The Question

If a profession declares the bite outside the scope of its own practice, what remains of the profession?

That is not a rhetorical opening. That is the structural question facing dentistry today, and it is the question that organized dentistry has so far refused to answer plainly. In 2020, the American Dental Association recognized Orofacial Pain as the twelfth dental specialty. The application that secured that recognition explicitly carved occlusion out of the specialty’s scope. And yet the same specialty claims authority over temporomandibular disorders — a condition in which the overwhelming majority of patients present with mandibles that are not in physiologic position.

Occlusion is the foundation of dentistry. To classify it as outside the scope of the specialty responsible for masticatory pain is to redefine dentistry out of its own foundation. This essay is about how that happened, what it means, and what comes next.

Two Directions of Causation

Before the institutional history, the framework distinction.

There are two ways to think about the relationship between the body and the mind in chronic pain. The first is psychosomatic — the mind drives the body. Stress, anxiety, behavioral patterns, and central sensitization produce or amplify physical symptoms. The body is, in this view, primarily a screen on which psychological states are projected.

The second is somatopsychic — the body drives the mind. Structural dysfunction, mechanical loading, mandibular malposition, occlusal interference, and the resulting muscle and joint pathology produce physical symptoms which then generate psychological consequences. The body’s actual mechanical state generates the patient’s experience, including the patient’s psychological experience.

These are not subtle differences. They are opposite directions of causation. They lead to opposite treatment plans. A patient whose pain is psychosomatic is helped by cognitive behavioral therapy, medication, biofeedback, and self-management training. A patient whose pain is somatopsychic is helped by measurement of mandibular position, identification of occlusal interference, neuromuscular relaxation, and physiologic reconstruction of the bite.

The same patient, presented to a clinician working from each framework, will be diagnosed differently and treated differently. The clinical outcomes will differ. The cost to the patient will differ. The duration of suffering will differ.

The question of which framework is correct is not philosophical. It is empirical. And the empirical evidence, as published research has consistently shown, points firmly in the somatopsychic direction for the great majority of TMD patients. The studies routinely cited — Cooper and Kleinberg,¹ʼ² Haskin et al.,³ Emshoff et al.,⁴ Tasaki et al.,⁵ and Katzberg et al.⁶ — document that 70-89% of TMD patients present with TM degenerative disease, 71.8% with posterior mandibular displacement, 53.9% with lateral displacement, 82.1% with over-closure, and 84.1% with mandibular positions not coincident with the myo-trajectory.

Eighty-four percent. That is not a marginal finding. That is the dominant clinical reality. A framework that excludes mandibular position from scope is excluding most of the etiology.

The Institutional Drift

The American Academy of Orofacial Pain was founded in 1975. For three decades, organized dentistry declined to recognize it as a specialty. Two prior applications — in 1997 and 2000 — were rejected. The pattern of rejection was not procedural. It was substantive. Dentists who actually treated TMD patients, working from the bio-physiologic and neuromuscular tradition, raised consistent objections about scope, evidentiary basis, and the proposed specialty’s drift away from dentistry’s foundational concerns.

The third application, submitted in 2019, succeeded. On March 31, 2020, the ADA’s National Commission on Recognition of Dental Specialties and Certifying Boards granted Orofacial Pain specialty status. The same year, the National Academies of Sciences, Engineering, and Medicine published its consensus report on TMDs, framing the condition primarily as a chronic pain disorder requiring biopsychosocial management. Two years later, the American Board of Orofacial Pain was recognized as the certifying board.

Three institutional events. Same orbit. Same year cluster. Mutually reinforcing.

What changed between 2000 and 2020 was not the underlying science. The bio-physiologic literature on EMG, jaw tracking, and physiologic occlusion had grown more substantial in those two decades, not less. What changed was the assembly of an institutional pipeline — research funding flowing through the National Institute of Dental and Craniofacial Research, consensus framing through NASEM, training programs accredited through CODA, board certification through ABOP, insurance reimbursement codes negotiated with state regulators, and standard-of-care language that follows specialty recognition into legal and clinical contexts.

