Residency for TMD/Orofacial pain?

[Angle Jr.]

I have a great interest in TMD, and my career goal is to become a TMD specialist. But when it comes to choosing a postgraduate program, I become a bit confused. Some famous people in the field are maxillofacial surgeons. But there are also many orthodontists who are teaching CE courses in TMD. Some other TMD specialists are prosthodontists. I also know some GP’s who have a Diplomate status of the American Academy of Craniofacial Pain and whose practice is concentrated on treating TMD and orofacial pain.

So my question is, which postgraduate program would be the best option if I am primarily interested in TMD? I am also equally interested in orthodontics and occlusion. I spoke with a prosthodontics resident and he told me that prosthodontics residency would be the best. Then what about certificate/MS programs in TMD/Orofacial pain? Many people I know did such residency programs after they did residency either in OMFS, orthodontics, or prosthodontics. Also, is TMD/Orofacial Pain likely to become one of the accredited specialties in the near future? I talked with many people but different people say different things. So I would really appreciate it if someone could give me advice as to which postgraduate program would be the best option for becoming a TMD specialist. Thank you in advance.

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[Dr. Dai Phan]

Hi there,

There is NO such thing as TMD Specialist. To advertise so is fraud since it is not one of 9 recognized specialties. But look in the Yellow pages and Net will give you all sort of "TMD Specialist". Anybody can treat TMD from GP to Public Health. It involves mainly medications, masage therapy, splint and TMD surgery by OS (in very rare cases). Any other treatment modalities are questionable. Many prosthodontists treat TMD because making a splint fall within their specialty. At my hospital, all TMD cases are referred to me for treatment as well obstructive sleep apnea too. DP

 

[Angle Jr.]

Thank you for your advice. One of the prosthodontics residents I know also told me that he would choose prosthodontics residency rather than an MS/certificate program in TMD/Orofacial pain. Since I am also very much interested in occlusion and enjoy manual work, prosthodontics seems to be a suitable option for me. But then I wonder why some schools now have specific MS/certificate programs in TMD/Orofacial pain rather than incorporating them into prosthodontics residency. I would like to go to whichever postgraduate program that prepares me better for treating TMD cases, and I am still not sure if I should choose prosthodontics over those programs which are specifically designed for studying TMD/Orofacial pain… What do you think?

 

[petunia99]

This may be of interest to you.

http://www.urmc.rochester.edu/dentistry/education/clin_post_cert/tmj.cfm

 

[rrc]

So may this:

http://www.aaop.org/vertical/Sites/...ds/{A7B206E6-EA4A-4B00-9C0E-FE3C344B747E}.PDF


Us OMS need good TMJ specialists out there! The more the better!

 

[Angle Jr.]

Thank you very much for the links. These programs sound very interesting. Maybe I should try contacting those directors. Thanks again for your input 🙂 .

 

[toofache32]

Does Jeffery Okeson at U of Kentucky still have a fellowship?

 

[gryffindor]

Here is the link for the program at my old dental school:

http://www.sdm.buffalo.edu/programs/postgrad/tmdmain.html

But I would really double check with them if this program still exists. There are faculty members on that list who are definitely deceased or retired, so they obviously don't update the website very often.

 

[Jediwendell]

Does Jeffery Okeson at U of Kentucky still have a fellowship?

yep
http://www.mc.uky.edu/dentistry/theprog.html

 

[Angle Jr.]

Thanks, everyone 🙂

Edit: I asked some questions here but I deleted them as I realized that those questions were too broad to be answered. I will do more research by myself, and I will post here again when I get some helpful information about TMD residencies 🙂

 

[EuroOMFS]

So may this:

http://www.aaop.org/vertical/Sites/...ds/{A7B206E6-EA4A-4B00-9C0E-FE3C344B747E}.PDF


Us OMS need good TMJ specialists out there! The more the better!

I guess I'll ask this in this tread instead of starting a new one. Do the OMSs in this forum see a lot of TMDs at their program/department and do your attendings generally agree on how to treat them?

