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J Am Dent Assoc, Vol 138, No 2, 231-237.
© 2007 American Dental Association |
TRENDS |
A survey of U.S. and Canadian dental schools
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ABSTRACT |
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 TOP ABSTRACT MATERIALS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Methods. The authors sent an 11-question survey regarding predoctoral teaching of TMDs to the appropriate faculty members in all U.S. and Canadian dental schools either electronically or via the postal service between June and December 2005.
Results. Predoctoral teaching of TMD—both didactic and clinical aspects—has progressed. Some schools, however, do not address these topics adequately, while others teach outdated concepts.
Conclusions. Both qualitative and quantitative standards are needed to ensure that all predoctoral dental students learn about the diagnosis and treatment of nondental orofacial pain problems.
Practice Implications. Owing to the lack of standardized predoctoral teaching of TMD, U.S. or Canadian patients with TMD or facial pain are at risk when seeking appropriate primary care for their problems.
Key Words: Temporomandibular disorder; surveys; education; pain; orofacial
Abbreviations: AAOP: American Academy of Orofacial Pain • AUTOPP: Association of University TMD and Orofacial Pain Programs • CDA: Commission on Dental Accreditation • EU: European Union • OFP: Orofacial pain • TMD: Temporomandibular disorder • TMJ: Temporomandibular joint
The subject of temporomandibular disorders (TMDs) continues to be a source of considerable disagreement among practicing dentists, despite the fact that both basic science and clinical researchers have reached some degree of consensus on many controversial issues in the field. This situation has the potential to cause confusion for new graduates of dental schools as they enter clinical practice. To understand this problem better, we felt it would be helpful to know what these graduates have learned about TMDs in their predoctoral training. To accomplish this, we conducted a survey of all U.S. and Canadian dental schools to determine what they are teaching in this field. We report the results of that survey in this article.
In an article published more than 30 years ago, Greene1 reported the results of a similar survey involving 45 U.S. and Canadian dental schools. At that time, 40 schools returned questionnaires that were used to collect data, while five schools returned incomplete or unanswered forms. Using the terminology of that period, TMDs were divided into organic (pathological) and functional categories. These topics were taught in the same course at 22 schools, and separately at 16 schools; the remaining two schools did not provide adequate information in answer to this question. There were 46 different course titles under which the topics were taught; only three schools included the term "TMJ" (temporomandibular joint) in the title. The organic TMJ topics were presented most often in oral pathology and oral surgery courses, while the functional TMJ topics were discussed in oral surgery, oral diagnosis, occlusion and periodontal courses. Only five created separate courses for covering TMJ topics, while 30 schools created a course on occlusion that featured TMJ issues. However, of 22 schools that created behavioral science courses, only six covered TMJ topics within those courses.
The first attempt to establish a standardized predoctoral TMD teaching program in the United States and Canada was completed in 1990 by the Association of University TMD and Orofacial Pain Programs (AUTOPP), in conjunction with the American Association of Dental Schools. These groups conducted an educational conference at the University of Medicine and Dentistry at New Jersey and developed a document proposing a complete curriculum outline for teaching about TMDs that included educational goals, core content and behavioral objectives.2 This proposal was slated for inclusion in the American Dental Association’s Commission on Dental Accreditation (CDA) guidelines for evaluating and accrediting dental schools.3
A second educational conference was held in 1992 with the goal of discussing educational methodologies for the implementation of formal TMD curriculum guidelines in the dental curriculum. The conference included 64 participants who discussed problem-based learning, decision analysis and computer technology.4 Unfortunately, the detailed guidelines for accrediting U.S. dental schools for more than 50 years were replaced in 1998 by the much broader and less specific guidelines that are being used today, so these TMD curriculum proposals never were implemented as there was no longer any pressure to do so. (The CDA refers to the old guidelines as being "prescriptive" and the new ones as being "outcomes-based" and "competency-based.")
A third educational conference to develop a curriculum for TMDs and orofacial pain (OFP) was held in April 2000 and included more than 130 educators. The main objective of this conference was to enhance the teaching of TMD and OFP to predoctoral dental students.4 The specific goals of the conference were to
Despite the efforts of this and the previous conferences, there are no standardized curricula or requirements to establish guidelines on the teaching of topics associated with TMDs. As a result, the public continues to be at risk of encountering dental practitioners who have had vastly different exposure to these topics in dental school. This article is intended to stimulate further discussion about the necessity of correcting this problem.
We did not perform statistical analyses, as the responses to this questionnaire were descriptive and observational.