Once the pipeline assembles, every component reinforces the others. The institute funds the research that the specialty’s curriculum disseminates that the consensus committee summarizes that the insurance regulators cite as evidence-based that the courts use to define the standard of care. Every step of that pipeline is closed to the clinician who uses objective measurement of mandibular position, because the framework that built the pipeline excludes such measurement from its definition of legitimate practice.

On the Record Before the Recognition

I want to be clear that this institutional drift was not unopposed.

On October 1, 2019 — five months before the recognition was granted — I submitted a formal letter to the Director of the National Commission on Recognition of Dental Specialties and Certifying Boards. The letter analyzed the AAOP application against each of the six ADA requirements for specialty recognition and explained why, in my reading, the application failed each one.

I was not alone. ICCMO clinicians and others in the bio-physiologic and neuromuscular community submitted similar opposition. The ADA’s own Council on Dental Education and Licensure had previously opined that the AAOP described a medical, not a dental, specialty. That prior internal opinion is referenced in my letter. It was on the institutional record.

The recognition went through anyway.

I am not writing here to relitigate the decision. I am writing to establish that the structural objections raised in this essay are not new, were submitted in writing to the body responsible for the decision before the decision was made, and were considered and set aside. The recognition is now a fact. What it means clinically is what the rest of this essay addresses.

What the Application Actually Said

The strongest evidence for the argument I am making here comes not from my correspondence or from outside critics. It comes from the AAOP’s own 2019 application to the National Commission. That document is on the record. It defines the specialty in the AAOP’s own words. And on careful reading, it admits the scope problem directly.

On the question of scope, the application states that Orofacial Pain “does not include diagnosis and management of conditions that are included in the scope of practice for any existing dental specialties including… correction of malocclusions.” It states that the field does not overlap with Prosthodontics because “Orofacial Pain does include restorative dental treatments” — a typographic error in the original document that, read either way, confirms the carve-out. It states that there is no overlap with Orthodontics because “the field does not include orthodontic or orthopedic movement of teeth.” The application explicitly defines the specialty as excluding occlusion, restoration, prosthodontics, and orthodontics.

On the question of instrumentation, the application states twice — on page 22 and again on page 91 — that surface EMG and jaw tracking are “untested diagnostic tests that have no evidence of reliability and validity for TMD and orofacial pain conditions” and that their use “has been promoted to increase revenue for the provider.” There is exactly one clinical framework in dentistry that uses surface EMG and jaw tracking as core diagnostic instrumentation. That sentence, in the document the ADA approved, is a direct claim against the bio-physiologic tradition.

On the question of how the specialty actually treats patients, the application’s own treatment table lists eight categories. Three are pharmacological — NSAIDs, tricyclics, muscle relaxants, sleep medications, neuropathic medications, migraine medications. One is behavioral — cognitive behavioral therapy, mindfulness, biofeedback, meditation, hypnosis, habit reversal. One is injection-based — Botox, steroids, dry needling, trigger point injections. One is splint-based, with explicit limits on use. One is physical therapy. One — and only one — is dental: “occlusal equilibration,” which the application categorizes as having “some clinical trials but no systematic reviews.” Occlusal therapy is the only treatment category in their own table that the application admits lacks systematic review evidence. Every other category is downstream of the position question.

On the question of specialist usage of objective instrumentation, the application reports its own internal survey: 84 to 89 percent of orofacial pain dentists report that they “never” use electronic diagnostic testing. The application reports this approvingly, framing it as agreement across the field. What it actually documents is that the AAOP framework has self-selected for clinicians who do not measure mandibular position. The 89 percent non-use is presented as consensus. It is more accurately described as a closed loop.

The Self-Inflicted Contradiction

Read together, the application makes two claims that cannot both be true.

