The importance of teaching dental students

Transcription

1 Assessment of Diagnosed Temporomandibular Disorders and Orofacial Pain Conditions by Predoctoral Dental Students: A Pilot Study Shawn S. Adibi, DDS, MEd; Krishna Kumar Kookal, MS; Nichole M. Fishbeck; Chris R. Thompson; Muhammad F. Walji, PhD Abstract: Temporomandibular disorders and orofacial pain (TMD/OFP) conditions are challenging to diagnose for predoctoral dental students due to the multifactorial etiology, complexity, and controversial issues surrounding these conditions. The aim of this study was to determine if patients in the clinic of one U.S. dental school reported existing signs and symptoms of TMD/ OFP, whether the dental students diagnosed the condition based on the reported signs and symptoms, and if the condition was then treated. The study was based on a retrospective analysis of electronic health record data over a three-year period. The results showed that, during the study period, 21,352 patients were treated by student providers. Of those patients, 5.33% reported signs or symptoms associated with TMD/OFP; 5.99% received a TMD/OFP diagnosis; and 0.26% received at least one form of TMD/ OFP treatment that had either a diagnosis or signs/symptoms of TMD/OFP. In addition, a small percentage (0.24%) of patients with no documented diagnosis received some sort of TMD/OFP-related treatment. A randomly selected sample of 90 patient charts found that no diagnoses of TMD/OFP were recorded in any of them. The results suggested that students had only marginally diagnosed the problems. Training for students including comprehensive didactic courses and clinical experiences to gain knowledge, context, and skill may be required to ensure they reach the required level of competence and prepare them to face the diagnostic challenges of TMD/OFP after graduation. Dr. Adibi is Associate Professor, Department of General Practice and Dental Public Health, The University of Texas School of Dentistry at Houston; Mr. Kookal is Clinical Informatics Research Data Warehouse Systems Analyst, Technology Services and Informatics, The University of Texas School of Dentistry at Houston; Ms. Fishbeck is a senior dental student, The University of Texas School of Dentistry at Houston; Mr. Thompson is a senior dental student, The University of Texas School of Dentistry at Houston; and Dr. Walji is Professor and Associate Dean, Department of Diagnostic and Biomedical Sciences, The University of Texas School of Dentistry at Houston. Direct correspondence to Dr. Shawn Adibi, Department of General Practice and Dental Public Health, The University of Texas School of Dentistry at Houston, Suite 5429, 7500 Cambridge Street, Houston, TX 77054; ; shawn.adibi@uth.tmc.edu. Keywords: dental education, temporomandibular disorders, orofacial pain, oral pain management Submitted for publication 4/13/16; accepted 5/30/16 The importance of teaching dental students about temporomandibular disorders and orofacial pain (TMD/OFP) conditions and about evidence-based solutions to these conditions has long been emphasized by the American Dental Education Association (ADEA). 1 The ADEA Competencies for the New General Dentist, approved by the 2008 ADEA House of Delegates, include the diagnosis and management of TMDs as a core competency (6.9). 2 ADEA s emphasis on the need for TMD/OFP education is based on the prevalence of these conditions in the U.S. population. According to the National Institute of Dental and Craniofacial Research (NIDCR), up to 12% of the population is affected by TMD, leading to $4 billion in health care costs. 3 Okeson reported that 75% of the population has at least one sign of joint dysfunction and at least 56% show clinical signs of TMD. 4 In another study, TMD prevalence in the general population was found to be about 10-12%, but only 3-4% of the population were actively seeking treatment. 5 Most TMD/OFP conditions present with clinical waxing and waning symptoms, thus making them challenging for patients to recognize and care providers to treat. A study by de Kanter et al. found that, of all the dysfunction-reporting subjects with moderate to severe clinically assessed dysfunction, only onethird to half of the patients who experienced pain sought treatment. 6 Reports on prevalence of TMDs from cross-sectional epidemiological studies vary considerably from study to study because of differences in descriptive terminology, data collection, analytic approaches, and individual factors selected for study. 7 A recent systematic review using Research 1450 Journal of Dental Education Volume 80, Number 12

