental Press Journal of Orthodontics, v.
20, p. 127-133, 2015

Stuginski-Barbosa J ; Silva Rafael dos Santos; Cunha C.O. ; Bonjardim L. R; CONTI, Ana Cláudia C F ; CONTI, P. C. R. . Pressure
pain threshold and pain perception in temporomandibular disorder patients: is there any correlation? Revista Dor, v. 16, p. 22-26, 2015.

Cunha C. O.; Pinto L. M. S.; Lauris J. R. P. ; Castro A. C. P. C.; Conti P. C. R. . Determination of a pressure pain threshold cut-off value
for the diagnosis of temporomandibular joint arthralgia. Journal of Oral Rehabilitation (Print), v. 41, p. 323-329, 2014.

Pinto L. M. S.; Carvhalo J. J. F.; Cunha C. O.; SILVA, Rafael dos Santos; Fiamengui Filho, JF; CONTI, PCR . Influence of myofascial
pain on pressure pain threshold of masticatory muscles in women with migraine. The Clinical Journal of Pain , v. 29, p. 362-365, 2013.

Conti PCR; Pinto L.M.S; Cuhna C. O.; Conti, ACCF . Orofacial pain and temporomandibular disorders ? the impact on oral health and
quality of life. Brazilian Oral Research (Impresso), v. 26, p. 120-123, 2012.

Orotogpsa C; Pinto L.M.S ; Mendoca, L. M. ; Saldanha Aline Dantas Diógenes ; CONTI, Ana Cláudia C F ; Conti P. C. R. . Bilateral
asymptomatic fibrous-ankylosis of the Temporomandibular Joint associated to rheumatoid arthritis: a case report. Brazilian Dental
Journal (Impresso), v. 23, p. 779-782, 2012.

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i https://www.nidcr.nih.gov/research/data-statistics/facial-pain/prevalence (accessed March 2019)

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ii List, T., Jensen, R. H.; Temporomandibular disorders: Old ideas and new concepts. Cephalalgia, 2017 37(7), 692-704
iii
Schiffman E, Ohrbach R, Truelove E, Look J, Anderson G, Goulet JP, List T, Svensson P, Gonzalez Y, Lobbezoo F, Michelotti A,
Brooks SL , Ceusters W, Drangsholt M, Ettlin D, Gaul C, Goldberg LJ, Jennifer A. Haythornthwaite, Lars Hollender, Odont Dr, Rigmor
Jensen, Mike T. John, Antoon De Laat, de Leeuw R, Maixner W, van der Meulen M, Murray GM, Nixdorf DR, Palla S, Petersson A,
Pionchon P, Smith B, Visscher CM, Zakrzewska J, Dworkin SF; Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for
Clinical and Research Applications: Recommendations of the International RDC/TMD; Consortium Network and Orofacial Pain Special
Interest Group; J Oral Facial Pain Headache. J Oral Facial Pain Headache. 2014 Winter; 28(1): 6–27
iv https://www.nidcr.nih.gov/research/data-statistics/facial-pain/prevalence (accessed March 2019)
vVegard Østensjø V, Moen K, Storesund T, Rosén A; Prevalence of Painful Temporomandibular Disorders and Correlation to Lifestyle
Factors among Adolescents in Norway; Pain Research and Management; Volume 2017
vi https://www.nidcr.nih.gov/research/data-statistics/facial-pain/treatment-needs (accessed March 2019)
vii IASP Fact Sheets on Orofacial Pain; https://www.iasp-pain.org/Advocacy/Content.aspx?ItemNumber=1078 (acessessed March 2019)
viii Dao TT, LeResche L.; Gender differences in pain; J Orofac Pain. 2000 Summer;14(3):169-84; discussion 184-95.
ix Channing J. Paller, Claudia M. Campbell, Robert R. Edwards, Adrian S. Dobs;
Sex-Based Differences in Pain Perception and Treatment; Pain Med. 2009 Mar; 10(2): 289–299
xMaixner W,Diatchenko L,Dubner R, Fillingim RB, Greenspan JD, C7 Ohrbach R, Weir B, Slade GD; Orofacial Pain Prospective
Evaluation and Risk Assessment Study – The OPPERA Study.J Pain. 2011 Nov; 12(11 Suppl): T4–T11.e2.
doi: 10.1016/j.jpain.2011.08.002
xi
Pijanowski L, Jurecka P, Irnazarow I, Kepka M, Szwejser E, Verburg-van Kemenade BM, Chadzinska M.; Activity of the
hypothalamus-pituitary-interrenal axis (HPI axis) and immune response in carp lines with different susceptibility to disease. Fish Physiol
Biochem. 2015 Oct;41(5):1261-78. doi: 10.1007/s10695-015-0084-3. Epub 2015 Jun 4.
xii
Tseng, Kong Y, Eippert F; Tracey I; Determining the Neural Substrate for Encoding a Memory MTof Human Pain and the Influence of
Anxiety; ournal of Neuroscience 6 December 2017, 37 (49) 11806-11817
xiii
Turk DC. Psychosocial aspects of chronic pain. In: Benzon HT, Rathmell JP, Wu CL, Turk DC, Argoff CE, Hurley RW, eds. Practical
Management of Pain. 5th ed. Philadelphia, PA: Elsevier Mosby; 2014:chap 12.
xiv
Shueb SS, Nixdorf DR, John MT, Fonseca A, Durham J; What is the impact of acute and chronic orofacial pain on quality of life?
Journal of Dentistry. Volume 43, Issue 10, October 2015, Pages 1203-1210

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Appendix V. Letters from each institution's chief executive officer verifying sponsorship of the program

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