The first claim is that Orofacial Pain is a distinct specialty whose scope is separate from existing dental specialties — a claim made by carving occlusion, restoration, orthodontics, and prosthodontics explicitly out of the specialty’s domain.

The second claim is that this specialty has authority over the diagnosis and management of temporomandibular disorders — a condition in which 84.1 percent of patients present with mandibular positions not coincident with the myo-trajectory.

These claims contradict each other. A specialty that excludes occlusion from scope cannot competently address a condition whose dominant clinical finding is mandibular malposition. Either the scope definition is wrong or the specialty’s claim of authority over TMD is wrong. The application asserts both, and the National Commission accepted both.

To say this plainly: The AAOP officially declared, in the document the ADA approved, that occlusion is outside their scope. And then they claimed authority over TMD — a condition where 84.1 percent of patients have mandibles not coincident with the myo-trajectory. The contradiction is on the record. It has not been answered. It cannot be answered without amending one of the two claims.

What the Framework Actually Does

A patient with somatopsychic TMD — that is, a patient whose pain originates in mandibular malposition, occlusal interference, and the resulting muscular and joint pathology — arrives at an orofacial pain specialist’s office. What happens?

The specialist conducts a behavioral and psychosocial assessment. The application calls this a required competency. The specialist administers psychometric testing for depression, anxiety, and addiction risk. The specialist coordinates with health psychology professionals and may set up “contingency-based treatment contracts” — the application’s term — for patients with what the framework classifies as behavioral problems. The specialist prescribes pharmacotherapy: tricyclics, SSRIs, muscle relaxants, sleep medications, anticonvulsants, opioids when indicated, and what the application calls “centrally acting pain medications.” The specialist refers to physical therapy, recommends biofeedback and mindfulness, and considers Botox or trigger-point injections.

The specialist does not measure mandibular position. The specialist does not record physiologic rest, isotonic closure path, or the relationship between habitual occlusion and myo-trajectory. The specialist does not use surface EMG to assess muscle status, jaw tracking to record mandibular movement, or electrosonography to evaluate joint sounds. The application explicitly excludes these tools from the specialty’s accepted practice. The specialist’s training did not include them.

The patient’s bite remains where it was. The mandibular position remains unmeasured. The occlusal interferences remain unidentified. The pain is treated as a chronic pain syndrome to be managed pharmacologically and behaviorally, not as a structural problem with a structural solution. If the patient improves, it is because the medications are dampening the symptom. If the patient does not improve — and many do not, and many become more dependent on medication over time — the framework attributes the failure to the chronicity of the pain, the patient’s psychological factors, central sensitization, or non-compliance with the self-management program.

This is the somatopsychic patient routed into psychosomatic care. The framework cannot see what it has trained itself not to look at. The patient pays the cost.

The Patients Who Fall Through

Patients reading this know the experience already. The cycle of providers. The ineffective splints. The steady accumulation of medications. The behavioral interventions that did not address the cause. The crowns that were added or modified without measurement. The 15 root canals on the wrong teeth. The growing certainty that the system does not understand what is happening in the body.

The patients who eventually find their way to bio-physiologic and gneuromuscular practices arrive after years of failed conventional care. They have seen, on average, multiple providers across multiple specialties. They have spent tens of thousands of dollars. Many have lost trust in dentistry as a profession. Some have become dependent on medications they were prescribed in lieu of structural treatment.

When these patients are evaluated with objective neuromuscular instrumentation — when the K7 system records their muscle activity, their jaw tracking data, and their joint sounds — the cause of their symptoms is, in most cases, immediately visible. The mandible is not where it physiologically wants to be. The muscles are firing in patterns that confirm strain. The closure path deviates from the isotonic trajectory. The occlusal interferences are measurable, not theoretical.

These patients did not need a chronic pain framework. They needed a clinician who would measure the mandible. The institutional pipeline does not produce such clinicians in significant numbers. It actively discourages the training that would produce them.

