Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: recommendations of the International RDC/TMD Consortium Network* and Orofacial Pain Special Interest Group†

Pain paper 2b: classification of orofacial pain and an update on assessment and diagnosis

The classification of chronic orofacial pain remains a contentious area. However, more recently, with the clarification of pain mechanisms and improved understanding of the underlying neurophysiology and modulation factors, there is more clarity of the possible division of pain conditions. Interestingly, the pathophysiology provides a basis for classification that has more clinical relevance. The principles of assessing and managing patients with pain have modified significantly, in line with recent improved understanding of the affective and emotional components in pain behaviour and suffering. Clinical Relevance: This paper aims to provide the dental and medical teams with a review of the classification of trigeminal pain with an overview of how to assess and diagnose patients with trigeminal pain.

Gene Mutations Associated with Temporomandibular Joint Disorders: A Systematic Review

Background

The temporomandibular joint (TMJ) is a bilateral synovial joint between the mandible and the temporal bone of the skull. TMJ disorders (TMDs) are a set of complicated and poorly understood clinical conditions, in which TMDs are associated with a number of symptoms including pain and limited jaw movement. The increasing scientific evidence suggests that genetic factors play a significant role in the pathology of TMDs. However, the underlying mechanism of TMDs remains largely unknown.

Objective

The study aimed to determine the associated genes to TMDs in humans and animals.

Methods

The literature search was conducted through databases including Medline (Ovid), EMBASE (Ovid), and PubMed (NLM) by using scientific terms for TMDs and genetics in March 2015. Additional studies were identified by searching bibliographies of highly relevant articles and Scopus (Elsevier).

Results

Our systematic analyses identified 31 articles through literature searches. A total of 112 genes were identified to be significantly and specifically associated with TMDs.

Conclusion

Our systematic review provides a list of accurate genes associated with TMDs and suggests a genetic contribution to the pathology of TMDs.

Subtyping Somatic Tinnitus: A Cross-Sectional UK Cohort Study of Demographic, Clinical and Audiological Characteristics

Somatic tinnitus is the ability to modulate the psychoacoustic features of tinnitus by somatic manoeuvres. The condition is still not fully understood and further identification of this subtype is essential, particularly for the purpose of establishing protocols for both its diagnosis and treatment. This study aimed to investigate the characteristics of somatic tinnitus within a large UK cohort using a largely unselected sample. We believe this to be relatively unique in comparison to current literature on the topic. This was investigated by using a total of 608 participant assessments from a set of recognised tinnitus and audiology measures. Results from a set of chi-square tests of association found that amongst the individuals with somatic tinnitus, a higher proportion had pulsatile tinnitus (different from heartbeat), were under the age of 40, reported variation in the loudness of their tinnitus and reported temporomandibular joint (TMJ) disorder. The same pattern of results was confirmed using a multivariate analysis of the data based on logistic regression. These findings have strong implications towards the profiling of somatic tinnitus as a distinct subtype of general tinnitus.

Do changes in oral health-related quality-of-life, facial pain and temporomandibular disorders correlate after treatment of severe malocclusion?

INTRODUCTION

The aim was to evaluate the relationships of changes in facial pain, temporomandibular disorders (TMDs) and oral health-related quality-of-life (OHRQoL) in adults who underwent orthodontic or orthodontic/surgical treatment.

METHODS

Sixty-four patients (46 women, 18 men, range 18-64 years) with severe malocclusion and functional problems were treated in Oulu University Hospital. Of these, 44 underwent orthodontic-surgical and 20 orthodontic treatment. Data were collected with questionnaires and clinical stomatognathic examinations before and on average 3 years after treatment. The OHRQoL was measured with OHIP-14 (The Oral Health Impact Profile), the intensity of facial pain with the Visual Analogue Scale (VAS) and the severity of TMD with the Helkimo's anamnestic (Ai) and clinical (Di) dysfunction indices.

RESULTS

A significant improvement was found in facial pain, signs and symptoms of TMD and OHRQoL after the treatment (p < 0.05). The decrease in VAS was associated with improvement in OHIP-14 severity (r = 0.296, p = 0.019). The correlations between changes in OHIP-14 severity and Ai and Di were not statistically significant.

CONCLUSION

Treatment of severe malocclusion seemed to improve OHRQoL via decreased facial pain. Decreased facial pain was associated especially with improved OHRQoL dimensions of physical pain, physical disability and social disability.

Deep dry needling of trigger points located in the lateral pterygoid muscle: Efficacy and safety of treatment for management of myofascial pain and temporomandibular dysfunction

Background

To determine whether deep dry needling (DDN) of trigger points (TPs) in the lateral pterygoid muscle (LPM) would significantly reduce pain and improve function, compared with methocarbamol/paracetamol medication.