We get a LOT of TMD referrals to the department where I'm currently working and as a resident I get my share of these people in the clinic. We have three attendings who "specialize" in TMD and what frustrates me is how their treatment approaches differ, mainly when it comes to do doing surgery.

They agree that for most TMD cases, they'll try conservative treatment to begin with. And most of the time they agree on which kind of surgery to do (arthoscopy/arthrocentes/condylar shaving/discectomy etc.)

What they don't agree on is WHEN to do surgery. One will wait only a few weeks for the conservative treatment to work it's magic, before going in. Another one will drag it out for months or even years, sending the patient again and again to a TMD/Orofacial pain specialist to get the appliance adjusted, physical or behvioral therapy, painkillers etc.

I tend to side with the guy who's quick to do surgery, because it seems to me his patients get better results, but......I don't know. Do you guys have any thoughts?

 

[Dr. Dai Phan]

I guess I'll ask this in this tread instead of starting a new one. Do the OMSs in this forum see a lot of TMDs at their program/department and do your attendings generally agree on how to treat them?

We get a LOT of TMD referrals to the department where I'm currently working and as a resident I get my share of these people in the clinic. We have three attendings who "specialize" in TMD and what frustrates me is how their treatment approaches differ, mainly when it comes to do doing surgery.

They agree that for most TMD cases, they'll try conservative treatment to begin with. And most of the time they agree on which kind of surgery to do (arthoscopy/arthrocentes/condylar shaving/discectomy etc.)

What they don't agree on is WHEN to do surgery. One will wait only a few weeks for the conservative treatment to work it's magic, before going in. Another one will drag it out for months or even years, sending the patient again and again to a TMD/Orofacial pain specialist to get the appliance adjusted, physical or behvioral therapy, painkillers etc.

I tend to side with the guy who's quick to do surgery, because it seems to me his patients get better results, but......I don't know. Do you guys have any thoughts?

I see about 5 TMD patients a month and the treatment I provide is reversible and conservative. That means a properly made TMJ splint, medications and home self-care physical therapy. I do not refer to OS for considerations for surgery unless the disease is getting worse and it is interfering with the patient's ability to function. It is interesting but not suprising that each doctor within his specialty suggests what is best for the patient. Many patients who have gone to their OS were offered surgery, or were offered chiropratic adjustments by their chiropractors or with orthodontic treatment by their orthodontists. I believe that conservative treatment based on sound evidence should be tried first with surgery as the last resort. You will be amazed of what a properly made TMJ splint can do. DP

 

[Dr. Dai Phan]

I have a great interest in TMD, and my career goal is to become a TMD specialist. But when it comes to choosing a postgraduate program, I become a bit confused. Some famous people in the field are maxillofacial surgeons. But there are also many orthodontists who are teaching CE courses in TMD. Some other TMD specialists are prosthodontists. I also know some GP’s who have a Diplomate status of the American Academy of Craniofacial Pain and whose practice is concentrated on treating TMD and orofacial pain.

So my question is, which postgraduate program would be the best option if I am primarily interested in TMD? I am also equally interested in orthodontics and occlusion. I spoke with a prosthodontics resident and he told me that prosthodontics residency would be the best. Then what about certificate/MS programs in TMD/Orofacial pain? Many people I know did such residency programs after they did residency either in OMFS, orthodontics, or prosthodontics. Also, is TMD/Orofacial Pain likely to become one of the accredited specialties in the near future? I talked with many people but different people say different things. So I would really appreciate it if someone could give me advice as to which postgraduate program would be the best option for becoming a TMD specialist. Thank you in advance.

