Abstract

Temporomandibular Disorders (TMDs) affect a substantial proportion of dental patients, yet they remain underrecognized and undertreated. Limited training in TMD screening and initial management is a persistent barrier to clinician preparedness and appropriate patient referral. As oral health care increasingly embraces interprofessional models of care, integrating TMD screening and interdisciplinary collaboration into dental training and clinical workflows represents an important opportunity to improve patient outcomes in this chronically underserved population. This short communication reports the implementation and initial outcomes from a dental medicine-Physical Therapy (PT) TMD screening and referral activity. Evidence-based TMD screening instruments were incorporated into routine clinical workflows for patients initiating dental care and for those who developed TMD symptoms during ongoing treatment. The program generated clinically meaningful insights: 81 patients developed TMD symptoms while receiving dental care and were referred for screening consultation in PT yet fewer than half of patients who screened positive for a painful TMD completed the recommended referral. The findings highlight the need to screen TMD symptoms during dental care and that identification of TMD-related symptoms and referral alone is not enough to ensure successful interprofessional care delivery. The results underscore challenges in translating evidence-based screening into clinical action. This communication provides practical, scalable strategies for integrating TMD screening, referral and interprofessional collaboration into routine dental practice with relevance for clinical dental education, patient-centered dental care around TMDs, interprofessional pathways and quality improvement initiatives aimed at enhancing the early recognition and management of TMDs in dental practice.

Keywords: Temporomandibular Disorders; Physical Therapy; Dental Practice

Introduction

In 2020, the National Academies of Sciences, Engineering and Medicine Committee on Temporomandibular Disorders (TMDs) released a consensus report which highlighted multiple challenges and failings of the healthcare system in the care of individuals with TMDs [1]. TMDs are a group of more than 30 painful and/or dysfunctional conditions related to the muscles of mastication, temporomandibular joints and related structures that can be associated with other systemic medical conditions [1-5]. Current evidence recognizes TMDs as multifactorial conditions that can transition to chronic pain states necessitating individualized and initial conservative management within a biopsychosocial model of care [6,7]. Mechanical strain or injury to the temporomandibular joint, including prolonged or excessive mouth opening during dental procedures, may precipitate or exacerbate TMDs in susceptible individuals [8].

Dental providers should utilize validated TMD screening tools to allow early identification of symptom onset to appropriately guide initial evidence-based treatment strategies which include supported self-management and Physical Therapy (PT) [9]. Identification and appropriate management of symptoms when they first develop can be critical to preventing development of chronic pain and disability. Despite recommendations to include TMD screening for all patients receiving dental care [10], it may not always be a routine part of dental practice. Additionally, dentists often lack specific strategies, including interdisciplinary referral, to appropriately manage patients who develop TMD pain during dental treatment contributing to the medical-dental divide that patients can fall into [11].

Early and reliable identification of individuals with TMDs can have a significant impact on their prognosis by helping to prevent the development of persistent pain [1]. Exposure to patients with TMDs during dental training has been shown to improve confidence, competence and knowledge retention although challenges exist in providing authentic TMD patient experiences during training [12-14]. Limitations in dental training in TMDs is a challenge to implementing appropriate screening and referral in TMD care [1]. In 2022, the Commission on Dental Accreditation mandated the inclusion of education on TMDs in all U.S. predoctoral dental programs. However, while dental training programs work to implement TMD content into dental education, no such imperative is present for practicing dentists [14]. Promoting interdisciplinary collaboration and appropriate screening for TMDs during dental training is an essential component to improving competence in appropriate management and interprofessional communication around TMDs, but this needs to be extended to practicing dentists.

Prior to the start of this initiative, existing clinical dental faculty did not have training in orofacial pain or practical application of patient management for TMDs beyond oral appliance therapy and there was no clear mechanism of clinical action if a patient developed TMD symptoms during dental treatment, leaving patients potentially underserved and untreated. This is similar to the situation that can be seen in general dental practice, particularly around lack of interdisciplinary collaboration [15]. This communication paper describes the implementation of an interdisciplinary dental medicine and PT program for TMD screening and referral in an academic dental clinic that is scalable to other practice types. Prior to this program initiative, there was no formal method of clinical screening for TMDs at the dental clinic. Additionally, there was no clinical interaction or mechanism to facilitate interdisciplinary care/referral between dentistry and PT. This communication shows how TMD screening and referral was implemented at a dental clinic utilizing current recommendations for TMD screening and initial management [9]. It provides data to show the number of patients impacted, highlighting key barriers to program success with potential solutions to improve interprofessional clinical program enactment and improvement. Lessons learned from this program can inform dental providers around initial TMD screening and care.