2 Diagnostic Criteria for Temporomandibular Disorders reported a prevalence of up to 13% for masticatory muscle pain, up to 16% for disc derangement disorders, and up to 9% for temporomandibular joint (TMJ) pain disorders in the general population. 8 That totals 38% for all three conditions, although another meta-analysis showed a prevalence of 45.3% for group I muscle disorder diagnoses, 41.1% for group II disc displacements, and 30.1% for group III joint disorders. 9 It is our opinion that there are two significant potential pitfalls for novice or inexperienced practitioners in diagnosing and treating TMD/OFP. One involves the ability to understand patients chief complaint and underlying complex etiologies with thorough history-taking skill, and the other is claiming premature success in a not necessarily evidence-based treatment modality prescribed when patient compliance is absent or the patient s return for evaluation is an issue. In 1993, the International Association for the Study of Pain proposed a comprehensive outline of curricula on pain for dental education at both the predoctoral and postdoctoral levels. 10 Borromeo and Trinca assessed the understanding of basic OFP concepts among dental students and general dentists in Australia and found that only 48% of practicing dentists scored correctly on a test on pain knowledge. 11 Without a dedicated and comprehensive course in TMD/OFP, there are risks of gaps in dentists competence in diagnosing and treating those conditions. This need supports the importance of a comprehensive course covering this discipline for predoctoral students. 12 Simm and Guimaraes s study of education in TMD/OFP at the undergraduate level in 53 Brazilian dental schools found minimal teaching of pain-related disorders in the orofacial region and found that the departments responsible for these topics dedicated 5% or less of their time to teaching pain mechanisms. 13 In a survey of senior dental students in several schools to assess their perception of competence in TMD/OFP, Greenwood et al. found that perceptions of competence increased as theory and practical teachings were integrated. 14 Alsafi et al. compared undergraduate dental schools throughout Europe and found that it was not only essential to gain competence in TMD/OFP but to experience a sufficient level of clinical exposure to patients with TMD/OFP conditions. 15 Those researchers also found that clinical experience immediately after didactic and theoretic exposures enhanced students learning. A survey of U.S. and Canadian dental schools by Klasser and Greene found a lack of standardized predoctoral teaching of TMD/OFP, which puts populations at risk when seeking appropriate primary care for their problem. 16 Of the 53 schools participating in that study, only three described their TMD teaching situations as ideal. The other 50 schools reported that their teaching on the subject of TMD was not organized systematically in specific departments. Educators and students are likely to achieve desired outcomes when topics are presented in an orderly and logical manner, as opposed to a fragmented and unsystematic fashion. 16 Gonzalez and Mohl argued that predoctoral programs should focus on detection, evaluation, differential diagnosis, and management of the most common types of conditions encountered by general practice environment. 17 Those investigators also found that differential diagnosis and clinical judgment are essential components in understanding the differences between evidence-based care and care resulting from purely anecdotal information. As with the importance of clinical teaching, gaining prerequisite knowledge in biology, physiology, biochemistry, and oral sciences before preclinical and clinical components, in an integrated fashion as early as the second year, is the most desirable arrangement. 18 To achieve that goal, dental schools must assess the current status of TMD/ OFP teaching in their curricula, identify deficiencies and shortcomings, and address those barriers effectively. As a first step in that process, the aim of this study was to determine if patients in the clinic of The University of Texas School of Dentistry at Houston reported existing signs and symptoms of TMD/OFP, whether the dental students diagnosed the condition based on the reported signs and symptoms, and if the condition was then treated. Methods The University of Texas School of Dentistry at Houston Institutional Review Board approved this pilot study (HSC-DB ) with an exempt status because no protected health information was abstracted. In this study, we queried the axium electronic health record (EHR) at The University of Texas School of Dentistry at Houston and conducted a retrospective chart review. The EHR was queried over a three-year period (9/1/2011 through 8/31/2014) to determine the following: 1) number of patients under the care of predoctoral dental students who were diagnosed with TMD/OFP (see Table 1 December 2016 Journal of Dental Education 1451

