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What is the Standard of Care? – Part 2

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History has shown all of us that most in our dental profession do not objectively measure or use advanced scientific instrumentation technology in the diagnosis and or treatment of their patients as do our medical counterparts. Measuring muscle activity or occlusal function in microvolts, or measuring jaw position and functional ability in 10ths of millimeters or evening monitoring and measuring TM joint sound conditions using frequency (Hz), amplitude (mV) and even trying to comprehend and understand the powerful use of Fast Fourier Transfer (FFT) analysis when analyzing electrosonography is typically outside the box of most general dentists and prosthodontist, orthodontists and even orofacial pain specialists.  Dentistry as a whole is far behind in their appreciation of what evidence based dentistry is really about.  The thought or even the consideration of measuring muscle activity of a paining dysfunctional TMD patient and comparing before and after involuntary TENS is beyond the typical scope of awareness within our dental profession for the past 57 years.  This is not new!

Most in our dental profession and leaders continue to make excuses why they don’t want to measure objectively the bio-physiologic responses of their patients. They excuse themselves from getting the proper training to learn what EMGs actually means or what jaw tracking (CMS) and ESG data would indicate clinically before and after TENsing.  You all realize why they don’t want to learn.  Yet they continue to perpetuate the importance of following the latest in research.  Present day research is often biased and handed down generation after generation, from professors, instructors to students to be the standard.  Existing research and dental literature is overwhelming replete showing the validity of the objective measuring science of the bio-physiologic function of the masticatory system.  But this science, this research and literature is ignored by many who seem to have other interest other than the truth of how the human jaw works and functions.

Consider the importance of objective measurements. Reflect on how your dentist have objectively measured your bio physiology of jaw movements and resting modes as they related to the health of yoru teeth and gums. How did the EMG (electromyography), CMS (computerized mandibular scanning/jaw tracking) and ESG (electrosonography, joint sound) data influence your understanding, diagnostic assessment and treatment planning of your case. Moreover, think about how objective measurements have informed the clinical decision-making, enabling you to address the challenges you faced. The power of objective, measured data—how did it change your perspective, awareness, and realization about your case and how the dentists practices his/her skills to help treat your condition? Did it give you confidence in the dentistry being performed on you?

The American Academy of Dentistry emphasizes a standard of care that’s focused on delivering high-quality, ethical treatment with patient safety and well-being as top priorities. It involves staying up-to-date with the latest advancements and guidelines in the field, ensuring comprehensive diagnosis, clear communication, and informed consent. This standard guides dentists to provide consistent, effective, and compassionate care across all aspects of dental practice.

The American Dental Association (ADA) defines the standard of care as the level of care and expertise that a reasonably prudent dentist would provide under similar circumstances.

This includes:

  1. Evidence-Based Practice: Following the latest research and clinical guidelines.
  2. Patient Safety: Ensuring a safe environment and taking reasonable precautions.
  3. Informed Consent: Clearly communicating with patients and obtaining their consent before treatment.
  4. Timely Care: Providing treatment in a timely manner.
  5. Comprehensive Care: Addressing all aspects of the patient’s oral health.

The ADA emphasizes that the standard of care can vary based on legal definitions and community practices, but it generally revolves around what is considered reasonable and prudent in the dental profession.

In California, the legal definition of the standard of care in dentistry is generally based on what a reasonably prudent dentist would do under similar circumstances. This includes providing care that meets the level of skill, knowledge, and care that is commonly possessed and exercised by other dentists in the same or similar situations.

For patients presenting with myofascial pain, having no bite, and or temporomandibular joint (TMD) problems, the standard of care would involve:

  1. Accurate Diagnosis: Conducting a thorough examination to accurately diagnose the condition.
  2. Evidence-Based Treatment: Utilizing treatments that are supported by current research and clinical guidelines.
  3. Patient Education: Informing the patient about their condition and the proposed treatment plan.
  4. Informed Consent: Obtaining the patient’s informed consent before proceeding with any treatment.
  5. Ongoing Monitoring: Regularly monitoring the patient’s progress and adjusting the treatment plan as necessary.

