Journal of Oral Rehabilitation 2007 34; 475–477

The gap between dental education and clinical treatment in

SUMMARY Implementation of research findings in in the hands of the general dental practitioner.
patient care ideally will follow in a continuous cycle, European dental schools should define additional
and clinical questions from practitioners should amendments to the recently proposed profile and
stimulate research. Even in the most optimal situa- competencies for the European dentist, in order to
tions, there will be a gap between the steady flow of focus on the relevant and current knowledge on tem-
new findings from research and their eventual poromandibular disorders and orofacial pain. These
implementation in clinical practice. In the clinical amendments should address the adequate diagnosis
practice of temporomandibular disorders and oro- and management of non-complex TMD cases and
facial pain (TMD/OFP) simple cases outnumber the the need to refer to a TMD/OFP specialist in complex
more complex cases by far. Therefore, research cases. Professional organizations such as the Eur-
implications for the general dental practitioner, opean Academy of Craniomandibular disorders can
whose patients are rarely represented in research endorse better TMD/OFP education and training.
populations, may differ from what is published and KEYWORDS: temporomandibular disorders, Orofacial
taught. Treatment options like counselling, occlusal pain, dental education
treatments (reversible as a rule and irreversible by
exception) and physiotherapy can be very successful Accepted for publication 11 October 2006

Implementation of research findings in patient care treatment of temporomandibular disorders and oro-
ideally will follow in a continuous cycle, and clinical facial pain (TMD/OFP). This is one reason for the
questions from practitioners should stimulate research. unavoidable albeit acceptable delay between research
Dental education should incorporate new findings into findings and clinical application. Concerns about this
its curriculum, which in turn, should modify clinical gap are only credible if the lag is exaggerated by the
protocols. Examples are the paradigm shift away from quality of dental education. Another concern is that
the formerly believed primary causal role of occlusion differences between the general dental population and
in temporomandibular disorders and the growing referred patient populations are not appreciated when
understanding of other associated mechanisms behind most of what is published and taught is about the latter
orofacial pain, which has impacted diagnosis and group. This skews the research implications for the
management. However, even in the most optimal general dental practitioner whose patients are rarely
situations, there will be a gap between the steady flow represented in the research population. Nevertheless,
of new findings from research and their eventual the development of clinical guidelines or recommen-
implementation in clinical practice. dations based upon new research can help the GDP
It is almost impossible for the general dental practi- deliver ever more adequate patient care.
tioner (GDP) to continuously keep abreast of new Dental faculties can teach their students to critically
developments because of the enormous flow and wide appraise the literature, although it is clear that profi-
range of new knowledge regarding diagnosis and ciency goals are not maintained unless they are put into