The credential changed in 2020. The clinical capability did not. Patients still arrive at gneuromuscular offices having seen orofacial pain specialists, and the same complex cases that were unresolved before the specialty existed remain unresolved now. The specialty designation is real. The competence to address mandibular position, occlusal load, and the structural causes of masticatory pain is not part of what the specialty trains. A title is not a tool.

The Scope Question

If occlusion is medicine, dentistry is reduced to restoration and surgery. That is the structural implication of the AAOP application’s scope definition. A specialty whose curriculum is pain neuroscience, pharmacology, behavioral medicine, and diagnostic imaging interpretation — and which explicitly excludes occlusion, prosthodontics, orthodontics, and restoration — is not a dental specialty in the traditional sense of the word. It is a medical specialty, practiced under a dental license, focused on the head and neck.

That is a coherent thing to be. It is not a dishonorable thing to be. Pain medicine is a real and necessary field, and clinicians who dedicate themselves to chronic pain management do important work. The question is whether such work is appropriately housed under the dental profession’s specialty system, or whether it more properly belongs in medicine.

The ADA’s own Council on Dental Education and Licensure, in its prior internal opinions, reached a clear answer: the AAOP described a medical, not a dental, specialty. The Council’s view was set aside in the 2020 recognition. But the underlying analysis was correct. A specialty that excludes the foundational dental disciplines and centers itself on pharmacology, behavioral therapy, and chronic pain management is not the dental profession’s natural home for masticatory pain. It is medicine, importing dental credentials.

The patients who suffer from this arrangement are the ones whose pain is somatopsychic — whose bodies are signaling a structural problem that requires a structural solution. They arrive at dental offices because their teeth and jaws hurt. They are routed into a framework that treats their bodies as screens for psychological projection rather than as mechanical systems with measurable malfunctions. The framework is sincere. It is also incomplete. And the incompleteness is no longer a private intellectual disagreement among dentists. It is now codified institutionally.

A dentist who has trained themselves not to look at the bite has redefined themselves out of dentistry. The credential remains. The dental license remains. The masticatory system, the actual proper object of dental study, has been left behind.

The Somatopsychic Alternative

There is another way.

Gneuromuscular dentistry — the synthesis of gnathologic structural principles with the objective neuromuscular sciences — has been doing the work the AAOP framework abandoned. For four decades, GNM and its predecessors have measured what could be measured: the resting position of the mandible, the trajectory of isotonic closure, the activity of the masticatory muscles at rest and in function, the sounds of the temporomandibular joints during movement, the relationship between habitual occlusion and physiologic position. The instrumentation is FDA-cleared. The K7 Evaluation System has held the ADA Seal of Recognition and Seal of Acceptance. The science is published. The clinical results are documented.

GNM does not deny that psychological factors influence chronic pain. It does not reject the value of behavioral support, of patient education, or of the careful management of medications when they are clinically indicated. What GNM rejects is the substitution of these tools for the structural diagnosis they cannot replace. The mandible has a position. That position is measurable. When it is not where the body’s neuromuscular system wants it to be, symptoms follow. When it is restored to physiologic position, symptoms in the great majority of cases resolve.

If a mandibular position is not objectively measured, it is ultimately being assumed.

That sentence is the entire epistemological case in thirteen words. The AAOP framework assumes the mandible is in an acceptable position, focuses on the symptoms that arise when the assumption is wrong, and treats those symptoms as the disease. The GNM framework measures the mandible, identifies when it is not where it should be, and addresses the structural cause. The first framework’s failure rate is not a research mystery. It is a measurable consequence of working from assumption rather than data.

A Closing Question

To the dentists reading this — particularly the younger clinicians whose frameworks have not yet calcified — I would ask you to consider what it means to be a dentist. The masticatory system is the proper object of our profession’s study. The bite is the foundation of dental practice. To accept a framework that classifies these as outside scope is to accept a profession smaller than the one we trained for, and smaller than the one our patients need.

