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AMERICAN ACADEMY
OF CRANIOFACIAL PAIN
Application for Fellowship Status
Fee: $500.00
(U.S. Funds only - MasterCard or Visa also accepted)
Signed and Notarized Affidavit
(page 3 of application form - original only, no copies accepted)
and all required documentation and fees are to be received in
AACP Central Office by pre-announced deadline in order to qualify you for the next exam offering.
AACP EXECUTIVE OFFICE
12100 Sunset Hills Road, Suite 130 • Reston, VA 20190 • Phones: 800-322-8651; 703-234-4142 • Fax: 703-435-4390
Internet Website Address: www.aacfp.org • E-mail Address: [email protected]
Page 1- May be kept for your records.
Excerpted from the official By-Laws of the American Academy of Craniofacial Pain
ARTICLE V- FELLOWSHIP STATUS
1). Fellowship Status in the Academy shall be granted to those members who have fulfilled the following
requirements:
A. Submit a written application to the Directors, on its standard application form for Fellowship status which:
1. is accompanied by the application fee established by the Directors,
2. is sponsored by two (2) Academy members holding Fellow, Distinguished Fellow, or Master of
Excellence status,
3. is received by the Directors at least thirty days prior to its annual meeting in order to qualify the
applicant to take the subsequent annual Fellowship examination. Pre-registration to the annual
convention must be sent to the Central Office by the registration deadline.
B. Establish to the satisfaction of the Directors, that the applicant has completed the requisite advanced study
and training. Said advanced study and training requirements will be satisfied by:
At least two (2) or more academic years of graduate study in an accredited dental school program which
resulted in a certificate or advanced degree in the diagnosis and treatment of Craniofacial Pain and
Temporomandibular disorders; OR
A minimum of two hundred (200) hours of “related” continuing education courses which have been
completed within the immediate ten years prior to the date of submission of written application for
fellowship in the Academy.
C. Submit a notarized affidavit to the Directors on a form approved by the Secretary of the Academy attesting
that:
1. The applicant has personally completed all aspects of diagnosis and treatment for fifty (50) patients
whose chief complaints included Craniofacial Pain of non-dental or alveolar origin. To ensure privacy,
the patient list documenting completed cases may include patients’ initials and or chart # with the
patients’ date of birth or last four digits of social security number. At the request of the Directors, the
applicant may be required to demonstrate to representatives of the Academy, radiographs and records of
acceptable quality, which clearly delineate the scope of the patients’ complaints and treatment. Failure
to provide said records or other information to these representatives shall be considered reasonable cause
for refusing Fellowship status to the applicant or the request of his/her immediate resignation; and
2. The applicant has been involved for the previous two (2) years in the diagnosis and treatment of
craniofacial pain and temporomandibular disorders (Phase 1) of non dental or alveolar origin.
D. Satisfactorily complete the psychometrically derived written Fellowship examination (100 questions or by
successfully passing all examinations given by the AACP Craniofacial Pain Mini-residency) that shall be
administered at least once a year by the Academy.
E. The candidate may be requested to take other such examinations as are required by the Directors. The dates
of the examinations will be established by the Directors, as well as cut-off dates for applications and fees
for the examination and any reexamination.
F. Execute an affidavit which provides:
1. that the applicant will keep records in sufficient detail to enable the truthfulness of all statements and
representations made by the applicant to be determined, including but not limited to, those statements
concerning the number of patients applicant has treated for Craniofacial Pain, continuing education and
other post graduate courses completed, and
2. that the applicant will permit representatives of the Academy (to be appointed by the Directors) to
examine said records during normal business hours upon reasonable notice to the extent necessary to
verify any and all statements and representations made by the applicant to the Academy.
Dates of all examinations, deadlines, fees, benefits and dues will be established by the Directors and are to be
listed in the Policy and Procedure Manual.
Page 2- May be kept for your records.