We asked each school to describe its situation for teaching TMD using the terms "fragmented" (separate departments that present a few lectures or seminars with no overall organizational plan), "competing" (viewpoints presented by various departments, which may leave the students confused) or "ideal" (well-organized). Twenty-two schools described their situation as fragmented, two schools chose the term "competing," and three stated they had an ideal situation; the remaining 26 schools either did not provide clear answers to this question or did not answer it.
We asked each school about the departments that were responsible for teaching didactic courses on TMD to predoctoral dental students. The departments most commonly identified, in descending order, were prosthodontics/restorative (26 schools), oral medicine/oral diagnosis (22 schools), oral surgery (16 schools) and OFP/TMD (14 schools) (Table 1
MATERIALS AND METHODS
TOP
ABSTRACT
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSIONS
REFERENCES
Measures.
We conducted an 11-question structured survey regarding the predoctoral teaching of TMD in U.S. and Canadian dental schools between June and December 2005. The questionnaire included items about courses in the predoctoral curriculum dealing with relevant basic sciences, as well as questions about didactic materials, clinical courses, and clinical training and experiences that students were exposed to. We sent the questionnaire to the faculty member who was responsible for teaching this topic at each U.S. and Canadian dental school. Whenever possible, we identified the faculty member based on our personal knowledge. Otherwise, we consulted with the American Academy of Orofacial Pain (AAOP), American Academy of Oral Medicine and AUTOPP and searched dental school Web sites for the appropriate faculty member. If we could not identify the appropriate faculty member, we sent the questionnaire to the dean for distribution to an appropriate faculty member. The questionnaire was sent either electronically or via the postal service. We sent the questionnaire a second time if we did not receive a response to the first questionnaire.
RESULTS
TOP
ABSTRACT
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSIONS
REFERENCES
We sent the questionnaires to all dental schools in the United States (n = 56) and Canada (n = 10). Fifty-three of these schools responded, providing a response rate of 80.3 percent. We found that 18 schools (34.0 percent) reported using didactic courses in TMD to teach predoctoral dental students, while the remaining 35 schools (66.0 percent) reported using a combination of didactic and clinical teaching. Seventy-nine percent of schools reported that didactic courses on TMD are presented in the third year and 97 percent reported that clinical training and experiences occur in the fourth year. 
). We analyzed these data further to determine if these departments were the only department or were one of several departments performing that function.
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). We analyzed these data further to determine if these departments were the only department or were one of several departments performing that function.
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).
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). However, 58 percent of the schools still were teaching students to conduct an occlusal evaluation as part of the basic diagnostic work-up, despite the fact that findings from such analyses rarely are relevant to the development of TMDs.5 We were disappointed to find that only 57 percent of the schools included psychosocial history among the information to be collected from each patient, despite the fact that such information is crucial in the diagnosis and management of TMD.6
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). However, fewer than 50 percent of the schools reported teaching physical therapy, behavioral management, or diagnostic or therapeutic anesthetic injections. Occlusal adjustment, either regional (23 percent) or full-mouth (11 percent), still was being taught at a substantial number of the schools.
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DISCUSSION |
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TOPABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Despite the positive developments in TMD education at particular dental schools, it appears that some schools do not adequately address these topics, while in other schools the educators adhere to outdated concepts. At the other end of the spectrum, 10 dental schools in the United States and one in Canada offer postgraduate training programs in OFP and TMD. Indeed, our survey found that the curricula and faculties at these schools provided predoctoral students with good evidence-based and contemporary training in TMDs. A similar scenario would be expected from schools with a strong oral medicine faculty, because these schools generally have a major interest in the diagnosis and treatment of OFP.
The survey participation rate of 80.3 percent was encouraging, indicating a strong interest in this topic, while providing a diverse range of responses from many institutions. Most schools reported teaching didactic courses in the third year, while providing clinical training experiences usually in the fourth year. This seems to be both reasonable and appropriate, as students can best understand the complex nature of TMD after they have been exposed to more basic concepts and principles in the initial years of dental education.