Material and Methods

Forty-eight patients with chronic myofascial pain located in the LPM were selected and randomly assigned to one of two groups (DDN test group, n=24; drug-treated control group, n=24). The test group received three applications of needling of the LPM once per week for three weeks, while control group patients were given two tablets of a methocarbamol/paracetamol combination every six hours for three weeks. Assessments were carried out pretreatment, 2 and 8 weeks after finishing the treatment.

Results

A statistically significant difference (p<0.05) was detected for both groups with respect to pain reduction at rest and with mastication, but the DDN test group had significantly better levels of pain reduction. Moreover, statistically significant differences (p<0.05) up to day 70 in the test group were seen with respect to maximum mouth opening, laterality and protrusion movements compared with pretreatment values. Pain reduction in the test group was greater as a function of pain intensity at baseline. The evaluation of efficacy as assessed both by patients/investigators was better for the test group. 41% of the patients receiving the combination drug treatment described unpleasant side effects (mostly drowsiness).

Conclusions

DDN of TPs in the LPM showed better efficacy in reducing pain and improving maximum mouth opening, laterality, and protrusion movements compared with methocarbamol/paracetamol treatment. No adverse events were observed with respect to DDN.

Key words: Myofascial pain syndrome, myofascial trigger points, deep dry needling, lateral pterygoid muscle, randomized controlled trial, temporomandibular disorders.

Local group I mGluR antagonists reduce TMJ-evoked activity of trigeminal subnucleus caudalis neurons in female rats

Group I metabotropic glutamate receptors (mGluR1 and mGluR5) are functionally linked to estrogen receptors and play a key role in the plasticity of central neurons. Estrogen status strongly influences sensory input from the temporomandibular joint (TMJ) to neurons at the spinomedullary (Vc/C1-2) region. This study tested the hypothesis that TMJ input to trigeminal subnucleus caudalis/upper cervical cord (Vc/C1-2) neurons involved group I mGluR activation and depended on estrogen status. TMJ-responsive neurons were recorded in superficial laminae at the Vc/C1-2 region in ovariectomized (OvX) female rats treated with low-dose estradiol (2 μg/day, LE) or high-dose estradiol (20 μg/day, HE) for 2 days. TMJ-responsive units were activated by adenosine triphosphate (ATP, 1mM) injected into the joint space. Receptor antagonists selective for mGluR1 (CPCCOEt) or mGluR5 (MPEP) were applied topically to the Vc/C1-2 surface at the site of recording 10 min prior to the intra-TMJ ATP stimulus. In HE rats, CPCCOEt (50 and 500 μM) markedly reduced ATP-evoked unit activity. By contrast, in LE rats, a small but significant increase in neural activity was seen after 50 μM CPCCOEt, while 500 μM caused a large reduction in activity that was similar in magnitude as that seen in HE rats. Local application of MPEP produced a significant inhibition of TMJ-evoked unit activity independent of estrogen status. Neither mGluR1 nor mGluR5 antagonism altered the spontaneous activity of TMJ units in HE or LE rats. High-dose MPEP caused a small reduction in the size of the convergent cutaneous receptive field in HE rats, while CPCCOEt had no effect. These data suggest that group I mGluRs play a key role in sensory integration of TMJ nociceptive input to the Vc/C1-2 region and are largely independent of estrogen status.

Association between waking-state oral parafunctional behaviours and bio-psychosocial characteristics

The term 'oral parafunctional behaviours' encompasses behaviours that are different from those required for, or associated with, physiological functional needs such as mastication, communication, swallowing or breathing. Previous reports have associated waking-state oral parafunctional behaviours with biopsychosocial characteristics such as female gender, presence of psychological symptoms, intensity of pain and pain-related temporomandibular disorders (TMD) diagnosis. However, the findings have been inconsistent, possibly due to methodological limitations and differences. In the present investigation, we aim to determine whether any association is present between waking-state oral parafunctional behaviours and biopsychosocial characteristics. All participants were investigated using a set of standardised and validated self-reporting questionnaires and diagnostic criteria for temporomandibular disorders (DC/TMD) examination protocol for clinical characterisation. Univariate analysis found that self-reported waking-state oral parafunctional behaviours were statistically significantly associated with presence of anxiety, depression and physical symptoms, pain intensity and TMD diagnosis. However, forward model multiple linear regression analysis indicated that only self-reported presence of physical and depression symptoms could explain statistically significant portions of the variance in self-reported waking-state oral parafunctional behaviours.

Temporomandibular Disorders (TMD) in Edentulous Patients: A Review and Proposed Classification (Dr. Bader's Classification)

Temporomandibular disorders (TMD) are a collective term given to a number of clinical problems that involve the masticatory musculature, the temporomandibular joints and associated structures, or both. Although the aetiology of TMD has not been fully understood, in general it is considered to be multifactorial. The signs and symptoms of TMD which present in patients with natural teeth may also occur in edentulous patients. These symptoms may appear in various combinations and degrees. TMD has attained a prominent role within the context of dental care due to its high prevalence. The present paper is a review of the current literature on TMD in edentulous patients; with an attempt to propose a classification for the same.