AMERICAN ACADEMY OF CRANIOFACIAL PAIN
Fellowship Affidavit
(Revised January 2013)
State, County, Country: ________________________________________________________ §
__________________________________________________________, being first duly sworn, deposes and says:
(Affiant’s name – please print clearly)
1. I have personally completed all aspects of diagnosis and treatment (Phase I) for (50) patients whose chief complaints included
head, neck or craniofacial pain of non dental origin. To ensure privacy, the patient list documenting completed cases and
include patients’ initials and or chart # with the patients’ date of birth or last four digits of social security number (please total
patients at the bottom of the exhibit). This patient documentation is attached hereto, marked “Exhibit A” and hereby made a
part hereof. I further certify none of the patients in Exhibit A were treated by the undersigned specifically for malocclusions
and none of the patients received orthodontic or prosthodontic care by the undersigned without first being symptomatic [e.g.
headaches and/or facial pain] and then being rendered essentially pain free; and
2. I have completed at least two (2) or more academic years of graduate study in an A.D.A. accredited dental school program
which resulted in a certificate or advanced degree in the diagnosis and treatment of head, neck, craniofacial pain and
temporomandibular disorders. A copy of the certificate documenting such study is attached hereto, marked “Exhibit B-1”
and made a part hereof; OR
I have completed (200) hours of continuing education courses within the immediate ten years prior to the date of submission
of this application which are specifically related to head, neck and craniofacial pain and temporomandibular joint disorders,
not specifically related to the pathosis of the teeth or supporting structures. A list of the courses, lecturers, dates, and either
the places of administration of the courses or the sponsoring organizations is attached hereto, marked “Exhibit B” (please
total hours at the bottom of the exhibit) and made a part hereof; and
3. During the two (2) year period ending with my execution of this Affidavit, I have devoted a portion of my professional practice
to the diagnosis and treatment of head, neck, craniofacial pain and temporomandibular joint disorders (Phase I). I have and
will maintain records requisite for the independent verification of the aforementioned inclusion of TMD diagnosis and
treatment in my professional practice and I will make such records available for inspection in a timely manner by a
representative of the American Academy of Craniofacial Pain; and
4. My application for the status of Fellow is supported by at least two Academy members holding Fellow, Distinguished Fellow,
or Master of Excellence status. These two individuals are:
(1) ______________________________________
and
(2) _____________________________________
A letter of sponsorship from each is included and marked “Exhibit C” or “Exhibit D”; and
5. I will be taking the psychometrically derived written Fellowship examination that shall be administered at least once a year by
the Academy; OR
I have satisfactorily completed the psychometrically derived written examination given by the AACP Craniofacial Pain
Mini-residency on (Date) ____________________
and
(Location) ________________________________
6. If I am granted Fellowship status in the Academy, I will only represent to the public such Fellowship status and will not claim
any other status in the Academy. I will also not use this credential to imply specialty status.
The statements made herein are true and correct and are made for the purpose of obtaining Fellowship status in the
American Academy of Craniofacial Pain. I understand any false statements contained herein shall be grounds for
immediate disciplinary action which may include expulsion from the Academy and termination of any status and benefits
obtained therein.
Notary Public’s Seal:
____________________________________________
Affiant's Signature
Sworn to and subscribed before me
this _______ day of ___________________, 20_____
____________________________________________
Notary Public's Signature
My Commission expires:________________________
All required credentials should be legible, current, in completed form and submitted with this document on or before the pre-set deadline.
FOR CENTRAL OFFICE USE ONLY
Applicant: _____________________________________________________________________________
Date Mailed: ____________ Date Received Back: ____________ Checked by: _____________
Documentation: _________________________________________________________________________
Distributed to Credentials Committee: _________________ Presented to Board: ___________________
Page 3- Must be returned with required documentation.
Fellowship Application
PAYMENT FORM
Leading the TMD
Community
After completing your application, please submit with all supporting
documentation and the application fee ($500), to the AACP central office at the
email, fax or address below.