Our finding that only three schools described their TMD teaching situation as ideal is significant, because it suggests that in all of the other schools the topics related to TMD have not been organized systematically within specific departments. Both educators and students are more likely to achieve good outcomes when topics are presented in an orderly and logical manner, rather than in the fragmented manner described by 22 of the responding schools. Furthermore, the finding that prosthodontics/restorative and oral surgery departments often were the primary or only ones responsible for teaching TMD-related topics, both didactic and clinical, should raise some concerns about what kind of information is being presented (Tables 1
and 2). While departmental labels do not automatically reflect either the expertise or the bias of the faculty about TMD issues, there are reasons to expect that oral medicine and OFP/TMD departments would be more knowledgeable about these topics. Because the main disagreement between historical and current concepts of TMD etiology revolves around theories of good versus bad occlusion or ideal craniomandibular relationships, one might expect that prosthodontics/restorative and oral surgery departments would focus more on condylar positions, maxillomandibular skeletal relationships, occlusal interferences and related topics. Given what we now know about the relatively small role that such phenomena play in the etiology of most TMD cases,12–16 we believe that dental students need to be exposed more to current concepts of pain physiology and conservative biomedical treatment strategies.
We were encouraged to see that most schools addressed the basic science topics of anatomy, neurosciences and physiology. However, while some clinical topics were fairly well-covered (pharmacology and pathology), other important ones (behavioral medicine and epidemiology) were addressed by only one-half of the schools. Between two-thirds and three-fourths of the schools taught their students to perform crucial clinical diagnostic procedures (head/neck examination, TMJ and muscle examinations, and history taking). However, only 57 percent taught students to take a psychosocial history, while 58 percent taught them to perform occlusal examinations; the former nearly always yields desirable information,17 while the latter is seldom important in reaching either diagnostic or etiologic conclusions about patients with TMD.5 We were not surprised to learn that 72 percent of schools discussed the use of oral appliances in the treatment of TMDs, and we were encouraged to find that 64 percent discussed the importance of patient education and the value of prescription medications.18 However, we were disappointed to learn that only one-third to one-half of the schools taught their students about physical therapy19; behavioral management6; or the use of anesthetic injections for diagnosis,20 treatment21,22 or both. The use of regional occlusal adjustments was endorsed by 23 percent of respondents, and 11 percent reported teaching full-mouth occlusal equilibration as a TMD treatment modality, despite the recommendation by the National Institute of Dental and Craniofacial Research,23 the International Association for Dental Research Neuroscience Group24 and AAOP10 that irreversible occlusal changes generally should be avoided when treating TMDs.25
In the absence of official guidelines for teaching or sanctions for not teaching students about modern concepts of TMD, it is unlikely that any standardized curriculum for these topics will be adopted in the near future in the United States or Canada. European countries have had similar problems. They, however, have an incentive for developing more uniform teaching practices, as dentists can move freely throughout the European Union (EU) to practice in any country. In response to this challenge, the European Academy of Craniomandibular Disorders recently developed curriculum guidelines for teaching OFP and TMDs in the dental schools in all EU countries. These guidelines are based, in part, on the history in several European countries of teaching comprehensively about normal and abnormal stomatognathic function during all predoctoral years.26,27
One limitation of our study was that it was based entirely on a self-reported questionnaire, and, therefore, it has inherent errors that are associated with such a method. However, the people who were responsible for teaching about TMD to predoctoral students answered all survey questions. Therefore, the answers they provided would appear to be an accurate representation of what is being taught at their institutions. We did not verify the information provided by the faculty members according to the schools’ curricula or syllabi. Nevertheless, considering the high response rate (80.3 percent), it seems that we obtained a broad and diverse representation of what U.S. and Canadian dental schools are teaching about TMDs.
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CONCLUSIONS |
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TOPABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Therefore, we urge the CDA, the American Dental Education Association and the American Association of Dental Examiners, as well as similar agencies in Canada, to emphasize this educational topic at the predoctoral level more firmly and more specifically than they have in the past. At the least, minimum quantitative standards should be set for the time and substance required to cover the management of nondental facial pain problems. This should include an emphasis on the need for multidisciplinary treatment of these disorders, especially for patients who have chronic OFP. It also would seem sensible and prudent that TMD and OFP be included among the accreditation standards for dental education at both the predoctoral and postdoctoral levels. The curriculum for accomplishing this goal inevitably will be different at each school, but hiring of faculty members who are trained in this discipline will go a long way toward ensuring that these topics are presented within an evidence-based framework.
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FOOTNOTES |
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REFERENCES |
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This article has been cited by other articles:
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  M. R. Bucholtz TMD DEBATE J Am Dent Assoc, June 1, 2007; 138(6): 712 - 712. [Full Text] [PDF]
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T. J. Spahl MORE ABOUT TMD J Am Dent Assoc, June 1, 2007; 138(6): 713 - 714. [Full Text] [PDF]
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