Diagnostic criteria for temporomandibular disorders: self-instruction or formal training and calibration?

BACKGROUND

To investigate the difference in diagnostic reliability between self-instructed examiners and examiners taught in a Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) course and if the reliability of self-instructed examiners improves after the course.

METHODS

Six examiners were divided into three groups: (1) formal two-day training and calibration course at a DC/TMD training center (Course group), (2) self-teaching through documents and movie (Self group) with three examiners on each and the Self group later participated in the course (Self + course group). Each group examined sixteen subjects, total of 48 volunteers (36 patients with TMD and 12 asymptomatic) and the reliabilities in relation to the diagnoses derived by a Reference Standard Examiner were compared by Cohen's Kappa coefficient.

RESULTS

The reliability was good to excellent in all three groups of examiners for all DC/TMD diagnoses, except for Myofascial pain with referral in the Self + course group. The course seemed to improve the reliability regarding Myalgia and Arthralgia at the same time as the examiners experienced the course to be valuable for self-perceived ability and confidence.

CONCLUSIONS

This study shows that the diagnostic reliability of formal DC/TMD training and calibration and DC/TMD self-instruction are similar, except for subgroups of Myalgia. Thus, self-instruction seems to be possible to use to diagnose the most common TMDs in general dental practice. The course further improves the reliability regarding Myalgia and Arthralgia at the same time as the examiners experienced the course to be valuable for self-perceived ability and confidence.

Analgesia evaluation of 2 NSAID drugs as adjuvant in management of chronic temporomandibular disorders

The aim of this triple-blind full-randomized clinical trial was to quantify analgesia in masticatory muscles and temporomandibular joints after occlusal splint therapy associated with the adjuvant administration of nonsteroidal anti-inflammatory drugs (NSAID) isolated or associated with other therapeutic agents. Pain relief was also recorded. Eighteen volunteers who had been suffering from chronic pain in masticatory muscles due to temporomandibular disorders were selected after anamnesis and assessment using RDC/TMD translated to Portuguese. The 3 proposed treatments were NSAID (sodium diclofenac), panacea (sodium diclofenac + carisoprodol + acetaminophen + caffeine), and a placebo. The total treatment duration was 10 days, preceded and succeeded by patients' pain assessment. A washout interval of 11 days was established between each therapy. All participants received all treatments in different moments, in a full randomized crossover methodology. The assessment of drug therapies was performed using visual analogue scale for pain on palpation followed by 11-point numerical scale to quantify pain during treatment. Statistical analysis has shown that, after 10 days of treatment, all therapies were effective for pain relief. NSAID therapy promoted analgesia on the third day, while placebo only promoted analgesia in the eighth day. It has been concluded that sodium diclofenac used as splint adjuvant therapy, promotes significant analgesia in a shorter time.

Orofacial pain and fibromyalgia pain: Being aware of comorbid conditions

Orofacial pain originating from myofascial pain of temporomandibular disorders is the second most common source of pain, after tooth pain. However, diagnosis of myofascial pain is challenging due to its characteristic referral pattern. Furthermore, pain arising from structures in the orofacial region may be a presentation of fibromyalgia and treatment directed at temporomandibular disorders fails to alleviate the pain. Similarly, patients with fibromyalgia may present with pain in the orofacial region. The physician in this case should be aware of temporomandibular disorders, its characteristic findings and treatment approaches that might be included in the treatment plan.

Association of Masseter Muscle Activities during Awake and Sleep Periods with Self-Reported Anxiety, Depression, and Somatic Symptoms

AIM AND BACKGROUND

The objective of this study was to determine if duty factors (DF) of low-magnitude MMA during awake and sleep periods were associated with self-reports of anxiety, depression, and somatic symptoms, and if so, whether or not any associations were modified by gender or the presence of pain. Limited information is currently available in the literature regarding the association of low-magnitude masseter muscle activities (MMA) in habitual environmental settings and the presence of psychological symptoms.

MATERIALS AND METHODS

Sixty-eight consenting participants were classified using the Diagnostic Criteria for Temporomandibular Disorders examination and validated self-reporting psychological symptom evaluation questionnaires. Each subject also had masseter electromyography recordings during standardized biting tasks in 2 laboratory sessions to calibrate the in-field MMA collected during 3 awake and 3 sleep periods.

RESULTS

During awake periods, subjects with self-reported depression and somatic symptoms had statistically high odds of having higher DF of low-magnitude MMA (defined by ≥ 75th percentile of sample). The association between high DF of low-magnitude MMA and self-reported depression symptoms was significantly augmented among male participants, whereas, the association between high DF of low-magnitude MMA and self-reported somatic symptoms was significantly increased among female participants without pain.