3 Table 1. Subcategories of temporomandibular disorders in the Dental Diagnostic System of the electronic health record Subcategories 1. Altered Sensation 2. TMJ Disc Displacement 3. TMJ Joint Diseases 4. Masticatory Muscle Disorder, extrascapular 5. TMJ Congenital/Developmental Disorders 6. Headache 7. TMJ Clicking 8. TMJ Pain 9. TMJ Joint Sounds/Noises 10. TMJ Limitation of Motion 11. TMJ Mobility Disorders-Joint Based, intracapsular and Table 2 for lists of diagnoses used in the EHR); 2) number of patients who answered yes to specific questions in various forms in the EHR indicating TMD/OFP, such as facial pain, pain in jaw, habitual clenching or grinding during day or night, and popping, clicking, or other noises from the jaw (Table 3); and 3) number of patients who did or did not receive TMD/OFP treatment during the study period with selected category and subcategory codes, treatment codes, and form questions. The CDT codes usually used for TMD/OFP patients were D7880 occlusal orthotic device, by report; D7899 unspecified TMD therapy, by report; D9940 occlusal guard, by report; and D9942 repair and/or reline of occlusal guard. The study was facilitated by the recent adoption and use of the Dental Diagnostic System (DDS) in the school s EHR. 19 The DDS allows clinical providers to document a structured diagnosis using a standardized terminology. The use of DDS can be fundamental to developing diagnostic reasoning skills with experiences that utilize critical thinking skills. Promotion of a dental diagnostic terminology for use in patient treatment planning, via the axium EHR, has been shown to impact dental students critical thinking skills. 20 Additionally, numbers and types of diagnostic terms selected will shed light on the progress of students learning in particular categories or subcategories. Understanding what our students are diagnosing will reveal the need for treatment types that patient populations in dental schools are demanding. This information is valuable knowledge for the teaching institutions involved. From the larger set of records retrieved from the EHR query, we randomly selected 100 for further interrogation by calibrated chart auditors. Two third-year dental students with past experience in research served as the chart auditors. They were calibrated in a preparatory session to understand the study protocol and chart audit approach. These chart reviewers independently deidentified data. Interrater agreement (Cohen s Kappa) was calculated for the auditors. In case of disagreement, a third reviewer (a senior faculty member) evaluated the case and reached consensus with the other reviewers. Descriptive statistics such as frequency and proportion were determined. McNemar s test was used to examine the agreement on paired dichotomous outcomes. A p-value 0.05 was considered significant. Statistical analysis was done using SAS, Version 9.3 for Windows (SAS Institute, Cary, NC, USA). Results During the three-year study period, 21,352 patients were treated by student providers. A total of 1,138 patients indicated signs or symptoms associated with TMD/OFP (5.33% of study population) (Table 4). However, only 164 (0.77%) of the patients received a TMD/OFP diagnosis. In total, 1,280 patients (5.99% of study population) were either diagnosed with TMD/OFP and/or answered yes to TMD/OFP questions. Only 56 patients (0.26%) received at least one form of TMD/OFP treatment. Fifty-one (0.24%) patients with no documented diagnosis received some sort of TMD/OFP treatment. In the randomly selected 100 records, ten patient charts were excluded from the study as they were found to be virtual patient charts, leaving 90 for analysis. Of these, chart auditors had substantial agreement, with Kappa=0.610 (95% CI: 0.548, 0.672). The audit revealed age ranges of patients who were years of age (as opposed to general patients of the school, whose ages range from infant to 99 years). The mean age of these patients was years with standard deviation of In the study population, 63 were female (70%), and 27 were male (30%), as compared to 57% female patients in the total predoctoral clinic population. The chart audit showed that the completion rate for TMD/OFP assessment screening forms was ten (11.1%) of the patient charts (Table 5). This audit also showed that 76 (84.4%) of the 90 patients responded yes to TMD/OFP-related problems or signs and symptoms in the forms section of the record. However, of the 76 patients who responded yes to TMD in the forms, only eight (10.53%) had 1452 Journal of Dental Education Volume 80, Number 12