To the patients reading this — particularly those who have been told that your pain is best treated by medications, by behavioral therapy, and by management of expectations — I would ask you to consider that your body may be telling you what your providers have been trained not to hear. Mandibular position is measurable. Muscle activity is measurable. The mechanical state of your masticatory system is not a matter of opinion. There are clinicians who measure it. The question worth asking your dentist is not whether your pain is chronic but whether your bite has been measured.

To everyone reading this — clinician, patient, or interested observer — the institutional pipeline that built the current framework was assembled by people. It can be revised by people. The first step is naming what it is and what it leaves out. That is what this essay attempts.

Occlusion is the foundation of dentistry. To deny the role of occlusion as the initiating or perpetuating factor in the etiology of TMD does not eliminate the role. It only eliminates the specialty’s ability to see it.

References

1. Cooper BC, Kleinberg I. Examination of a large patient population for the presence of symptoms and signs of temporomandibular disorders. Cranio. 2007 Apr;25(2):114-26. doi: 10.1179/crn.2007.018. PMID: 17508632.

2. Cooper BC, Kleinberg I. Establishment of a temporomandibular physiological state with neuromuscular orthosis treatment affects reduction of TMD symptoms in 313 patients. Cranio. 2008 Apr;26(2):104-17. doi: 10.1179/crn.2008.015. PMID: 18468270.

3. Haskin CL, Milam SB, Cameron IL. Pathogenesis of degenerative joint disease in the human temporomandibular joint. Crit Rev Oral Biol Med. 1995;6(3):248-77. doi: 10.1177/10454411950060030601. PMID: 8785264.

4. Emshoff R, Brandlmaier I, Gerhard S, Strobl H, Bertram S, Rudisch A. Magnetic resonance imaging predictors of temporomandibular joint pain. J Am Dent Assoc. 2003 Jun;134(6):705-14. doi: 10.14219/jada.archive.2003.0256.

5. Tasaki MM, Westesson PL, Isberg AM, Ren YF, Tallents RH. Classification and prevalence of temporomandibular joint disk displacement in patients and symptom-free volunteers. Am J Orthod Dentofacial Orthop. 1996 Mar;109(3):249-62. doi: 10.1016/s0889-5406(96)70148-8.

6. Katzberg RW, Westesson PL, Tallents RH, Drake CM. Anatomic disorders of the temporomandibular joint disc in asymptomatic subjects. J Oral Maxillofac Surg. 1996 Feb;54(2):147-53; discussion 153-5. doi: 10.1016/s0278-2391(96)90435-8. PMID: 8604061.

7. Cooper BC, Kleinberg I. Relationship of temporomandibular disorders to muscle tension-type headaches and a neuromuscular orthosis approach to treatment. Cranio. 2009 Apr;27(2):101-8. doi: 10.1179/crn.2009.016. PMID: 19455921.

8. American Academy of Orofacial Pain. Application for Specialty Recognition of Orofacial Pain. Submitted to the National Commission on Recognition of Dental Specialties and Certifying Boards, 2019. (On file with the Commission.)

9. National Academies of Sciences, Engineering, and Medicine. Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press; 2020. doi: 10.17226/25652.

10. American Dental Association. National Commission on Recognition of Dental Specialties and Certifying Boards. Recognition of Orofacial Pain as the twelfth dental specialty. March 31, 2020.