CONCLUSION

These pilot data support associations of low-magnitude masseter muscle activities with self-reported depression and somatic symptoms during awake periods.

Symptoms and physiological responses to prolonged, repeated, low-level tooth clenching in humans

BACKGROUND

The traditional view contends bruxism, such as tooth grinding/clenching, is part of the etiology of temporomandibular disorders (TMD) including some subtypes of headaches. The purpose of this study is to investigate if a low-level but long-lasting tooth-clenching task initiates TMD symptoms/signs.

METHODS

Eighteen healthy participants (mean age ± SD, 24.0 ± 4.3 years) performed and repeated an experimental 2-hour tooth-clenching task at 10% maximal voluntary occlusal bite force at incisors (11.1 ± 4.6 N) for three consecutive days (Days 1-3). Pain and cardiovascular parameters were estimated during the experiment.

RESULTS

The task evoked pain in the masseter/temporalis muscles and temporomandibular joint after 40.0 ± 18.0 minutes with a peak intensity of 1.6 ± 0.4 on 0-10 numerical rating scale (NRS) after 105.0 ± 5.0 minutes (Day 1). On Day 2 and Day 3, pain had disappeared but the tasks, again, evoked pain with similar intensities. The onset and peak levels of pain were not different between the experimental days (P = .977). However, the area under the curve of pain NRS in the masseter on Day 2 and Day 3 were smaller than that on Day 1 (P = .006). Cardiovascular parameters changed during the task but not during the days.

CONCLUSIONS

Prolonged, low-level tooth clenching evoked short-lived pain like TMD. This intervention study proposes that tooth clenching alone is insufficient to initiate longer lasting and self-perpetuating symptoms of TMD, which may require other risk factors.

Masticatory sensory-motor changes after an experimental chewing test influenced by pain catastrophizing and neck-pain-related disability in patients with headache attributed to temporomandibular disorders

Background

Recent research has shown a relationship of craniomandibular disability with neck-pain-related disability has been shown. However, there is still insufficient information demonstrating the influence of neck pain and disability in the sensory-motor activity in patients with headache attributed to temporomandibular disorders (TMD). The purpose of this study was to investigate the influence of neck-pain-related disability on masticatory sensory-motor variables.

Methods

An experimental case–control study investigated 83 patients with headache attributed to TMD and 39 healthy controls. Patients were grouped according to their scores on the neck disability index (NDI) (mild and moderate neck disability). Initial assessment included the pain catastrophizing scale and the Headache Impact Test-6. The protocol consisted of baseline measurements of pressure pain thresholds (PPT) and pain-free maximum mouth opening (MMO). Individuals were asked to perform the provocation chewing test, and measurements were taken immediately after and 24 hours later. During the test, patients were assessed for subjective feelings of fatigue (VAFS) and pain intensity.

Results

VAFS was higher at 6 minutes (mean 51.7; 95% CI: 50.15-53.26) and 24 hours after (21.08; 95% CI: 18.6-23.5) for the group showing moderate neck disability compared with the mild neck disability group (6 minutes, 44.16; 95% CI 42.65-45.67/ 24 hours after, 14.3; 95% CI: 11.9-16.7) and the control group. The analysis shows a decrease in the pain-free MMO only in the group of moderate disability 24 hours after the test. PPTs of the trigeminal region decreased immediately in all groups, whereas at 24 hours, a decrease was observed in only the groups of patients. PPTs of the cervical region decreased in only the group with moderate neck disability 24 hours after the test. The strongest negative correlation was found between pain-free MMO immediately after the test and NDI in both the mild (r = −0.49) and moderate (r = −0.54) neck disability groups. VAFS was predicted by catastrophizing, explaining 17% of the variance in the moderate neck disability group and 12% in the mild neck disability group.

Conclusion

Neck-pain-related disability and pain catastrophizing have an influence on the sensory-motor variables evaluated in patients with headache attributed to TMD.

Parasympathetic reactivity in fibromyalgia and temporomandibular disorder: associations with sleep problems, symptom severity, and functional impairment

Despite evidence of autonomic disturbances in chronic multisymptom illnesses such as temporomandibular disorder (TMD) and fibromyalgia, additional work is needed to characterize the role of parasympathetic reactivity in these disorders. Given the high levels of comorbidity with psychiatric disorders characterized by stronger parasympathetic decline than controls in safe contexts (leading to higher arousal), it was hypothesized that individuals with TMD and fibromyalgia would respond similarly. In this preliminary investigation, 43 women with TMD (n = 17), TMD + fibromyalgia (n = 11), or neither (controls; n = 15) completed a baseline assessment of respiratory sinus arrhythmia (a measure of parasympathetic activity) followed by ongoing parasympathetic assessment during a questionnaire period. As predicted, patients showed greater parasympathetic decline during psychosocial assessment, suggesting an autonomic stance that supports defensive rather than engagement behaviors. Individual differences in parasympathetic reduction during the questionnaire period were related to a variety of physical and psychosocial variables. Although this study has a number of key limitations, including a convenience sampling approach and small group sizes, if replicated in larger samples, the findings would have important implications for the treatment of patients with these disorders.

