A prevalence study of the clinical signs associated with mandibular dysfunction

Comparison of three clinical techniques for evaluating joint sounds

Two-hundred two consecutive adult patients presenting to the University of Kentucky for general dental care screening were examined for temporomandibular joint sounds by three techniques: (1) lateral pole surface palpation, (2) digital palpation in the external auditory canal, (3) auscultation by a stethoscope. Sixty-nine patients reported joint sounds, but only 32 had sounds diagnosed by auscultation resulting in a 54% false-negative reporting rate. Stethoscopic auscultation was used as the standard to which the other two techniques were compared. The false-negative rate for auditory canal digital palpation was 71% and 77% for lateral pole surface palpation. Surface palpation had only a 2% false-positive incidence while auditory canal digital palpation had a 51% false-positive rate. There was poor agreement between the patients' subjective reporting and clinical exam by any technique. Using stethoscopic auscultation as the standard, both auditory canal and surface palpation had a very high false-negative rate, but only the auditory canal palpation had a poor false-positive incidence. Auditory canal palpation often produces TMJ sounds that are not heard with a stethoscope during normal opening and closure.

A comparative study of temporomandibular symptoms following mandibular advancement by bilateral sagittal split osteotomies: rigid versus nonrigid fixation

Rigid fixation to attach proximal and distal segments during bony healing of osteotomy sites has become increasingly popular. The effects of rigid fixation on the temporomandibular joints have been questioned. The purpose of this study was to evaluate the effects of rigid fixation after bilateral sagittal split osteotomies on temporomandibular dysfunction symptoms. Forty patients who had mandibular advancement surgery were evaluated for temporomandibular joint dysfunction. Twenty had received rigid fixation, and twenty had received nonrigid fixation. It was determined that there was no statistically significant difference in temporomandibular signs or symptoms between patients who were treated with rigid internal fixation for bilateral sagittal split osteotomies for mandibular advancement and those patients who were treated with nonrigid wire fixation.

A comparison of the signs of temporomandibular joint dysfunction and occlusal discrepancies in a symptom-free population of men and women

To date, there has been no conclusive explanation for the predominance of female patients with temporomandibular joint (TMJ) dysfunction. The purpose of this study was to survey a normal population without symptoms for the presence of certain putative signs of TMJ dysfunction in association with certain signs of occlusal discrepancy and to determine the presence of any gender variation. The subjects (217 men and 217 women) were examined for the presence of three putative signs of TMJ dysfunction: limited mandibular opening (under 37 mm), deviation on opening, and joint sounds. The subjects were also examined for the presence of four signs of occlusal discrepancy: an anterior slide from centric relation (CR) to centric occlusion (CO), lateral slide from CR to CO, nonworking occlusal contacts, and working disclusive contacts distal to the canines. CR is the mandibular position at which the condyles are in their most superior position on the posterior aspect of the articular tubercles. CO is the mandibular position at which the mandibular and maxillary teeth are in maximum intercuspation. There were no significant differences in the prevalence of the putative signs of TMJ dysfunction and occlusal discrepancy between men and women. It was concluded that factors other than the presence of these signs of TMJ dysfunction and occlusal discrepancy are responsible for the high predominance of female patients with TMJ dysfunction.

Prevalence of temporomandibular symptoms in a large United States metropolitan area

The prevalence of five symptoms of temporomandibular disorder and associated symptoms of pain, headache, and stress was estimated in a random telephone survey of a large United States metropolitan area. The prevalences for nocturnal bruxing, joint noise with use, soreness on waking, soreness with use, and diurnal clenching were roughly equivalent (ranging from 8% to 12%) and were within the range of prevalences reported in previous studies. Overall, 149 of the 500 respondents reported one or more of the five symptoms. Symptoms were not more prevalent among women than men, but were more prevalent among younger respondents. Soreness on waking and daytime clenching were the only symptoms significantly associated with report of pain. Pain was more commonly reported by respondents with multiple (four or five) symptoms. The results are compared with those of previous random surveys, and limitations to generalization of the present findings are discussed.