The California Civil Jury Instructions (CACI) provide guidance on how the standard of care is determined in legal cases, emphasizing the importance of expert testimony to establish what constitutes reasonable care in the dental profession.

According to the Orofacial Pain Specialty what is the standard of care?

The American Academy of Orofacial Pain (AAOP) defines the standard of care for orofacial pain specialists as the diagnosis, management, and treatment of pain disorders of the jaw, mouth, face, head, and neck. This specialty focuses on evidence-based understanding and interdisciplinary patient care.

For patients with myofascial pain, TMD joint problems, and other orofacial pain conditions, the standard of care includes:

  1. Accurate Diagnosis: Conducting a thorough examination to identify the underlying cause of pain.
  2. Evidence-Based Treatment: Utilizing treatments supported by current research and clinical guidelines.
  3. Patient Education: Informing patients about their condition and treatment options.
  4. Informed Consent: Obtaining the patient’s informed consent before proceeding with any treatment.
  5. Ongoing Monitoring: Regularly monitoring the patient’s progress and adjusting the treatment plan as necessary.

The AAOP emphasizes an interdisciplinary approach, collaborating with medical doctors, physical therapists, and mental health specialists to provide comprehensive, holistic care.

What is the standard of care for prosthodontic specialist when dealing with TMD pain problems?

The standard of care for prosthodontic specialists dealing with temporomandibular joint (TMD) pain involves a comprehensive and evidence-based approach. Here are some key aspects:

  1. Accurate Diagnosis: Conducting a thorough examination, including patient history, physical examination, and possibly advanced imaging techniques like X-rays, MRI, or CT scans.
  2. Conservative Treatments: Initially focusing on non-invasive treatments such as medications (pain relievers or anti-inflammatory drugs), physical therapy, and lifestyle modifications (stress reduction techniques, dietary changes).
  3. Dental Appliances: Using occlusal splints or night guards to prevent teeth grinding and reduce jaw strain.
  4. Patient Education: Informing patients about their condition, treatment options, and the importance of following the treatment plan.
  5. Ongoing Monitoring: Regularly monitoring the patient’s progress and adjusting the treatment plan as necessary.

Prosthodontists are trained to manage TMD disorders and provide personalized care based on the severity and cause of the symptoms. They aim to alleviate pain and improve the patient’s quality of life through a combination of conservative and, if necessary, more advanced treatments.

Does the use of an intra oral orthotic appliance create TMJ changes that are damaging to the pain patient?

The use of intraoral orthotic appliances, such as splints or night guards, can be beneficial for managing TMD pain. However, there are potential risks if not used properly. Overuse or improper fitting of these appliances can lead to changes in the temporomandibular joint (TMJ) and surrounding structures, which might cause or exacerbate pain. 

It’s important to note that the effectiveness of any appliance can vary from patient to patient. Some studies have shown positive outcomes, while others suggest that the benefits may be comparable to other non-appliance treatments, such as jaw exercises and physical therapy. It’s always best to consult with a dental professional who specializes in TMJ disorders to determine the most appropriate treatment plan for your specific condition.

It’s crucial to have these appliances custom-made and regularly monitored by a dental professional to ensure they are effective and not causing harm. The goal is to provide relief from TMD symptoms without creating additional issues.

Is there a such thing as TMJ specialists according to the ADA?

The American Dental Association (ADA) does not have a specific designation for “TMJ specialists.” However, dentists who treat TMJ disorders often have additional training and experience in this area. These professionals may include general dentists, oral and maxillofacial surgeons, prosthodontists, orthodontists, and pain specialists.

What is the scope of any general dentist license of care?

A general dentist’s scope of practice typically includes the evaluation, diagnosis, and treatment of diseases, disorders, or conditions of the oral cavity, maxillofacial area, and associated structures. This can involve:

General dentists are trained to provide comprehensive dental care and may refer patients to specialists for more complex or advanced treatments.

What procedures is a dentist allowed to do as a general dentist?