PERSPECTIVE

Compared to controls, individuals with TMD or TMD and fibromyalgia demonstrated greater parasympathetic decline during psychosocial assessment, and individual differences in parasympathetic decline predicted negative patient outcomes. Such parasympathetic decline may demonstrate a tendency to readily perceive danger in safe environments.

Differential diagnoses for persistent pain after root canal treatment: a study in the National Dental Practice-based Research Network

INTRODUCTION

Pain present 6 months after root canal treatment (RCT) may be of odontogenic or nonodontogenic origin. This is important because treatments and prognoses are different; therefore, the aim of this study was to provide specific diagnoses of patients reporting pain 6 months after receiving initial orthograde RCT.

METHODS

We enrolled patients from the Midwest region of an existing prospective observational study of pain after RCT. Pain at 6 months was defined as ≥1 day of pain and average pain intensity of at least 1 of 10 over the preceding month. An endodontist and an orofacial pain practitioner independently performed clinical evaluations, which included periapical and cone-beam computed tomographic radiographs, to determine diagnoses.

RESULTS

Thirty-eight of the 354 eligible patients in the geographic area (11%) met the pain criteria, with 19 (50%) consenting to be clinically evaluated. As the sole reason for pain, 7 patients (37%) were given odontogenic diagnoses (4 involving the RCT tooth and 3 involving an adjacent tooth). Eight patients (42%) were given nonodontogenic pain diagnoses (7 from referred temporomandibular disorder pain and 1 from persistent dentoalveolar pain disorder). Two patients (11%) had both odontogenic and nonodontogenic diagnoses, whereas 2 (11%) no longer fit the pain criteria at the time of the clinical evaluation.

CONCLUSIONS

Patients reporting "tooth" pain 6 months after RCT had a nonodontogenic pain diagnosis accounting for some of this pain, with temporomandibular disorder being the most frequent nonodontogenic diagnosis. Dentists should have the necessary knowledge to differentiate between these diagnoses to adequately manage their patients.

The association between temporomandibular disorders and joint hypermobility syndrome: a nationwide population-based study

OBJECTIVES

This study aims to investigate the risk factors of temporomandibular disorders (TMDs), including disc or non-disc-related disorders, and joint hypermobility syndrome (JHS) retrospectively and to analyze the factors by estimating the magnitude of the association between the two conditions using a nationwide population-based dataset.

MATERIALS AND METHODS

A total of 975,788 eligible patients' de-identified data were obtained from a representative database composed of one million of Taiwan's population since 2004 to 2008. All associated factors, such as gender, age, facial trauma, and psychosis, which correlated with TMDs and JHS were examined. Multiple logistic regression modeling adjusted for confounding variables to determine the odds ratio of variables that made an important contribution to TMDs and JHS.

RESULTS

For all TMDs patients, only 1.47% patients had disc-related disorders. For all JHS patients, only 3.85% patients are diagnosed with concomitant TMDs. Statistically significant association was observed between joint hypermobility and TMDs. Furthermore, the prevalence of JHS patients shows significant difference within TMD subgroups, in which 9.52% of JHS patients have disc disorders and 90.48% of JHS patients do not. All associated factors, such as gender, age, JHS, facial trauma, and psychosis, had a significant impact on the TMDs. Interestingly, patients with TMJ articular disc disorders are 6.7 times more likely to be diagnosed with JHS compared to patients without disc-related disorders.

CONCLUSIONS

Our results confirm that there is a significant positive association between TMDs and JHS, highlighting that patients with disc-related TMDs are more likely to experience JHS than patients with TMDs without disc disorders.

CLINICAL RELEVANCE

Individuals with TMD associated with JHS should be carefully evaluated by inter-disciplinary specialists as these factors may eventually have impact on the prognosis of TMDs and JHS.

Long-term results of ORIF of condylar head fractures of the mandible: A prospective 5-year follow-up study of small-fragment positional-screw osteosynthesis (SFPSO)

BACKGROUND

Optimum treatment of condylar head fractures (CHF) remains subject to controversy. There are currently a variety of alternative techniques applied, data in literature are often inconsistent and especially systematic long-term data on results after treatment by open reduction and internal fixation (ORIF) have so far not been available. This study in hand is the first long-term prospective study of ORIF after CHF based on osteosynthesis with 1.7 mm small-fragment positional screws (SFPSO)via a retroauricular transmeatal approach (RA).