Temporomandibular joint sounds in adolescents: a longitudinal study

A 2-year longitudinal study on signs and symptoms of mandibular dysfunction was performed with 285 17-year-old adolescents living in a certain geographic area in Skellefteå, Sweden. Crepitation was neither reported nor recorded in any subject. Both reports and recordings of TMJ clicking sounds fluctuated with time. The 2-year period prevalence was 24%, and 5.8% consistently reported TMJ clicking sounds. The corresponding figures for clinically recorded clickings were 36% and 9.3%, respectively. Both reported and recorded joint sounds were significantly more frequently found in 19-year-old girls than in boys. No consistent pattern of relationships between reported and recorded clicking sounds and single factors obtained by the questionnaire or clinically recorded variables could be found. Palpation tenderness in three muscle sites was to a varying degree related to both reports and recordings of clicking. Each year, significant relationships were found between reports of TMJ sounds and symptom indices. Recorded sounds were significantly related to a clinical index in the two oldest age groups. The prevalence of TMJ clicking sounds increases with age, and girls are more prone to have them than boys. In view of the natural longitudinal fluctuations, most clickings only need to be supervised, and when there is a demand for treatment, reversible methods are advocated in adolescents.

Pressure pain thresholds, clinical assessment, and differential diagnosis: reliability and validity in patients with myogenic pain

Four studies are presented testing the validity and reliability of pressure pain thresholds (PPTs) and of examination parameters believed to be important in the clinical assessment of sites commonly used for such measures in patient samples. Forty-five patients with a myogenous temporomandibular disorder were examined clinically prior to PPT measures. Criteria for history and examination included functional aspects of the pain, tissue quality of the pain site, and the type of pain elicited from palpation. Control sites within the same muscle and in the contralateral muscle were also examined. PPTs were measured as an index of tenderness using a strain gauge algometer at these sites. The data from the 5 male subjects were excluded from subsequent analyses due to the higher PPT in the males and to their unequal distribution among the various factorial conditions. The first study demonstrated strong validity in PPT measures between patients (using pain sites replicating the patients' pain) and matched controls (n = 11). The PPT was not significantly different between the primary pain site (referred pain and non-referred pain collapsed) and the no-pain control site in the same muscle (n = 16). The PPT was significantly lower at the pain site compared to the no-pain control site in the contralateral muscle (n = 13). The second study indicated adequate reliability in patient samples of the PPT measures. In the third study, the PPT was significantly lower at sites producing referred pain on palpation compared to sites producing localized pain on palpation. The PPT findings from the control sites were inconsistent on this factor. The fourth study presented preliminary evidence that palpable bands and nodular areas in muscle were most commonly associated with muscle regions that produce pain; such muscle findings were not specific, however, for regions that produce pain. Further, the intraexaminer reliability in reassessing these pain sites qualitatively was only fair. Referred pain had a poor association with the pain pattern and physical findings, which may suggest a need to reevaluate part of the theory regarding referred muscle pain. The reliability of PPT measures was better overall than the reliability of the signs and site-specific symptoms, suggesting that pressure pain thresholds may be an important tool in clinical studies of pain. PPT measures demonstrate a high within-subject variability in pain patient subjects as well as non-pain subjects.(ABSTRACT TRUNCATED AT 400 WORDS)

Mandibular dysfunction in adulthood in relation to morphologic malocclusion at adolescence

The purpose of this 20-year follow-up study was to assess whether pronounced morphologic traits of malocclusion, persisting from adolescence to about 35 years of age, imply an increased risk of persistent and severe mandibular dysfunction. In 1965-66 malocclusion was recorded in 176 adolescents; in 1981 these persons responded to a questionnaire concerning symptoms of functional disorders, and in 1986-87 malocclusion and signs of dysfunction were registered. Highly significant associations were observed between some of the self-reported symptoms and the signs registered 5-6 years later. Spearman correlation coefficients between the persistent traits of malocclusion, occurring at both examinations, and the signs of mandibular dysfunction were low in general. No association was found between the most severe and persistent functional disorders and any particular malocclusion. It is concluded that orthodontic screening of morphologic malocclusion in childhood would seem of limited value in attempts to predict mandibular dysfunction in adulthood.