General dentists are quite versatile and can perform a wide range of procedures, including:

General dentists are trained to handle a variety of dental issues and are often the primary care providers for most dental needs. However, for more complex cases, they may refer patients to specialists like orthodontists, periodontists, or oral surgeons.

Are general dentist allowed to treat TMJ pain problems?

Yes, general dentists are allowed to treat temporomandibular joint disorder (TMD) pain problems. They can offer a variety of non-invasive treatments, such as:

For more complex or severe cases, general dentists may refer patients to specialists like oral surgeons or orthodontists.

Are general dentist allowed to treat orofacial pain problems according to their license of care?

Yes, general dentists can treat orofacial pain problems. Their training includes a basic understanding of diagnosing and managing common orofacial pain conditions, such as temporomandibular joint disorders (TMD) and bruxism (teeth grinding).

For more complex or persistent orofacial pain issues, general dentists may collaborate with or refer patients to specialists like orofacial pain specialists, neurologists, or oral surgeons who have advanced training in managing these conditions.

What is the advance training involve for Orofacial Pain specialty?

Advanced training for the Orofacial Pain specialty typically involves a combination of clinical, didactic, and research components. Here are some key aspects:

  1. Graduate or Postgraduate Education: Programs usually require completion of a formal advanced education program in Orofacial Pain, which is accredited by the Commission on Dental Accreditation (CODA). These programs often last around 24 months.
  2. Clinical Training: This includes hands-on experience in diagnosing and managing orofacial pain disorders, such as temporomandibular joint (TMJ) disorders, neuropathic pain, and sleep-related disorders.
  3. Didactic Training: This involves coursework in the basic and clinical sciences related to orofacial pain, including anatomy, physiology, pharmacology, and pain management principles.
  4. Research: Many programs incorporate research components, allowing trainees to contribute to the evidence-based understanding of orofacial pain and its treatment.
  5. Certification: After completing the training program, candidates may need to pass a certification examination, such as the American Board of Orofacial Pain (ABOP) Certification Examination.
  6. Interdisciplinary Collaboration: Training often emphasizes collaboration with other healthcare providers, such as physicians and physical therapists, to provide comprehensive patient care.

Is FDA approved objective measuring instrumentation useful in establishing a standard of care in the dental profession?

Yes, FDA-approved objective measuring instrumentation can be very useful in establishing a standard of care in the dental profession. These instruments provide reliable and accurate data that can help standardize diagnostic and treatment processes, ensuring consistent and high-quality patient care1. By using these tools, dentists can:

  1. Enhance Diagnostic Accuracy: Objective measurements can reduce the variability in diagnoses, leading to more precise treatment plans.
  2. Monitor Treatment Outcomes: These instruments allow for the tracking of treatment progress and outcomes, helping to refine and improve care protocols.
  3. Support Evidence-Based Practice: Objective data supports the use of evidence-based practices, which are essential for maintaining high standards of care.
  4. Facilitate Research and Development: Reliable data from these instruments can contribute to ongoing research, leading to advancements in dental care.

Overall, the integration of FDA-approved objective measuring instruments can help elevate the standard of care in dentistry by providing a solid foundation of accurate and consistent data.

NM/GNM dentistry is much more than occlusion. “It transcends mechanical dental constructs and embraces generic biologic and physiologic principles that apply to all articular, muscular, neural and central nervous system organs” (R. Jankelson). It recognizes the value and importance of objective measuring physiologic responses of our patients using instrumentation (CMS, Dental TENS, EMG and ESG).

If one doesn’t objective measure, the dentists doesn’t know what they don’t know.  Objectively measuring and actually gathering data of your patient’s muscle activity, jaw position and joint sounds brings a greater clinical awareness and understanding about your patients as well as this dental profession.

“The most strident  appear to flutter from the citadels of old and threatened occlusal dogma while other pigeons feasting on IME fees or with other self-serving agendas reject occlusal or biomedical causality and impose their Standard of Care”. (Robert Jankelson, DDS).

I hope this will shed some light on the present day status regarding the “Standard of Care”.

Clayton A. Chan, D.D.S. – Dentist

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