METHODS

The study made use of radiologic, anatomic and objective functional parameters (axiography and MRI) to assess vertical height, disk mobility, protrusive and translatory movement as well as potential physical complaints. Included were surgical long-term sequelae after RA, such as incidence of stenosis of the auditory canal, the facial nerve and resulting disturbance of facial skin sensitivity. Retroauricular scars were evaluated according to the Vancouver Scar Scale. Helkimo and RDC/TMD indices were applied for patient's self-assessment of quality of life aspects after ORIF via RA. The sample in the first follow-up trial (FFT) in the years 2003-2004 comprised 26 patients (36 CHF). 22 patients (31 CHF) were re-evaluated in a second follow-up trial (SFT) between 2006 and 2008. A reference collective (43 patients, 56 CHF) treated with ORIF from 1993 to 2000 mainly by mini- or microplates (MMP) served as a surgical control group.

RESULTS

Five years after ORIF all fractured condyles (FC) continued to show stable anatomic restoration of the pre-trauma vertical height. FC treated with SFPSO exhibited a significantly superior range of motion (p < 0.05) of disk and condyle during mouth opening and protrusion compared to a previous MMP reference collective. Also, no difference was found between condylar mobility of FC five years after surgery and non-fractured condyles (NFC). SFPSO had thus successfully achieved a sustainable, stable physiological restoration of protrusive mobility of the articular disk and condyle. Remarkably, these long-term results were even slightly better in SFT vs. FFT (p < 0.05). Except for sporadically occurring minor complaints, the patients' subjective overall long-term perception of the success of the treatment was equally positive to the surgeons' objective assessment.

CONCLUSIONS

This first long-term prospective follow-up study, based on objective assessment tools, demonstrates that in all cases the major goals of ORIF in CHF could be fully achieved. These goals are: restoration of vertical height viz. prevention of occlusal disorders, physiological function of disk and condyle as well as of the lateral pterygoid muscle. Accordingly, ORIF of CHF e.g. with SFPSO and via the RA secures both a long-term functionally and anatomically stable result and as best as possible pain-free result for the patient, a central prerequisite of optimum perceived HRQoL. The paper has been amended by an extensive review part that covers the current knowledge of the major surgical aspects regarding the treatment of condylar head fractures.

Prevalence and severity of temporomandibular disorders among university students in Riyadh

Objective

The aim of this study was to evaluate the prevalence and severity of temporomandibular disorders (TMDs) among male university students in Riyadh, Saudi Arabia. The role of relevant medical and dental histories in the assessment of TMD in this Arab population was also addressed.

Methods

Required information was collected via a questionnaire. The first part of the questionnaire was used to obtain the medical and dental histories of participants. The second part included 10 questions regarding common TMD symptoms. Fonseca’s anamnestic index (FAI) was used to classify TMD severity as “no dysfunction”, “light dysfunction”, “moderate dysfunction”, or “severe dysfunction”.

Results

Of the 600 distributed questionnaires, 400 questionnaires were completed (response rate: 66.6%). Mean age of eligible participants was 21.90 ± 1.79 years. Psychological stress (30.5%) and direct restorations (77%) were the most commonly reported items on the medical and dental histories respectively for the total number of participants. According to the FAI, 53.2% of participants were classified as having no dysfunction, followed by light (36.1%), moderate (9.6%), and severe dysfunction (1.1%).

Conclusions

Based on the FAI, mild to moderate prevalence of TMD appears to exist among male university students in Riyadh. Histories of psychological stress and dental treatment were evident among these students. Information obtained from the FAI may be helpful in assessing the prevalence of TMD and has important implications for the early diagnosis of TMD and the prevention of future TMD-related complications.

Temporomandibular disorders, headaches and chronic pain

Temporomandibular disorders (TMDs) are a major cause of non-dental orofacial pain with a suggested prevalence of 3% to 5% in the general population. TMDs present as unilateral or bilateral pain centered round the pre-auricular area and can be associated with clicking and limitation in jaw movements. It is important to ascertain if there are other comorbid factors such as headaches, widespread chronic pain and mood changes. A biopsychosocial approach is crucial with a careful explanation and self-care techniques encouraged.

Report of the NIH Task Force on research standards for chronic low back pain

Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed non-specific and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus. Therefore, NIH Pain Consortium charged a Research Task Force (RTF) to draft standards for research on cLBP. The resulting multidisciplinary panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimum dataset to describe research participants (drawing heavily on the PROMIS methodology); reporting "responder analyses" in addition to mean outcome scores; and suggestions for future research and dissemination. The Pain Consortium has approved the recommendations, which investigators should incorporate into NIH grant proposals. The RTF believes that these recommendations will advance the field, help to resolve controversies, and facilitate future research addressing the genomic, neurologic, and other mechanistic substrates of chronic low back pain. We expect that the RTF recommendations will become a dynamic document and undergo continual improvement.