Post-orthodontic occlusal function

The significance of orthodontic treatment in the aetiology of temporomandibular dysfunction continues to be a matter of controversy. However, the evidence of any association has been generally negative. This investigation involved the examination of a study group of 87 post-orthodontic patients, the average time out of all retention being 52 months. They were compared with an untreated control group. Signs and symptoms of temporomandibular disfunction were assessed for both groups. In only one instance, soft joint click, was there found to be a significant association between the treatment category and the occurrence of the symptom, there being a higher rate of soft clicks in the post-treatment group. While this may be ascribed to orthodontic treatment, there was also a different restorative pattern in the two groups. No other significant associations were found.

Right-left asymmetry of maximum jaw opening

According to several studies on human populations, the mandible deviates on opening significantly more often to the left than to the right. An association between the asymmetry of opening and handedness has been suggested. The present study of 143 left-handed Finnish conscripts showed no significant difference from the asymmetry reported for populations unselected for handedness. It was concluded that the opening asymmetry and handedness are not associated. The asymmetry proved also to be unassociated with the side of first unilateral tooth contact on guided hinge closure, with the side of palpatory tenderness of the muscles of mastication, and with the side of temporomandibular joint sounds.

Short-term effect of two therapeutic methods on myofascial pain and dysfunction of the masticatory system

In conclusion, a short-term intervention with IS therapy was found to result in a substantial decrease in facial pain for most of the subjects treated. Generally, groups were not found to be significantly different in respect to palpation pain change from session 1 to session 2. Neither therapy significantly altered the range of mouth opening. EMG findings were variable but suggest that RI therapy may alter muscle myoelectric activity. From these findings, ice and stretch of the masticatory and neck musculature would appear to be a good short-term adjunctive therapy to control pain with little apparent risk of negative effects.

Prevalence of symptoms associated with temporomandibular disorders in a Canadian population

Few epidemiologic studies of TM disorders have used random samples drawn from the general population. The aim of this study was to estimate the prevalence and distribution of symptoms commonly associated with such disorders among a sample of adults in Toronto, Canada. A random digit dialing technique was used to identify 1002 individuals aged 18 and over. A symptom questionnaire was completed by 67.7%. Overall, 48.8% responded positively to one or more of the nine questions concerning symptoms. Joint sounds, tiredness or stiffness of jaw muscles, and an uncomfortable bite were the symptoms most frequently reported. Functional pain or pain while at rest was reported by 12.9%. Sex and age differences were small although statistically significant, with women and the younger age groups more likely than men or the older age groups to report one or more symptoms. Significant associations were observed between the reporting of symptoms and potential risk factors such as parafunctional behaviours and reports of frequent stress. The proportion in need of treatment varied from 3.5% to 9.7% according to the case definition used.

The effects of treatment on masticatory muscle activity and mandibular posture in myofascial pain-dysfunction patients

The purpose of this study was to evaluate tonic masticatory muscle activity and the postural rest position of the mandible, pre- and post-treatment, in patients with TM disorders. Forty-one patients diagnosed as suffering from myofascial pain-dysfunction (MPD) were evaluated, with electromyography (EMG) used to measure the muscle activity of the masseteric and anterior temporal areas at rest. Postural rest position was assessed by measurement of interocclusal distance. Twenty-three asymptomatic subjects were also tested as controls. Treatment for the pain group emphasized cognitive awareness of dysfunctional orofacial behavior and biofeedback training of the masseteric area to teach masticatory muscle relaxation. The pre-treatment EMG values of both the masseteric and anterior temporal areas were significantly higher for the pain group than for the control group. Post-hoc division of the pain group into successful and unsuccessful subgroups was made on the basis of the degree of symptom improvement. EMG activity decreased significantly in the masseters of both subgroups, but only the unsuccessful subgroup showed a significant decrease in anterior temporal activity following therapy. Interocclusal distance was significantly increased in both subgroups. These results suggest that tonic masticatory muscle activity may be elevated in MPD patients. They also suggest that a decrease in EMG activity in the masseter and anterior temporalis muscles and an opening of the postural rest position of the mandible may accompany completion of psychophysiological therapy, but these changes do not correspond directly with the outcome of that therapy.