4 Table 2. Diagnostic terms related to temporomandibular disorders and orofacial pain in the Dental Diagnostic System of the electronic health record Term Acute TMJ trauma Altered taste Ankylosing spondylitis TMJ Anterior disc displacement w/o reduction (ADD-R)=1 month Anterior disc displacement w/o reduction (ADD-R) >1 month Anterior disc displacement with reduction (ADD+R) Arthrogenous TMD pain ( Arthralgia )=12 weeks Arthrogenous TMD pain ( Arthralgia ) >12 weeks Articular disc dislocation with reduction Articular disc dislocation without reduction Articular disc displacement Atypical neuralgia Bell s palsy Bony TMJ ankylosis Burning mouth/tongue syndrome Capsular fibrosis TMJ Centrally mediated myalgia Condylar agenesis Condylar hyperplasia Condylar hypoplasia Condylar neoplasia Condylar subluxation Coronoid process impedance Deviation in articular disc form Deviation in condyle form Deviation in fossa form Disc to condyle adhesion Disc to fossa adhesion Fibromyalgia Fibrous adhesion/ankylosis Glossalgia Glossopharyngeal neuralgia Habitual TMJ luxation Halitosis Healthy TMJ Hyperuricemia TMJ Incidental TMJ luxation Infectious arthritis TMJ Limited mouth opening with a myogenous origin Term Localized masticatory muscle soreness Masticatory muscle hypertrophy Masticatory muscle hypotrophy Masticatory muscle myospasm Masticatory muscle neoplasia Mucositis Myofascial pain disorder Myofibrotic masticatory muscle contracture Myogenous TMD pain ( Tendomyalgia )=6 months Myogenous TMD pain ( Tendomyalgia ) >6 months Myostatic masticatory muscle contracture Nocturnal bruxism Osseous adhesion/ankylosis Osteoarthritis TMJ Other headache Other internal derangements of the TMJ Partial nonreducing anterior disc displacement (ADD±R) Postherpetic neuralgia Protective co-contraction of masticatory muscles Psoriatic arthritis TMJ Radiation mucositis Retrodiscitis Rheumatoid arthritis TMJ Sialorrhea Spontaneous condylar dislocation Stylomandibular ligament inflammation Symptomatic TMJ hypermobility Synovitis and capsulitis Temporal tendonitis Temporomandibular joint-pain disorder Tension headache TMJ clicking TMJ joint sounds/noises TMJ limitation of motion TMJ pain Traumatic arthritis TMJ Trigeminal neuralgia Unspecified neural condition Xerostomia signs and symptoms in the note, while for the 14 patients who responded no to TMD/OFP in the forms, two (14.29%) had signs and symptoms in the note, demonstrating significant disagreement (p<0.0001) (Table 6). Discussion Our study found that although a large number of patients were seen by students (21,352), only 5.99% had a formal TMD/OFP-related diagnosis documented in their charts (either in the note or using the structured DDS terminology). Out of the 90 randomly selected charts that we analyzed, only six (6.7%) received some sort of TMD/OFP treatment. This percentage is smaller than the expected 10-12% range reported for the general population. 3,5 Knowing that all of the randomly selected population in this study had some signs or symptoms of TMD/OFP but only less than 1% were diagnosed suggests that TMD/OFP-related diagnoses may have not been December 2016 Journal of Dental Education 1453

5 Table 3. Elements in electronic health record related to temporomandibular disorders and orofacial pain Form Name Form Question Medical/Dental History (Full) Facial pain or pain in your jaw joint Pain Clicking/popping Limited opening Other Do you have difficulty, pain, or both when opening your mouth for instance, when yawning? Do you have difficulty, pain, or both when chewing, talking, or using your jaws? Are you aware of noises in the jaw joints? Do your jaws regularly feel stiff, tight, or tired? Do you have pain in or about the ears, temples, or cheeks? Do you have frequent headaches, neckaches, or toothaches? Have you had a recent injury to your head, neck, or jaw? Have you been aware of any recent changes in your bite? Have you previously been treated for unexplained facial pain or a jaw joint problem? Table 4. Results of electronic health record query of records from September 1, 2011 to August 31, 2014 Patient Category Number Percentage Unique patients seen by students 21, % Patients who answered YES to TMD/OFP form questions 1, % Patients diagnosed (using DDS) with TMD/OFP % Patients