Methods

Participants

All patients receiving care at one multispecialty dental clinic at Midwestern University, Downers Grove, IL USA from October 2022 to September 2023 were included. Institutional review board approval was granted (IRB # 24002) for a retrospective review of Electronic Health Records (EHRs) to track patient outcomes. Student dentists (end of year two of training) were instructed in physical exam and history items specific to red flag screening items for non-odontogenic orofacial pain, screening for TMD-related pain using a validated pain screener (Table 1), documentation within the dental EHR system and the process for referral to Physical Therapy (PT) if needed for implementation during their clinical training activities (third and fourth training years).

TMD Screening Program

The objective of the program was to implement a process for screening all patients for painful TMD symptoms accepted to dental care, to provide a clear mechanism of action for students when a patient screened positive by collaborating with the PT at the same institution and to track program outcomes. The two-year pre-clinical dental curriculum is designed to prepare students for third- and fourth-year clinical activities at the Multispecialty Clinic. Didactic courses in the dental curriculum already covered onset, etiology, pathogenesis and progression of TMDs, diagnostic classification, screening and evaluation of TMDs, oral appliance therapy and interprofessional practice in TMD related to collaboration between PT and dentistry. However, prior to this program initiative, there was no carryover of didactic content to clinical activities at the clinic and no standardized method to screen for TMDs in patients beginning dental care or to act on any TMD related symptoms developed during dental care. As such, a TMD screening activity was embedded into the dental workflow to provide guidance and a mechanism for interdisciplinary referral. Shown in Fig. 1 is the four-part TMD screening and referral process implemented for this initiative in all patients accepted for dental treatment. Prior to being accepted for dental treatment, patient presentation was evaluated by dental faculty for suitability and complexity of dental care as appropriate for dental treatment by student dentists. Individuals who presented with complex medical conditions were not accepted for dental treatment and this included non-odontogenic facial pain. The initial step when a patient was accepted for treatment was a comprehensive dental examination from an assigned student dentist under supervision of a dental faculty preceptor to determine an appropriate dental plan of care. The total number of dental comprehensive examinations completed during the program period was 2,781.

Specific screening components for painful TMDs were added to the dental EHR (axiUm; axiUm Academic Dental Software, Exan Software, Las Vegas, Nevada) at the clinic for completion during the comprehensive examination of every dental patient. Additionally, TMD screening was to be enacted at any subsequent dental visit when a patient reported new facial pain complaints. The TMD screening tool was a previously validated screening questionnaire (Table 1) which has shown a sensitivity of 0.99 and a specificity of 0.97 for correct classification of the presence or absence of pain-related TMDs [16]. According to published thresholds [16], if the score on this self-reported screening was 3 points or more (range from 0 to 7), the student dentist, in collaboration with their faculty preceptor, was expected to initiate a consultation for the patient for a more in depth TMD screening consultation to be conducted by PTs at the Physical Therapy Institute at the same institution. However, since PT used a different EHR system than dental, referral to PT for additional screening examination was made via a faxed consultation order requesting additional screening examination and initial management recommendations.

For individuals who screened positively for likely TMD pain, a 15-minute no cost additional screening consultation was scheduled either as an in-person visit or a telehealth visit based on patient preference using a secure web platform. Clinical PT faculty with experience in TMDs completed the additional screening consultation examination items (Table 2) to guide decision making and recommendations [17]. One of 4 possible recommendations were provided to the patient and student dentist at the end of the additional screening examination (Table 3).

Outcomes

EHR records were searched to identify the number of patients who screened positive for painful TMDs after being accepted for dental treatment, the number of consultation requests made to PT, the number of patients who declined or did not pursue recommended PT screening referral and the breakdown of PT screening referral recommendations. Data were used to identify barriers and solutions to inform program refinement and dental practice workflow.

Figure 1: Impact of TMD student screening activity.

Table 1: TMD screener [16].

Table 2: Additional TMD screening activities and care recommendations.

Table 3: Additional TMD screening activities and care recommendations.

Results

During the program period, 81 patients screened positive for TMD-related pain during dental treatment and almost all (97.5%) were documented as being referred for additional TMD screening examination in PT (Fig. 1). However, less than half (48.1%) of those that screened positive at the initial visit had a consultation request to PT that was acted on. The top two reasons identified for non-completion of in depth TMD screening consultation were patient related (non-follow-up for scheduling) and procedure related (e.g. lost or missing referral fax). However, the primary procedural barrier to effective referral was identified as problems related to missing interprofessional communication records (lost or no faxed referrals, no return communication on patient status etc.). Of the patients who were scheduled for PT follow-up screening consultation, 3 patients did not attend their scheduled appointment. Of the remaining 35, 62.8% additional screening visits were conducted using telehealth versus an in person visit based on patient preference. Three patients (8.5%) who completed the additional screening visit were determined to not have a painful TMD or other red flags despite the initial dental TMD screening finding and were returned to dental care. Fourteen patients were provided with self-management strategies and returned to dental care, while 18 were recommended to complete a full TMD examination for structured care and management in PT with all but 3 of those patients recommended continuing dental care with concurrent PT support. Three patients were recommended to halt non-urgent dental care until TMD symptoms were under control through a structured PT care plan for their TMD symptoms.