ª 2007 Blackwell Publishing Ltd doi: 10.1111/j.1365-2842.2007.01711.x

practice. To implement an efficient and high quality Despite the high prevalence of signs and symptoms of
strategy, dental schools should disseminate the results TMD, the general dental practitioner will rarely be
of critically appraised reviews, clinical guidelines and confronted with complex clinical cases. Thus, TMD
other developments in the respective fields of interest. diagnosis and treatment in a single clinician general
In this era of internet communication, contact with dental practice setting is by default mainly restricted to
students and alumni can easily be achieved, which can simple cases. Taking into account patient preferences,
also stimulate a continuing professional development. treatment options like counselling, occlusal treatments
All these strategies may help the GPD cope with (reversible as a rule and irreversible by exception) and
ubiquitous stream of non-research based non-profes- physiotherapy can be very successful in the hands of
sional information and facilitate a proper perspective. the general dental practitioner.
Dental students exposed to clinical training perceive a Although research findings regarding clinical man-
higher confidence level and state that they would use agement of TMD often seem conflicted, much can be
the theoretical knowledge and clinical skills gained in learned from the available studies. Multifactorial treat-
their private practice (1). ment strategies are hardly necessary in acute orofacial
The Association for Dental Education in Europe pain patients in contrast to the complex patients
(ADEE) recently approved the ‘Profile and Competen- referred to specialist university clinics. But an
cies for the European Dentist’ and distributed it to all evidence-based clinical approach can only be imple-
European dental schools by 7 March 2005 (2). A very mented if general dental practitioners are trained, and
positive development is that communication and inter- dental schools are training their dental students
personal skills are described as a major competency in adequately to diagnose and treat non-complex TMD
this document. In the clinical management of TMD/ cases. They need to be taught when to refer complex
OFP, the doctor–patient relationship with respect to cases, especially given the prevalence of dental pain
confidence, skills, empathy, knowledge, and insight conditions responsible for orofacial pain. Dentists
into beliefs and cognition needs to be optimal. Regard- should thereby be the key first-line professional regard-
ing orofacial pain, the document describes competen- ing diagnosis and management of orofacial pain condi-
cies for ‘assessing orofacial pain, competencies for tions, either in a dental or medical setting.
recognizing maxillofacial problems, the clinical charac- It is clear that undergraduate dental education needs
teristics of acute and chronic craniofacial pain of to address TMD more thoroughly than as suggested by
somatic, neurogenic and psychogenic origin, and for the recent ADEE document proposals, ultimately at the
identifying and diagnosing conditions that require cost of less education in complex pain conditions that
management by the dentist or other health providers, need to be managed in interdisciplinary settings. Nev-
as well as recognizing patient behaviour contributing to ertheless, more comprehensive training in diagnosis
orofacial problems’. Although limited in the scope of and management is better left to the specialty (univer-
the entire dental education, these demonstrate an sity) clinics performing research and management of
increased appreciation for orofacial pain conditions. complex cases.
However, temporomandibular disorders are mentioned European dental schools can additionally define
only once: ‘…be familiar with the diagnosis of tempo- amendments, following the curriculum guidelines
romandibular disorders’. In this respect, the document document (3). Too much attention has been focussed
fails to describe what is needed for competency in the on specialty issues, thereby neglecting the important
diagnosis and management of acute and chronic TMDs, role of the general dental practitioner. The educational
and their role in regular dental treatment. Professional committee of the European Academy of Cranioman-
organizations like the European Academy of Cranio- dibular Disorders is preparing recommendations for the
mandibular Disorders (EACD) and the International examination, diagnosis and treatment of TMD patients
Committee representing the worldwide Academies of and patients with orofacial pain by the general dental
TMD/OFP obviously should play a much more prom- practitioner. These recommendations are targeted at
inent role in spreading current knowledge on TMDs. this primary level of care, and thus may also help to
But the curriculum guidelines documented by the implement the current state of the art assessment,
Educational Committee of the EACD clearly achieved diagnosis and management of temporomandibular dis-
only minimal consideration (3). orders and orofacial pain.

ª 2007 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 34; 475–477

The Dutch TMD/OFP taskforce also produced a the EACD can produce documents that may help to
consensus meant for the general dental practitioner improve the ADEE document. The ADEE review
(4). Following up these initiatives, standard lectures process taking place until 2009 will give those Euro-
have been produced to be presented all over the pean dental schools endorsing better Orofacial pain and
country by recognized TMD/OFP dentists, who act as TMD education the opportunity to help close the gap
local ‘specialists’ for referral by general dental practi- between research and clinical management.
tioners. Physiotherapists in the Netherlands have been
trained to render special care in this field as well. They
References
are invited to follow the courses of the postgraduate
training programs for TMD/OFP specialists once a year. 1. Gonzalez YM, Mohl ND. Care of patients with temporoman-
Registers containing lists of these two kinds of health dibular disorders: an educational challenge. J Orofac Pain.
2002;16:200–206.
care professionals can be used by general dental
2. Plasschaert AJM, Holbrook WP, Delap E, Martinez C, Walmsley
practitioners for referral of patients or to participate in AD. Profile and competencies of the European Dentist. Eur J
(parts of) the management. These kind of bottom-up Dent Educ. 2005;9:98–107.
initiatives will facilitate the communication between 3. Nilner M. Curriculum guidelines for orofacial pain and
‘specialists’ and ‘generalists’. (5). temporomandibular disorders. European Academy of Cranio-
mandibular Disorders. Eur J Dent Educ. 2001;5:136–138.
Despite and because of the cultural differences in
4. Projectgroep Musculoskelettale stoornissen van het kauwstel-
European TMD/OFP education, more general imple- sel. Consensus Diagnostiek en therapie in de gnathologie. Ned
mentation of all of the above needs to be considered if Tijdschr Tandheelkd. 2003;110:281–287.
any improvement in the current situation is to be 5. Steenks MH. Generalists and specialists. Guest editorial.
expected. Much of what is referred to as adequate J Orofacial Pain. 2003;17:95–96.
knowledge in orofacial pain and TMD is already 6. Lund JP, Lavigne GJ, Dubner R, Sessle BJ (eds). Orofacial Pain,
from Basic Science to Clinical Management. The Transfer of
published concisely in Orofacial Pain, from Basic
Knowledge in Pain Research to Education. Quintessence
Science to Clinical Management (6). These viewpoints Publishing Co., Inc., Chicago 2001.
show that any dental school in Europe (and beyond)
can evaluate its curriculum, create a budget, and Correspondence: M. H. Steenks, P.O. Box 25060,
appoint a faculty for implementation. Since these kinds 3508 AB Utrecht, The Netherlands.
of decisions are politically based, organizations such as E-mail: [email protected]

ª 2007 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 34; 475–477