Hello,

If your goal is to treat TMD patients, then your best bet is to do fellowship in this field and read some good books on TMD subjects such as Okelsson or Dawson. Unless you are OS or ENT, you will see that the treatment options for general dentists are quite limited as splints, medications and self home care are all we can offer. If you look into offices that "specialize" in TMD, you will see that other treatment modalities offered to patients are highly questionable. Do not offer dubious treatments and get yourself in trouble. A few years back, I had one case that a patient was seen by one of the offices that he found in the yellow pages. The total cost was around 3 grands. What he got was a splint (more of a sport mouthguard), chiropractic adjustments, some sessions hooked up to a machine, "TMJ massage" by a therapist and a script for NSAIDS. When the symptoms did not get better he came to see me. I then made him a hard splint, placed him on SSRIs and instructed self care instruction. He did well on that regimen. I often tell my patients beware of the offices that advertise their staff as "TMD Specialists" and charge an arm or a leg with unsounded services. DP

 

[EuroOMFS]

I believe that conservative treatment based on sound evidence should be tried first with surgery as the last resort. You will be amazed of what a properly made TMJ splint can do. DP

Very true. It's when cons. treatment fails we go in. I should point out that very many of our patients don't get to surgery at all, because the conservative treatment works well.

With cons. treatment some patients get better, just not pain-free. Often their headache and muscle soreness will get better but they continue to have restricted mouth opening because of joint pain that isn't helped with a properly made splint. It's those cases that could be helped with eg. arthrocenteses. Now, here some are quick to go in, others will wait and try different things before saying: "OK. Lets just flush out those bad prostaglandins!".

I'm not debating the role of conservative and reversable treatment in TMD, I agree a 100%. Its the difficult cases I'm talking about. How long should one try before resorting to surgery. Now, arthrocenteses for example is a very simple and safe procedure and one that doesn't change the TMJs physical structure in any permanent way. I'd even argue it's "conservative". Yet some will not use it unless really pushed into a corner.

Another thing is chronic (painful) clicking. I'd think this is an extremely difficult thing to treat, because sometimes it's not just the pain, but also the noise that's troubling the patient. A good splint can eliminate the pain, but eliminating the clicking is more difficult with a splint. A vertical ramus osteotomy is a realitively risk free procedure that has about 85 - 90% success rate in eliminating both pain and clicking. What should we recommend to these patients? All I'm saying is that surgery certainly has a role in TMD.

 

[Doggie]

arthrocenteses for example is a very simple and safe procedure and one that doesn't change the TMJs physical structure in any permanent way. I'd even argue it's "conservative". Yet some will not use it unless really pushed into a corner.

I actually got to do one in the OR with one of my attendings. Pop 2 needles into the joint space and pump it full of saline and steroid. It was pretty easy and quick although my attending pointed out that the entire procedure cost only $60. YIKES!

 

[Dr. Dai Phan]

Very true. It's when cons. treatment fails we go in. I should point out that very many of our patients don't get to surgery at all, because the conservative treatment works well.

With cons. treatment some patients get better, just not pain-free. Often their headache and muscle soreness will get better but they continue to have restricted mouth opening because of joint pain that isn't helped with a properly made splint. It's those cases that could be helped with eg. arthrocenteses. Now, here some are quick to go in, others will wait and try different things before saying: "OK. Lets just flush out those bad prostaglandins!".

I'm not debating the role of conservative and reversable treatment in TMD, I agree a 100%. Its the difficult cases I'm talking about. How long should one try before resorting to surgery. Now, arthrocenteses for example is a very simple and safe procedure and one that doesn't change the TMJs physical structure in any permanent way. I'd even argue it's "conservative". Yet some will not use it unless really pushed into a corner.

Another thing is chronic (painful) clicking. I'd think this is an extremely difficult thing to treat, because sometimes it's not just the pain, but also the noise that's troubling the patient. A good splint can eliminate the pain, but eliminating the clicking is more difficult with a splint. A vertical ramus osteotomy is a realitively risk free procedure that has about 85 - 90% success rate in eliminating both pain and clicking. What should we recommend to these patients? All I'm saying is that surgery certainly has a role in TMD.

Excellent input into this topic! Suprisingly, 99% of my TMD patients do not wish to have any kind of surgery done. Perhaps it is due to the fact that these patients are not properly informed or advised? In this field, unless more research are done to determine the efficacy of different types of treatments for each diagnosis, it all depends on the doctor perference. As a prosthodontist, I could only offer prosthetic option that provide optimum position of the condyles with ideal occlusal contacts and excursions. DP