Method of Payment:
Check
Visa
MasterCard
If paying by check please make it payable to the AACP (in US funds and drawn on a US bank)
Card Number: ________________________________ ______________________
Expiration Date: ____
Security Code: ________
Today’s Date: _________
Cardholder (name as it appears on card): _______________________________
Billing Address for this card: ________________________________ _________
Cardholder’s signature: ________________________________ ______________
AMERICAN ACADEMY OF CRANIOFACIAL PAIN
EXECUTIVE OFFICE
12100 Sunset Hills Road, Suite 130 • Reston, VA 20190 • 800-322-8651; 703-234-4142 • Fax: 703-435-4390
Internet Website Address: www.aacfp.org • E-mail Address: [email protected]
Page 4- Must be returned with required documentation.
To: Prospective Examinees:
Leading the TMD
and Dental Sleep
Community
OFFICERS
PRESIDENT
Jeffrey S. McCarty, D.D.S.
IMMEDIATE PAST-PRESIDENT
Terry R. Bennett, D.M.D.
PRESIDENT-ELECT
Steven R. Olmos, D.D.S.
TREASURER
Richard E. Klein, D.D.S.
SECRETARY
Cynthia Mae Wiggins, D.D.S.
PROGRAM CHAIR
Edmund A. Lipskis, D.D.S., M.S.
DIRECTORS
Elliott J. Alpher, D.D.S.
Jeanne K. Bailey, D.D.S.
Michael A. Baylin, D.D.S.
Stacy V. Cole, D.D.S.
Richard Goodfellow, D.D.S.
Jack L. Haden, D.D.S.
Richard E. Klein, D.D.S.
Ira M. Klemons, D.D.S., Ph.D.
Edmund K.T. Liem, D.D.S.
Rick A. Light, D.D.S.
Dennis Marangos, D.D.S.
Allen J. Moses, D.D.S.
Gerald J. Murphy, D.D.S.
Mayoor Patel, D.D.S., M.S.
Brendan C. Stack, D.D.S., M.S.
Robert L. Talley, D.D.S.
Larry L. Tilley, D.M.D.
The Board of Directors of the American Academy of Craniofacial Pain
would like to congratulate you on your decision to prepare for the
Fellowship Examination. You will be challenged intellectually, but
this experience will most probably be a milestone in your professional
career. This examination is not intended to be punitive in nature;
rather, it will serve as a learning experience as well as a test of your
knowledge in the area of craniofacial pain and temporomandibular
disorders.
The examination consists of 100 questions. The written portion will be
constructed of questions from 20 different areas of study, with the
following number of questions:
Area of Study
1. Prolotherapy
2. Pharmacology
3. Phase II Treatment
4. Anatomy/Vascular
5. Neurology
6. Electromodalities
7. Muscles
8. Sleep Medicine
9. Neural Therapy
10. Nutrition
11. Osteology
12. Orthodontic
13. Trigger Points
14. Internal Derangements
15. Pain Syndromes
16. Orthotics
17. Radiology
18. Code of Ethics
19. Cranial Osteopathy
Approximate Proportion
4
4
4
6
2
6
22
4
4
5
6
4
2
2
4
8
7
2
6
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
You will be given four hours to complete the written portion
AMERICAN ACADEMY OF CRANIOFACIAL PAIN
EXECUTIVE OFFICE
12100 Sunset Hills Road, Suite 130 • Reston, VA 20190 • 800-322-8651; 703-234-4142 • Fax: 703-435-4390
Internet Website Address: www.aacfp.org • E-mail Address: [email protected]
Suggested Reading/Study List
AACP FELLOWSHIP EXAMINATION
The following materials may be acquired from TMData Resources in Albuquerque, NM [ph:
505/322-1400 or 800/533-5121 (for orders only), fax: 505/332-1661] or from other sources:
Books:
1. Craniofacial Pain, A Handbook for Assessment, Diagnosis and Management, by The American
Academy of Craniofacial Pain Edited by: H. Clifton Simmons III, D.D.S.
2. Evaluating and Managing Temporomandibular Injuries, Third Edition by Abdel-Fattah R.
3. Orofacial Pain by Bell W.
(especially chapters 7, 8, 11, 12, 16, and 17)
4. Myofascial Pain and Dysfunction, The Trigger Point Manual by Travell J and Simons D.
(especially chapters 1-17)
5. Myofascial Pain and Fibromylgia, Trigger Point Management by Rachlin ES and Rachlin
IS. (especially chapters 7,8,9, and 10)
6. The Medical Interview by Cole SA
(especially chapters 1,4,8,9, and 10)
7. Diagnosis of the Temporomandibular Joint by Katzberg & Westesson
(especially chapters 1, 2, 3, 5, 9, and 12)
8. TMJ: Its Many Faces
(This is a good source for information about MPD derangements, etc.)