Temporomandibular disorders. Part I: Functional status, dentomorphologic features, and sex differences in a nonpatient population

Freshman dental and dental hygiene students, 120 men and 102 women (mean age 23.9 years), were assessed for the presence of masticatory pain or dysfunction by questionnaire, clinical examination, and evaluation of dental casts according to strict criteria. The purpose was to identify and analyze the level of signs and symptoms in a nonpatient population and describe occlusal variation. The prevalence of TMJ signs and symptoms was notable even though two thirds reported only mild or early symptoms, with only 3% reporting severe symptoms. This population was noted for the absence of locking, the low frequency of severe pain or severe TMJ dysfunction, and the low prevalence of restricted ranges of mandibular movement and TMJ crepitation. Women showed significantly more headache, TMJ clicking and tenderness, and muscle tenderness than men. Men were noted for the absence of severe and widespread muscle tenderness and severe TMJ tenderness. TMJ clicking was not always clinically confirmable in subjects with widespread muscle tenderness. This group was considered compatible with previous epidemiologic findings, and also matches the age range of most subjects seeking treatment for TMJ disorders. Therefore, the subjects in the study were considered a representative group of young adults and suitable for study of the possible associations between early signs of TMJ disorders and variables of morphologic malocclusion, which are discussed in Parts II and III of this article.

Reliability of visual analog and verbal descriptor scales for "objective" measurement of temporomandibular disorder pain

Eight dentists viewed standardized videotapes showing palpations of the temporomandibular joint and muscles of mastication and recorded their judgments concerning the amount of pain the patient was experiencing. Judgments were recorded using a four-point verbal descriptor scale (VDS) ("none", "mild", "moderate", "severe" pain) or a 100-mm visual analog scale (VAS) anchored with the terms "no pain" and "worst pain possible". Test/re-test reliability over a one-week period and interjudge reliabilities were calculated for each scale; reliabilities of the two scales were directly compared based on the statistical equivalence of weighted kappa and the Intraclass Correlation Coefficient. Neither scale showed satisfactory reliability. Median test/re-test reliabilities were k = 0.590 for the VDS and r = 0.822 for the VAS. Interjudge reliabilities averaged k = 0.394 for the VDS and r = 0.735 for the VAS. Direct comparison of reliabilities for the two scales showed no clear advantage for either scale. The marginal reliabilities of these scales, when used by dentists to quantify the patient's pain, suggest that neither scale should be regarded as an "objective" pain measure.

Experimental masticatory muscle pain

Ten female subjects with no history of temporomandibular disorders performed five exercises designed to induce masticatory muscle pain. Three of the exercises were replications of Christensen's tooth-clenching (1970) and tooth-grinding (1971) studies and Scott and Lundeen's mandibular protrusion (1980) study. The other two exercises were designed to induce specific unilateral masticatory muscle pain. The amount of muscle pain as well as the time of onset and the duration were assessed by a clinical palpation exam and a pain questionnaire. These five pain-inducing methods did not consistently produce masticatory muscle pain in non-pain subjects. However, certain individuals appeared to be very susceptible to developing pain during or after most of the exercises. These susceptible individuals demonstrated a bilateral muscle pain pattern after the unilaterally stressful exercises. None of the five exercises produced a statistically significant amount of site-specific masticatory muscle pain as determined by either the palpation examination or the pain questionnaire, even when the exercise was intended to produce such specificity. The fact that some subjects did develop masticatory muscle pain is indicative that muscle exercise and fatigue may lead to TMD-like symptoms.