PERSPECTIVE

A task force was convened by the NIH Pain Consortium with the goal of developing research standards for chronic low back pain. The results included recommendations for definitions, a minimum dataset, reporting outcomes, and future research. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes.

Reduced mandibular range of motion in Duchenne Muscular Dystrophy: predictive factors

Patients with Duchenne muscular dystrophy (DMD) experience negative effects upon feeding and oral health. We aimed to determine whether the mandibular range of motion in DMD is impaired and to explore predictive factors for the active maximum mouth opening (aMMO). 23 patients with DMD (mean age 16.7 ± 7.7 years) and 23 controls were assessed using a questionnaire about mandibular function and impairments. All participants underwent a clinical examination of the masticatory system, including measurement of mandibular range of motion and variables related to mandibular movements. In all patients, quantitative ultrasound of the digastric muscle and the geniohyoid muscle and the motor function measure (MFM) scale were performed. The patients were divided into early and late ambulatory stage (AS), early non-ambulatory stage (ENAS) and late non-ambulatory stage (LNAS). All mandibular movements were reduced in the patient group (P < 0.001) compared to the controls. Reduction in the aMMO (<40 mm) was found in 26% of the total patient group. LNAS patients had significantly smaller mandibular movements compared to AS and ENAS (P < 0.05). Multiple linear regression analysis for aMMO revealed a positive correlation with the body height and disease progression, with MFM total score as the strongest independent risk factor (R(2) = 0.71). Mandibular movements in DMD are significantly reduced and become more hampered with loss of motor function, including the sitting position, arm function, and neck and head control. We suggest that measurement of the aMMO becomes a part of routine care of patients with DMD.

Canadian Orofacial Pain Team workshop report on the global year against orofacial pain

The year 2013-2014 has been designated the Global Year Against Orofacial Pain by the International Association for the Study of Pain. Accordingly, a multidisciplinary Canadian and international group of clinical, research and knowledge-transfer experts attended a workshop in Montreal, Quebec. The workshop had two aims: to identify new pathways for innovative diagnosis and management of chronic orofacial pain states; and to identify opportunities for further collaborative orofacial pain research and education in Canada. Three topics related to chronic orofacial pain were explored: biomarkers and pain signatures for chronic orofacial pain; misuse of analgesic and opioid pain medications for managing chronic orofacial pain; and complementary alternative medicine, topical agents and the role of stress in chronic orofacial pain. It was determined that further research is needed to: identify biomarkers of chronic orofacial post-traumatic neuropathic pain, with a focus on psychosocial, physiological and chemical-genetic factors; validate the short- and long-term safety (i.e., no harm to health, and avoidance of misuse and addiction) of opioid use for two distinct conditions (acute and chronic orofacial pain, respectively); and promote the use of topical medications as an alternative treatment in dentistry, and further document the benefits and safety of complementary and alternative medicine, including stress management, in dentistry. It was proposed that burning mouth syndrome, a painful condition that is not uncommon and affects mainly postmenopausal women, should receive particular attention.

Pain frequency moderates the relationship between pain catastrophizing and pain

Background: Pain frequency has been shown to influence sensitization, psychological distress, and pain modulation. The present study examined if pain frequency moderates the relationship between pain catastrophizing and pain.

Method: A non-clinical (247 students) and a clinical (223 pain patients) sample completed the Danish versions of the Pain Catastrophizing Scale (PCS), Beck Depression Inventory, and the State Trait Anxiety Inventory and rated pain intensity, unpleasantness and frequency.

Results: In both samples, high pain frequency was found to moderate the association between pain catastrophizing and pain intensity, whereas low pain frequency did not. The psychometric properties and the factor structure of the Danish version of the PCS were confirmed.

Conclusions: This is the first study to validate the Danish version of the PCS and to show that pain frequency moderates the relationship between pain catastrophizing and reported pain in both non-clinical and clinical populations.

Focus article: report of the NIH Task Force on Research Standards for Chronic Low Back Pain

Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed non-specific and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus. Therefore, NIH Pain Consortium charged a Research Task Force (RTF) to draft standards for research on cLBP. The resulting multidisciplinary panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimum dataset to describe research participants (drawing heavily on the PROMIS methodology); reporting "responder analyses" in addition to mean outcome scores; and suggestions for future research and dissemination. The Pain Consortium has approved the recommendations, which investigators should incorporate into NIH grant proposals. The RTF believes that these recommendations will advance the field, help to resolve controversies, and facilitate future research addressing the genomic, neurologic, and other mechanistic substrates of chronic low back pain. We expect that the RTF recommendations will become a dynamic document and undergo continual improvement.

PERSPECTIVE

A task force was convened by the NIH Pain Consortium with the goal of developing research standards for chronic low back pain. The results included recommendations for definitions, a minimum dataset, reporting outcomes, and future research. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes.