9. Face The Pain
[This is good for the various neuropathic pain syndromes (i.e., Ernest Syndrome, NICO,
Neuralgias, etc.)]
10. Contemporary Orthodontics, 4th edition by William Profit. Elsevier Publishers
(especially chapters 1-6)
11. Sleep Disorders: Diagnosis, Management & Treatment A Handbook for Clinicians by
Lavie, P., Pillar G., and Malhotra.
CDs:
1. Clinical Applications of Electro-Therapeutics in the Treatment of Craniofacial Pain
and TMD (CD/Manual) by Gerald J. Murphy, DDS
The following may be acquired from www.amazon.com as well as other sources:
Books
1. Restless Nights: Understanding Snoring and Sleep Apnea by Lavie, P. 2003: Yale
University Press: New Haven, CT.
The following materials will be provided on CD-ROM, free of charge, upon receipt of
the AACP Fellowship Exam fee by the Central Office:
1. Imaging of the Temporomandibular Joint by Westesson and Katzberg (formerly part
of the CRANIO Clinics series; now out-of-print)
2. Intraoral Orthotics by W. Steve Bledsoe, Jr. (formerly part of the CRANIO Clinics
series; now out-of-print)
3. Selected Articles from CRANIO Journal
4. Glossary: Craniofacial Pain & Temporomandibular Disorders
SAMPLE QUESTIONS FOR FELLOWSHIP EXAM
1). The greater wing of the sphenoid bone comprises the floor of both the anterior and
middle cranial fossae. Choose one:
A). True
B). False
2). All the muscles of mastication and the posterior digastric muscle are innervated by
the third division of the trigeminal nerve. Choose one:
A). True
B). False
3). The left common carotid artery arises from the aortic arch. The right common carotid
artery arises from the brachio-cephalic artery. Choose one correct answer.
A). Both statements are true.
B). Both statements are false.
C). Only the first statement is true.
D). Only the second statement is true.
4). The trigeminal nerve emerges from the side of the pons, near its upper border, by
(choose two):
A). Large motor root.
B). Small motor root.
C). Small sensory root.
D). Large sensory root.
5). Descending pathways from the somatosensory areas both I and II of the cerebral
cortex exert inhibitory control over ascending pathways of the somatosensory
systems. Choose one:
A). True
B). False
6). The axoplasm (cellular membrane of a neuron) exhibits a -70mV charge due to
(choose one):
A). The non-selective permeability of the liquid membrane.
B). The action of the sodium/potassium pump.
C). The lack of ion channels.
7). Obscuring the diagnostic value of a transcranial film could include (choose one):
A). Anterior and posterior clinoid processes.
B). Posterior clinoid process.
C). Petrous portion of the temporal bone.
D). A, B and C.
E). B and C.
8). Ernest Syndrome may mimic an internal derangement of the TM Joint and in fact,
clicking of the joint may also be heard.
A). True
B). False
9). Which of the following functions as a coenzyme in the production of collagen?
A). Vitamin K
B). Vitamin C
C). Vitamin B6
D). Tyramine
Choose one:
1). A
2). B
3). All of the above
4). D
10. The symptoms of temporal headache, ear pain, and tooth pain (especially when
chewing ) may indicate:
A). Temporal arteritis
B). Internal TM joint derangement
C). Temporal tendinitis
D). Ernest Syndrome
Choose one:
1). All
2). A, B and C
3). A, B and D
4). B, C and D
11). Temporal tendinitis presents with which of the following symptoms?
A). Retro-orbital pain
B). Temporal pain
C). Ear stuffiness
D). Temporal pain made worse with intraoral splint
Choose one:
1). All
2). B and D
3). A, B and D
4). B, C and D
12). Satellite trigger points are (choose one):
A). A hyperirritable spot in muscle or fascia due to a trigger point in an antagonist
muscle.