diagnosed (using DDS) or answered YES to TMD/OFP form questions 1, % Patients who received TMD/OFP treatment (CDT codes) % Patients with no diagnosis, but who received treatment % Table 5. Results of chart audit of randomly selected population (N=90) Data Element Extracted Summary of Data Elements TMD/OFP assessment screening form completion 11.1% (10) Signs, symptoms entries in any form 84.4% (76) TMD entries in note 13.3% (12) Signs, symptom in note 11.1% (10) Was there any TMD/OFP diagnosis in diagnosis section of clinical note? 0 Undergoing TMD/OFP treatment, using diagnostic codes and written note 6.7% (6) Table 6. Signs and symptoms in form by signs and symptoms in note Signs and Symptoms in Note No Yes p-value Signs and symptoms No 12 2 <0.0001* in form Yes 68 8 Note: The p-value was determined by McNemar s test. It suggests that there was disagreement between the signs and symptoms in form and signs and symptoms in note. *Statistically significant at p 0.05 documented in many cases. The number of patients who were either diagnosed or answered yes to the form questions but did not receive any TMD/OFP treatment was 1,280 (5.99% of the study population). Other studies have found that untreated patients could be 56-75% of the general population. 5,6 In our study, many patients charts did not contain completed TMD/OFP assessment forms; this finding indicates patients were not screened properly for TMD/OFP conditions. When signs and symptoms are evident, the intensity of pain or chronic waxing and waning nature of TMD/OFP may 1454 Journal of Dental Education Volume 80, Number 12

6 contribute to the lack of urgency to seek treatment. Therefore, patients and students may have prioritized conditions such as caries and periodontitis over other aspects of care such as TMD/OFP condition, leading to dormant and chronic pain conditions. Future studies are necessary to investigate the evidence base behind this problem. Our study also found a lack of consistency in documenting and addressing the signs and symptoms of TMD/OFP in the patient record. Some symptoms were listed in a problem section and others in the forms section and or in a simple progress note. However, in the randomized selected sample, there were no diagnoses of TMD/ OFP conditions in the diagnosis section of any chart, and only one diagnostic term was found written in the chart. Another possible explanation could be that many students were prepared to list only one diagnosis instead of providing differential diagnoses, or it could be due to lack of knowledge, attitude, and confidence in selecting from the list of diagnoses in the area of TMD/OFP. Since these students had only marginally diagnosed the problems, improved training in diagnosis of TMD/OFP conditions seems to be needed. Currently at this school, there is no dedicated comprehensive course addressing TMD/OFP conditions, which we believe is similar to the situation at many other schools. While relevant material may appear in various courses in the curriculum, a stronger thread may be needed that spans both basic and clinical sciences. Additional activities that focus on treating patients with TMD/OFP conditions would improve students knowledge and skills and aid them in diagnosing and treating TMD/OFP patients. As this study was conducted at one institution, generalization of the findings is not known, which is a possible limitation of the study. In future work, we will seek to expand this research and involve other academic institutions. Another possible limitation is that many of the diagnoses listed in the DDS may fall outside the scope of predoctoral training and practice. The inconsistency of data in the patient records could thus be due to a lack of knowledge, attitudes, or confidence. The intensity of pain or chronic waxing and waning nature of TMD/OFP may lead to a lack of urgency to seek treatment. As a result, students may prioritize other conditions such as caries and periodontitis instead of treating the TMD/OFP. Future studies are necessary to investigate the reasons behind the problems found in this study. It should also be noted that not all signs, symptoms, and diagnoses of TMD/OFP should lead to a treatment. Further evidence-based studies are needed to establish the effectiveness of treatment modalities. Conclusion Our study found that the numbers of patients with TMD/OFP-related diagnoses documented in their charts and those who received some sort of TMD/OFP treatment were below that expected based on the preponderance of these conditions in the general population. As students only marginally diagnosed the