Discussion

This interdisciplinary program was designed to close a care gap for patients who developed TMD symptoms during dental treatment at an academic dental clinic. The screening program identified 81 patients who developed TMD symptoms while receiving dental care, yet fewer than half of patients who screened positive for a painful TMD completed a recommended PT consultation. These findings highlight the gap between identification of TMD-related symptoms and successful interprofessional care delivery, underscoring important challenges in translating evidence-based screening into clinical action. By examining implementation barriers and facilitators, this paper provides practical strategies for integrating TMD screening, referral and interprofessional collaboration into routine dental practice. 

Implementing a simple screening process and interprofessional referral strategy for individuals who develop TMD symptoms during dental care can help to address a prevalent care gap for individuals with TMDs. Interdisciplinary collaboration is consistent with recommendations for biopsychosocial management for individuals with TMDs [7,8]. Providing practical experience to student dentists during training may help to improve confidence around TMD care, a known training deficit, offering the possibility that dental students will continue TMD screening and interdisciplinary collaboration after graduation [12]. Additionally, this interdisciplinary process offered guidance and an established framework to dental faculty, who may not have had expertise to evaluate presence and severity of TMD signs and symptoms.

While the program effectively identified patients who would otherwise not have had a resource to investigate their TMD symptoms, not all patients completed the additional screening and therefore did not receive support or additional review. The primary procedural barrier identified to explain this interruption in the provision of TMD care was ineffective communication between disciplines (dental and PT), despite them being located in the same building under the same organizational umbrella. Utilizing different EHRs that did not communicate directly with each other also proved to be a significant procedural barrier that needed to be overcome. It was challenging for all involved, including patients, to monitor referral and completion status and close the interdisciplinary communication loop. Later, the multispecialty clinic implemented a single EHR across all dental and medical departments (Epic Systems Corporation, Verona, WI) with a goal of efficiently and effectively improving interprofessional communication and referral tracking, as well as allowing patients to access and follow through with care recommendations. Interdisciplinary referral and communication are one potential barrier that must be overcome with TMD screening initiative in private practice settings.

Lack of awareness among dentists of evidence-based management options such as PT can be a barrier to enacting interprofessional practice [15] despite the strong evidence base for PT in all forms of TMDs, cervical and myofascial pain and other pain conditions [18-28]. This interdisciplinary TMD screening and referral program was facilitated by the availability of PT faculty with training in TMDs. Establishing a clear referral pathway between dentistry and PT would be needed to facilitate patient care in TMD in other settings. For dental practices without embedded PT and dental services, the framework developed is adaptable although dentists will need to locate physical therapists in their community to collaborate with. While minimal resources are required to embed TMD screening into a clinical workflow pathway, referral pathways need to be clearly identified a priori. Referral can be scaled to include other disciplines consistent with recommendations for multidisciplinary care needs for individuals with more complex forms of TMDs including primary care, behavioral health and orofacial pain specialists.

Limitations of this program include the lack of a method to assess if TMD screening was appropriately enacted for all dental patients and thus the number of patients who developed TMD pain during dental care may have been under reported. Additionally, not tracking how dental care was modified based on screening results precludes understanding how dental treatment was impacted. The retrospective nature of the study did not allow us to gather data regarding reasons why patients may not have completed recommended follow-up. Future exploration is planned to examine how TMD care changed with a single EHR system and the addition of a dental faculty member with residency training in orofacial pain. Despite these limitations, this program underscores the value of leveraging existing institutional partnerships and incorporating interprofessional care into dental education and practice with the ultimate goal of providing quality patient care and closing the care gap for individuals with TMDs.

Conclusion

An interprofessional referral program for patients who developed TMD symptoms during dental care can be enacted to help address care gaps but does present challenges in closing communication loops between disciplines, especially when different EHRs are used.

Conflict of Interest

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding Statement

This research did not receive any specific grant from funding agencies in the public, commercial or non-profit sectors.

Acknowledgement

The authors have no acknowledgments to declare.

Data Availability Statement

The data supporting the findings of this study are available from the corresponding author upon reasonable request.

Ethical Statement

The project did not meet the definition of human subject research under the preview of the IRB according to federal regulations and therefore was exempt.

Informed Consent Statement

Informed consent was obtained from all participants included in the study.

Authors’ Contributions

All authors contributed equally to this paper.

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