B). A hypoirritable spot in muscle or fascia due to a trigger point in an antagonist
muscle.
C). A hyperirritable spot in muscle or fascia due to the fact that it is in the zone of
reference of another muscle.
D). A hypoirritable spot in muscle of fascia due to the fact that it is in the zone of
reference of another muscle.
13). Mandibular whiplash may cause (choose one):
A). Epimysial fibrosis of the lateral pterygoid muscle.
B). Stretching or tearing of the collateral ligaments of the temporomandibular
joint.
C). Hemarthrosis into the TM joint.
D). All of the above.
14). Which of the following symptoms are characteristic of osteocavitation
lesions?
A). Undiagnosed facial and cervical pain.
B). Undiagnosed pain in shoulders, neck and arms.
C). History of tooth extraction.
D). Trigger areas.
Choose one:
1). A and C
2). A, B and C
3). A, C and D
4). All of the above
15). Evaluation of anterior neck trigger points is best done with:
Choose one:
A). Liquid crystal thermography
B). Electronic infra-red thermography
C). The patient in a supine position
D). The patient sitting
16). High voltage stimulators characteristically deliver? Choose one:
A). Twin peak pulse, short pulse duration, high voltage and high average current.
B). Twin peak pulse, long pulse duration, high voltage, low average current.
C). Twin peak pulse, short pulse duration, high voltage, low average current.
D). Twin peak pulse, short pulse duration, high voltage, low peak current.
17). Interferences on the non-working side can be caused by? Choose one:
A). Improper construction of the curve of Spee.
B). The curve of Wilson being too exaggerated.
C). B & C
D). A, B & C
18). Which statement is false? Choose one.
A). The nasopharynx extends from an area where the postero-superior border of the vomer
contacts the body of the sphenoid bone downward to the level of the hard palate.
B). Although the maxilla increases in length anterposteriorly by growth in its posterior portion,
the nasopharynx does not become progressively occluded in the growing individual
because simultaneous growth of the anterior cranial base carries the maxilla anteriorly.
C). A certain amount of adenoidal tissue is necessary for velopharyngeal closure
but too much can result in naso-pharyngeal airway obstruction.
D). The pharynx can be anatomically divided into an upper portion called the
oropharynx and a lower portion called the nasopharynx.
19). The indications for splint use include? Choose one:
A). Provisional deconditioning of TMD patients.
B). Provisional repositioning of asymptomatic patients in preparation of vertical or
anteroposterior restoration.
C). As an intermediate tool in dysfunctional patient’s occlusal corrections.
D). As a nightguard.
E). As a crutch for periodic use.
F). For long term mandibular repositioning.
G). All of the above.
20). What factors influence the cranial mechanism? Choose one:
A). Muscles.
B). Fascia.
C). Ligaments.
D). Occlusion
E). A, B and C
F). All of the above.
21). A disturbance in the position or physiologic motion of the sacrum can directly affect
the base of the skull and the tension on the cranium by affecting which structures?
A). Falx cerebri
B). Tentorium cerebelli
C). Dura mater
D). Spinal dura
Choose one:
1). A, B and C.
2). A, B and D.
3). A and B
4). All of the above.
22). After a severe blow to the mandible, a patient cannot open wide and deviates
consistently to one side. Which of the following should be suspected:
A). Acute dislocation without reduction of disc.
B). Condylar fracture.
C). Chronic dislocation without reduction.
D). Adhesion formation.
Select one:
1). A, B and D
2). B, C and D
3). A and B
4). All of the above.
23). Local anesthetics work primarily by inactivating sodium channels in the axon, thus
preventing depolarization and action potential propagation.
A). True
B). False
ANSWER KEY
1).
B
2).
B
3).
A
4).
B&D
5).
A
6).
B
7).
D
8).
A
9).
2
10). 4
11). 1
12). C
13). D
14). 4
15). B
16). C
17). E
18). C
19). G
20). F
21). 4
22). 1
23). A