problems, stronger didactic courses in both basic and clinical sciences, along with improved training in diagnosing TMD/OFP conditions, seem to be needed. In addition, more research is needed to explore evidence-based treatment modalities in order to enhance the profession s ability to provide care for patients suffering from these debilitating disorders. We must also continue to improve how we teach the available evidence to students and model how to provide care for patients with TMD/OFP conditions. Acknowledgments This pilot study was supported by the Department of General Practice and Dental Public Health. Many thanks to Mr. Stanley Cron for his initial sample size analysis and to Dr. Sangbum Choi for his input on this project. Also, we acknowledge the support provided by the Biostatistics/Epidemiology/Research Design component of the Center for Clinical and Translational Sciences (CCTS) for this project. CCTS is mainly funded by a grant (UL1 TR000371) from the National Center for Advancing Translational Sciences (NCATS), awarded to The University of Texas Health Science Center at Houston. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NCATS. Disclosure The authors reported no conflicts of interest in conjunction with this study. REFERENCES 1. Klasser GD, Gremillion HA. Past, present, and future of predoctoral dental education in orofacial pain and TMDs: a call for interprofessional education. J Dent Educ 2013;77(4): American Dental Education Association. ADEA competencies for the new general dentist. J Dent Educ 2016;80(7): December 2016 Journal of Dental Education 1455

7 3. National Institute of Dental and Craniofacial Research. Facial pain At: FindDataByTopic/FacialPain. Accessed 13 Apr Okeson J, American Academy of Orofacial Pain. Orofacial pain: guidelines for assessment, diagnosis, and management. Chicago: Quintessence, Le Resche L. Epidemiology of temporomandibular disorders: implication for the investigation of etiologic factors. Crit Rev Oral Biol Med 1997;8: De Kanter RJ, Truin GI, Burgersdijk RC, et al. Prevalence in the Dutch adult population and a meta-analysis of signs and symptoms of temporomandibular disorders. J Dent Res 1993;72: De Leeuw R, Klasser GD. Orofacial pain: guidelines for assessment, diagnosis, and management. Chicago: Quintessence, Dworkin SF, Le Resche L. Research diagnostic criteria for temporomandibular disorders: review, criteria, examination, and specifications critique. J Craniomandib Disord 1992;4: Manfredini D, Guarda-Nardini L, Winocur E, et al. Research diagnostic criteria for temporomandibular disorders: a systematic review of axis I epidemiologic findings. Oral Surg Oral Med Oral Pathol Radiol Endod 2011;112: Strong J, Meredith P, Darnell R, et al. Does participation in a pain course based on the International Association for the Study of Pain s curricular guidelines change student knowledge about pain? Pain Res Manag 2003;8(3): Borromeo GL, Trinca J. Understanding of basic concepts of orofacial pain among dental students and a cohort of general dentists. Pain Med 2012;13: Vallon D, Nilner M. Undergraduates and graduates perception of achieved competencies in temporomandibular disorders and orofacial pain in a problem-based dental curriculum in Sweden. Eur J Dent Educ 2009;13: Simm W, Guimaraes AS. The teaching of temporomandibular disorders and orofacial pain at undergraduate level in Brazilian dental schools. J Appl Oral Sci 2013;21(6): Greenwood LF, Townsend GC, Wetherell JD, Mullins GA. Self-perceived competence at graduation: a comparison of dental graduates from Adelaide PBL curriculum and the Toronto traditional curriculum. Eur J Dent Educ 1999;3: Alsafi Z, Michelotti A, Ohrback R, et al. Achieved competences in temporomandibular disorders/orofacial pain: a comparison between two dental schools in Europe. Eur J Dent Educ 2014;18: Klasser GD, Greene CS. Predoctoral teaching of temporomandibular disorders: a survey of U.S. and Canadian dental schools. J Am Dent Assoc 2007;138(2): Gonzalez YM, Mohl ND. Care of patients with temporomandibular disorders: an educational challenge. J Orofacial Pain 2002;16(3): Sessle BJ. Integration of basic sciences into the predoctoral curriculum to study temporomandibular disorders and orofacial pain. J Orofacial Pain 2002;16(3): Kalenderian E, Ramoni RL, White JM, et al. The development of a dental diagnostic terminology. J Dent Educ 2011;75(1): Reed SG, Adibi SS, Coover M, et al. Does use of an electronic health record with dental diagnostic system terminology promote dental students critical thinking? J Dent Educ 2015;79(6): Journal of Dental Education Volume 80, Number 12