Policy Statements

 

TEMPOROMANDIBULAR DISORDERS (TMD)

The AADR recognizes that temporomandibular disorders (TMDs) encompass a group of musculoskeletal and neuromuscular conditions that involve the temporomandibular joints (TMJs), the masticatory muscles, and all associated tissues. The signs and symptoms associated with these disorders are diverse, and may include difficulties with chewing, speaking, and other orofacial functions. They also are frequently associated with acute or persistent pain, and the patients often suffer from other painful disorders (comorbidities). The chronic forms of TMD pain may lead to absence from or impairment of work or social interactions, resulting in an overall reduction in the quality of life.

Based on the evidence from clinical trials as well as experimental and epidemiologic studies:

  1. It is recommended that the differential diagnosis of TMDs or related orofacial pain conditions should be based primarily on information obtained from the patient's history, clinical examination, and when indicated TMJ radiology or other imaging procedures. The choice of adjunctive diagnostic procedures should be based upon published, peer-reviewed data showing diagnostic efficacy and safety. However, the consensus of recent scientific literature about currently available technological diagnostic devices for TMDs is that except for various imaging modalities, none of them shows the sensitivity and specificity required to separate normal subjects from TMD patients or to distinguish among TMD subgroups. Currently, standard medical diagnostic or laboratory tests that are used for evaluating similar orthopedic, rheumatological and neurological disorders may also be utilized when indicated with TMD patients. In addition, various standardized and validated psychometric tests may be used to assess the psychosocial dimensions of each patient’s TMD problem.
  2.  It is strongly recommended that, unless there are specific and justifiable indications to the contrary, treatment of TMD patients initially should be based on the use of conservative, reversible and evidence-based therapeutic modalities. Studies of the natural history of many TMDs suggest that they tend to improve or resolve over time. While no specific therapies have been proven to be uniformly effective, many of the conservative modalities have proven to be at least as effective in providing symptomatic relief as most forms of invasive treatment. Because those modalities do not produce irreversible changes, they present much less risk of producing harm. Professional treatment should be augmented with a home care program, in which patients are taught about their disorder and how to manage their symptoms

References
1)   de Leeuw R, Klasser GD, Albuquerque RJ. Are female patients with orofacial pain medically compromised? J Am Dent Assoc 2005;136(4):459-68.
2)   Diatchenko L, Nackley AG, Tchivileva IE, Shabalina SA, Maixner W. Genetic architecture of human pain perception. Trends Genet 2007;23(12):605-13.
3)   Sessle BJ. Sensory and motor neurophysiology of the TMJ. In: Laskin DM, Greene CS, Hylander WL, eds. Temporomandibular Disorders: An Evidence-Based Approach to Diagnosis and Treatment. Chicago: Quintessence; 2006. p. 69-88.
4)   Reissmann DR, John MT, Schierz O, Wassell RW. Functional and psychosocial impact related to specific temporomandibular disorder diagnoses. J Dent 2007 Aug;35(8):643-50.
5)   Klasser GD, Okeson JP. The clinical usefulness of surface electromyography in the diagnosis and treatment of temporomandibular disorders. J Am Dent Assoc. 2006;137(6):763-71.
6)   Suvinen TI, Kemppainen P. Review of clinical EMG studies related to muscle and occlusal factors in healthy and TMD subjects. J Oral Rehabil 2007;34(9):631-44.
7)   Greene CS. The Role of Technology in TMD Diagnosis. In Laskin DM, Greene CS, Hylander WL (Eds).  TMDs – An Evidence-Based Approach to Diagnosis and Treatment.  Chicago, Quintessence Publishing Co, 2006, pp 193-202.
8)   Greene CS, Laskin DM. Temporomandibular disorders: moving from a dentally based to a medically based model. J Dent Res 2000;79(10):1736-9.
9)   Truelove E. Role of oral medicine in the teaching of temporomandibular disorders and orofacial pain. J Orofac Pain 2002;16(3):185-90.
10)  Dworkin SF, Massoth DL. Temporomandibular disorders and chronic pain: disease or illness? J Prosthet Dent 1994;72(1):29-38.
11)  Carlson CR. Psychological considerations for chronic orofacial pain. Oral Maxillofac Surg Clin North Am 2008;20(2):185-95.
12)  Lindroth JE, Schmidt JE, Carlson CR. A comparison between masticatory muscle pain patients and intracapsular pain patients on behavioral and psychosocial domains. J Orofac Pain 2002;16(4):277-83.
13)  AmericanAcademy of Orofacial Pain. Temporomandibular Disorders. In: de Leeuw R, ed. Orofacial Pain: Guidelines for Assessment, Diagnosis and Management. Chicago: Quintessence; 2008.
14)  Stohler CS, ZarbGA. On the management of temporomandibular disorders: a plea for a low-tech, high-prudence therapeutic approach. J Orofac Pain1999;13(4):255-61.
15)  Fricton J. Myogenous temporomandibular disorders: diagnostic and management considerations. Dent Clin North Am 2007;51(1):61-83.
16)  Okeson JP. Joint intracapsular disorders: diagnostic and nonsurgical management considerations. Dent Clin North Am 2007;51(1):85-103.
17)  Carlson CR, Bertrand PM, Ehrlich AD, Maxwell AW, Burton RG. Physical self-regulation training for the management of temporomandibular disorders. J Orofac Pain 2001;15(1):47-55.
18)  Dworkin SF, Huggins KH, Wilson L, Mancl L, Turner J, Massoth D, LeResche L, Truelove E. A randomized clinical trial using research diagnostic criteria for temporomandibular disorders-axis II to target clinic cases for a tailored self-care TMD treatment program. J Orofac Pain 2002;16(1):48-63.