Semiquantitative SPECT imaging for assessment of bone reactions in internal derangements of the temporomandibular joint

The temporomandibular joints (TMJs) of 60 patients with arthrographically confirmed internal derangements and 30 volunteers were examined with single photon emission computed tomography (SPECT). Semiquantitative evaluation was done by forming a quotient from the counts of a constantly sized TMJ-ROI relative to the overall counts of the cranium. The TMJ/cranium quotient depended on the age of the subject, with younger patients showing a larger quotient than older ones. Normal joints were separated from the afflicted ones by means of a discriminant analysis. Sensitivity of semiquantitative evaluation was 78% (disc displacements with reduction) and 89% (disc displacements without reduction). Correct visual evaluation was made in 53% of the reducing and 75% of the nonreducing discs. Semiquantitative SPECT of the TMJs provides important information on the extent of osseous changes in afflicted joints and is suitable for follow-up of splint therapy. It may also be helpful as a screening method in detecting clinically normal joints before arthrography is carried out and in assessing the presumptive response to treatment with a splint.

Psychosocial and demographic correlates of temporomandibular disorders and related symptoms: an assessment of community and clinical findings

This study investigated the factor structure and relative prevalence of temporomandibular disorder (TMD) symptoms, in relation to demographic and psychosocial variables in a community sample. Two empirically distinct clusters of TMD symptoms were identified. Similar to reports of TMD clinic patients, more symptoms were reported by females than males and the greatest symptom prevalence was found in subjects between the ages of 30 and 49 years. Further, the number of symptoms reported was significantly and linearly related to scores on depression and repression-sensitization scales. These relationships, however, were similar for both sets of symptom composites even though one composite is clearly identifiable as the core TMD symptoms and the second composite consists of peripheral symptoms. Since the two symptom composites share some common variance, the relationship between demographic and psychosocial characteristics and the number of composite I and composite II symptoms was examined while controlling for the presence of symptoms from the other composite. When controlling for the presence of composite II symptoms, the correlations between psychosocial and demographic characteristics and composite I symptoms are small. When the presence of composite I symptoms is controlled there is little change in the magnitude of the correlations between psychosocial and demographic characteristics and composite II symptoms. It is concluded that the psychosocial profile described in clinical research is actually more characteristic of individuals with pain/dysfunction symptoms other than the classic TMD symptoms and that the relationship between core TMD symptoms (composite I) is largely spurious. It is suggested that this psychosocial profile of TMD patients may have developed through associating certain psychosocial characteristics with TMD while such characteristics are actually present in TMD clinic patients because of the covariation of the two symptom composites in individuals seeking treatment in TMD clinics.

Prevalence of mandibular dysfunction in an urban population in Hungary

600 randomly selected subjects from an urban community in Hungary were examined anamnestically and clinically concerning signs and symptoms of mandibular dysfunction. The anamnestic (Ai) and clinical dysfunction (Di) indices according to Helkimo were used. The percentage distribution of the sample was the following: AiO = 79.3%, AiI = 15.3%, AiII = 5.3%; DiO = 20.1%, DiI = 72.3%, DiII = 7%, DiIII = 0.5%. Headache was reported in 23%, bruxism in 10%, joint sounds in 9%, pain in the face, neck, or around the ears in 6%. Clinical signs found at the examination were joint sounds in 46% (crepitation 29%, clicking 22%), muscle tenderness on palpation in 17%, joint tenderness in 3%, pain on movement in 2.5%, restricted mouth opening in 4%, deviation of the mandible in 20%.

Incidence of temporomandibular symptoms in patients with major skeletal malocclusions: a survey of oral and maxillofacial surgery training programs

A survey was done of 116 graduate training programs in oral and maxillofacial surgery to determine (1) the percentage of patients screened for orthognathic surgery who had symptoms of temporomandibular pain and dysfunction preoperatively and (2) how many who were asymptomatic preoperatively developed temporomandibular symptoms postoperatively. Of the fifty-one programs that responded, most reported that fewer than 20% of the patients were symptomatic before surgery and that few patients had symptoms postoperatively. The implications of these findings are discussed.