Continue Learning

🔹 The Framework Distinction

• What is TMJ? →
• Prevalent Philosophies of Treating TMJ →
• Psychosocial vs. Physiologic: Clarifying the Diagnostic Divide in Orofacial Pain →
• Psycho-social Intervention for Chronic Orofacial Pain: Weak Supportive Evidence →
• Psychosocial Anti-Instrumentation Perspective – What is Their Treatment? →
• Pain: The Psychological Effect On The Patient →

🔹 Standard of Care and Evidence

• What is the “Standard of Care”? →
• What is the Standard of Care? – Part 2 →
• Refuting TMD Guideline Misconceptions about NM Occlusion Part 1 →
• Refuting TMD Guideline Misconceptions about NM Occlusion Part 2 →
• The Controversy: How Effective is the Neuromuscular Occlusal Approach in the Diagnosis and Treating TMD →
• Something Dramatically and Significantly Is Missing in Dentistry →
• OCCLUSION DOESN’T MATTER??? →

🔹 The Original Science Behind GNM

• Why OC is Different — The Original Science Behind GNM Dentistry →
• Gneuromuscular vs. Neuromuscular Dentistry →
• GNM is Not the Same as NM →
• SCIENTIFIC TRUTHS: Bio-Physiology & Objective Measurements →
• What Does the K7 Technology Measure? →
• The Science Behind GNM — Evidence, Research & Objective Measurement →

🔹 For Dentists Ready to Train

• OC Masterclass Training — Course Schedule and Registration →
• Dr. Chan’s Blog Notes →

Frequently Asked Questions

What is the Orofacial Pain specialty and when was it recognized?

The American Dental Association recognized Orofacial Pain as the twelfth dental specialty on March 31, 2020, following an application from the American Academy of Orofacial Pain. The specialty’s defined scope includes the diagnosis and treatment of temporomandibular disorders, headache, neuropathic and neurovascular pain, and orofacial sleep disorders. The specialty’s defined scope does not include the correction of malocclusions, restorative dentistry, prosthodontics, or orthodontics — categories that are explicitly carved out in the application document.

Why does this matter to a TMD patient?

The framework that holds the specialty designation does not include objective measurement of mandibular position in its accepted clinical practice. Patients whose TMD symptoms originate in mandibular malposition — which research suggests is the great majority — may receive treatment focused on pain management, behavioral therapy, and medication rather than on the structural cause of their symptoms. A patient seeking to understand what is happening in their masticatory system has the right to ask whether their bite has been objectively measured.

What is the difference between psychosomatic and somatopsychic TMD?

A psychosomatic framework holds that psychological factors — stress, anxiety, central sensitization — are primary drivers of TMD symptoms. A somatopsychic framework holds that structural dysfunction in the masticatory system — mandibular malposition, occlusal interference, joint pathology — produces symptoms that then have psychological consequences. These are opposite directions of causation and lead to different treatment plans.

What does it mean that 84.1% of TMD patients have mandibular positions not coincident with the myo-trajectory?

Research from Cooper and Kleinberg,¹ʼ² Haskin et al.,³ Emshoff et al.,⁴ Tasaki et al.,⁵ and Katzberg et al.⁶ has documented that the mandible in most TMD patients is not in the position the body’s neuromuscular system would otherwise rest in. The myo-trajectory — the path of mandibular closure determined by relaxed masticatory muscles — is the physiologic reference. When habitual occlusion does not coincide with this trajectory, structural strain results. A clinical framework that does not measure this relationship cannot address it.

Was there opposition to the specialty recognition?

Yes. ICCMO clinicians and other practitioners in the bio-physiologic and neuromuscular tradition submitted formal opposition to the National Commission. The author of this essay submitted a letter to the Director of the Commission on October 1, 2019, analyzing the application against each of the six ADA requirements for specialty recognition. The ADA’s own Council on Dental Education and Licensure had previously opined that the AAOP described a medical, not a dental, specialty. The recognition was nonetheless granted on March 31, 2020.

What is GNM and how does it differ from the AAOP framework?

Gneuromuscular dentistry — GNM — is the synthesis of gnathologic structural principles with the objective neuromuscular sciences. It uses the K7 Evaluation System, low-frequency J5 Dental TENS, surface electromyography, jaw tracking, and electrosonography to measure mandibular position, muscle activity, and joint function. The framework is bio-physiologic rather than biopsychosocial: it treats structural dysfunction as the primary clinical question and addresses psychological consequences as downstream of structural causes when they are present.