(adopted 1996, revised 2010, reaffirmed 2015)

 

SEALANTS

Pit and fissure sealants are polymeric materials that are applied to the occlusal surfaces of teeth, which do not benefit from the caries-preventive effects of fluoride to the same extent as smooth surfaces. Dental caries, one of the most common diseases of childhood, occurs predominantly as carious lesions in pits and fissures of teeth. A large percentage of occlusal surfaces can remain caries-free for up to ten years or more after a single application of a sealant. There is strong evidence supporting the effectiveness of sealants for the prevention of dental caries. Furthermore, studies show that incipient carious lesions that remain sealed do not progress. Based on current evidence, the American Association for Dental Research (AADR) continues to strongly recommend greater use of sealants by practitioners in private and public health practice. The AADR also endorses the practice that sealants could be used in conjunction with other caries-preventive measures, such as fluoride application.

Supportive references:
JD Bader, DA Shugars, and AJ Bonito (2001). Systematic reviews of selected dental caries diagnostic and management methods.  J Dent Educ. 65(10): 960-968
Benedict I. Truman, Barbara F. Gooch, Iddrisu Sulemana, Helen C. Gift, Alice M. Horowitz, Caswell A. Evans Jr, Susan O. Griffin, Vilma G. Carande-Kulis. The Task Force on Community Preventive Services (2002). Reviews of Evidence on Interventions to Prevent Dental Caries, Oral and Pharyngeal Cancers, and Sports-Related Craniofacial Injuries. Am J Prev Med;23(1S)
Ahovuo-Saloranta A, Hiiri A, Nordblad A, Worthington H, Mäkelä M (2004). Pit and fissure sealants for preventing dental decay in the permanent teeth of children and adolescents. Cochrane Database of Systematic Reviews 2004, Issue 3. Art. No.: CD001830. DOI: 10.1002/14651858.CD001830.pub2.
Hiiri A, Ahovuo-Saloranta A, Nordblad A, Mäkelä M (2006). Pit and fissure sealants versus fluoride varnishes for preventing dental decay in children and adolescents.Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD003067. DOI: 10.1002/14651858.CD003067.pub2
Griffin SO, Oong E, Kohn W, Vidakovic B, Gooch BF, Bader J, et al (2008). The Effectiveness of Sealants in Managing Carious Lesions. Journal of Dental Research2008 (accepted).
ADA, and CDC Sealant Guidelines-To be published JADA 2008
Oong E, Griffin S, Kohn W, Gooch B, Caufield P. The effect of dental sealants on bacteria levels in caries lesions: a review of the evidence. JADA 2008 (accepted 12/31/2007)

(adopted 1991; revised 2009, revised 2015)

 

TOPICAL FLUORIDES

Fluoride’s predominant effect in caries prevention and management is post-eruptive and topical. However, as it relates to this statement, topical fluorides are those that are applied to erupted teeth, with the understanding that water fluoridation’s and dietary fluoride’s main effect is also topical. The American Association for Dental Research (AADR) strongly recommends twice daily use of fluoride-containing dentifrices as an effective means of reducing caries.

Furthermore, based on current evidence, the AADR also strongly recommends that fluoride-containing dentifrices should be used in small amounts in pre-school-aged children in order to reduce the risk of dental fluorosis through unintentional ingestion. It is important to note that professionally applied gels and varnishes also reduce caries incidence. Studies show that application at six-monthly intervals is appropriate for patients at increased caries risk, but application frequency may be decreased or increased according to risk status and degree of exposure to other sources of fluoride. Higher-risk patients should receive applications at three to six-month intervals. In addition, the AADR recommends the use of daily or weekly fluoride mouth rinses and gels for this group. The AADR makes the following caveat:  Because of their high fluoride concentration, mouthrinses and prescription gels are not recommended for pre-school-aged children. 

Supportive References:Weyant RJ, et al., Topical fluoride for caries prevention, Executive summary of the updated clinical recommendations and supporting systematic review, J Am Dent Assoc 2013;144(11):1279-1291. (Recommended by Carey ,Gonzalez and Zhan)
Am Dent Assoc, Center for Evidence-Based Dentistry, Topical fluoride for caries prevention, Council on Scientific Affairs, November 2013. 
Fluoride varnishes for preventing dental caries in children and adolescents. Marinho VC, Worthington HV, Walsh T, Clarkson JE. Cochrane Database Syst Rev. 2013 Jul 11;7:CD002279. doi: 10.1002/14651858.CD002279.pub2. 
Cochrane reviews on the benefits/risks of fluoride toothpastes. Wong MC, Clarkson J, Glenny AM, Lo EC, Marinho VC, Tsang BW, Walsh T, Worthington HV. J Dent Res. 2011 May;90(5):573-9. doi: 10.1177/0022034510393346. Epub 2011 Jan 19.
Guideline on fluoride therapy. Pediatr Dent. 2013 Sep-Oct;35(5):E165-8.
Wright JT, Hanson N, Ristic H, Whall CW, Estrich CG, Zentz RR. Fluoride toothpaste efficacy and safety in children younger than 6 years. J Am Dent Assoc. 2014 Feb;145(2):182-9. doi: 10.14219/jada.2013.37.

(adopted 1996; revised 2009, revised 2015)

 

ORAL DISEASE RELATED TO TOBACCO USE

Tobacco use is the principal risk factor for oral cancer. It also increases the risk for periodontal disease and decreases the ability of oral tissues to heal. Other oral effects include halitosis (bad breath), decreased ability to taste, and increased staining of the teeth. Smokeless tobacco (spit tobacco), snus and electronic nicotine delivery systems (ENDS) are, although considered harm reduction alternatives to smoked tobacco, are not without their risks. Tobacco use in any form is harmful to health and should be discouraged. The AADR urges oral health professionals to subscribe to practices that prevent initiation of tobacco use in any form among their patients and the public, and to facilitate and reinforce cessation among users and to carry out cessation programs in their offices using standard procedures and medications as appropriate.

(adopted 1996, revised 2015)

 

IMPACT OF TOBACCO USE ON ORAL HEALTH

The AADR recognizes that use of tobacco in any form increases the risk for death and disease among people that use these products and those exposed to second-hand tobacco smoke.  Cigarette smoking is causally related to chronic periodontitis, responsible for an estimated one-half of cases in the United States.  Cigarette smoking is the major causal factor for cancers of the oral cavity and pharynx in the United States.  Use of other combusted tobacco products — including cigars, pipes, and hookah —also increases the risk for these malignancies.    Use of smokeless tobacco is causally related to oral cancer, increases the risk for localized gingival recession, and may increase the risk for root surface caries.  Mounting evidence implicates exposure to second-hand tobacco smoke as a risk factor for early childhood caries.  Smoking also reduces the success rates for surgical and non-surgical periodontal therapy, increases the risk of failure of dental implants, and increases the risk of complications following oral surgical procedures. 

  1. Based on an extensive body of scientific literature on the negative impact of tobacco use on oral health, effective methods of reducing tobacco, and the inextricable link between oral health and overall health, it is recommended that:
  2. Oral health care professionals incorporate evidence-based approaches to tobacco use intervention into clinical practice and establish linkages with tobacco cessation resources in their communities.
  3.  National, state, and local dental professional organizations advocate for adoption of health policies that incorporate best practices for comprehensive tobacco control.
  4. Research be supported and conducted to assess the oral health effects of established and newly emerging tobacco products in the United States.
  5. Dental educational institutions increase the competency of students and residents in providing behavioral interventions for tobacco use and appropriate use of pharmacotherapy.
  6. Oral health care professionals become active members of tobacco control coalitions in their communities.
  7. In choosing meeting sites, AADR give preference to cities that have enacted comprehensive clean indoor air policies that include restaurants, hotels, conference centers, and other public spaces

(adopted 2015)

 

THE USE OF TOBACCO

The American Association for Dental Research (AADR) takes the following position regarding the use of tobacco by humans: Tobacco products come in many forms. Some are smoked and others are not, but none is safe for human consumption. In addition to their serious systemic effects, all have adverse oral health consequences, and risks usually are in proportion to the product used, its intensity and the duration of tobacco use. The use of tobacco products is a major risk factor for oral and pharyngeal cancers (head and neck cancers). Tobacco use also increases the risk of periodontal disease and decreases the ability of oral tissues to heal. Other oral effects include halitosis (bad breath), decreased ability to taste, and increased staining of teeth, gingival pigmentation, and a variety of mucosal lesions.  Tobacco smoking during pregnancy increases the risk of developing fetal anomalies such as cleft lip and cleft palate. The AADR encourages continued research to further elucidate the health effects of tobacco use, identify the biological mechanisms and behavioral patterns and relative risks involved in producing these effects, and to develop and evaluate effective methods for prevention and cessation. The AADR further encourages the development of collaborations with other organizations and non-dental healthcare providers, public and for-profit institutions to help inform members and the public of research findings about harm reduction products and the conditions and risks associated with tobacco use.

(adopted 1996, revised 2015)

 

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