Bayesian belief network analysis applied to determine the progression of temporomandibular disorders using MRI

OBJECTIVES

This study investigated the applicability of a Bayesian belief network (BBN) to MR images to diagnose temporomandibular disorders (TMDs). Our aim was to determine the progression of TMDs, focusing on how each finding affects the other.

METHODS

We selected 1.5-T MRI findings (33 variables) and diagnoses (bone changes and disc displacement) of patients with TMD from 2007 to 2008. There were a total of 295 cases with 590 sides of temporomandibular joints (TMJs). The data were modified according to the research diagnostic criteria of TMD. We compared the accuracy of the BBN using 11 algorithms (necessary path condition, path condition, greedy search-and-score with Bayesian information criterion, Chow-Liu tree, Rebane-Pearl poly tree, tree augmented naïve Bayes model, maximum log likelihood, Akaike information criterion, minimum description length, K2 and C4.5), a multiple regression analysis and an artificial neural network using resubstitution validation and 10-fold cross-validation.

RESULTS

There were 191 TMJs (32.4%) with bone changes and 340 (57.6%) with articular disc displacement. The BBN path condition algorithm using resubstitution validation and 10-fold cross-validation was >99% accurate. However, the main advantage of a BBN is that it can represent the causal relationships between different findings and assign conditional probabilities, which can then be used to interpret the progression of TMD.

CONCLUSIONS

Osteoarthritic bone changes progressed from condyle to articular fossa and finally to mandibular bone contours. Disc displacement was directly related to severe bone changes. Early bone changes were not directly related to disc displacement. TMJ functional factors (condylar translation, bony space and disc form) and age mediated between bone changes and disc displacement.

Local application of Aqua Titan improves symptoms of temporomandibular joint muscle disorder: a preliminary study

Aqua Titan (AT), comprising microscopic titanium particles dispersed in water, has been reported to have beneficial effects on muscle tissue. This study investigated the effects of local application of AT on symptoms in patients with muscle disorders of the temporomandibular joint (TMJ) compared to patients with joint disorders of the TMJ. Sixteen patients with unilateral masseter muscle pain during motion (muscle disorder group) and six patients with unilateral TMJ pain during motion (joint disorder group) applied an AT-permeated patch over the painful area every night for 2 weeks. Symptoms were evaluated clinically at the initial visit and 1 and 2 weeks later. Clinical symptoms in the joint disorder group showed no tendency towards improvement after 2 weeks. In contrast, mouth opening range with/without pain, visual analogue scale (VAS) scores for pain during mouth opening and eating, and activities of daily living (ADL) scores in the muscle disorder group were improved significantly after 2 weeks. Multiple comparison tests in the muscle disorder group showed significant improvements in the VAS for eating and ADL score after 1 week. These results suggest that the AT patch has a potential supplementary role in the treatment of patients with muscle disorders of the TMJ.

Can sonographic features be efficacy predictors of robotic massage treatment for masseter and temporal muscle in patients with temporomandibular disorder with myofascial pain?

OBJECTIVE

The aim of this study was to detect sonographic predictors for the efficacy of massage treatment of masseter and temporal muscle in temporomandibular disorders (TMDs) patients with myofascial pain.

METHODS

Thirty-seven TMD patients with myofascial pain (6 men and 31 women, a median age of 45 years) were enrolled. An oral rehabilitation robot massaged the patient's masseter and temporal muscles with a standard massage pressure of 10 N for 16 min. The standard treatment protocol was set five sessions every 2 weeks. The median total duration of treatment was 9.5 weeks. Efficacy of treatment was evaluated based on maximum mouth opening and visual analog scale scores of muscle pain and daily life impediments. The intramuscular echogenic bands and elasticity index ratios of the masseter muscles were evaluated on sonographic or sonoelastographic images obtained before treatment and after the third and last treatment sessions.

RESULTS

The sonographic features detected different changes after the third treatment session between the therapy-effective and therapy-ineffective groups: in the therapy-effective group, the frequency of visibility of the distinct echogenic bands increased, and the elasticity index ratio decreased.

CONCLUSION

Sonographic features after the third treatment session may be useful as predictors of therapeutic efficacy.

The effects of voxel size on cone beam computed tomography images of the temporomandibular joints

OBJECTIVES

This clinical study assesses the effect of cone beam computed tomography (CBCT) voxel size on the ability to detect osseous changes associated with degenerative disease of the temporomandibular joint (TMJ). The effect of voxel size on perceived CBCT image quality is also evaluated.

STUDY DESIGN

Twenty-two patients presenting for TMJ imaging with suspected degenerative disease were imaged with the Carestream 9000 CBCT unit, using separate right and left joint acquisitions (n = 44). Images were archived at native and downsampled voxel resolutions of 76 μm and 300 μm, respectively. Three oral and maxillofacial radiologists evaluated the images for osseous changes, as well as image quality by using a visual analog scale.

RESULTS

There was no statistically significant difference between the voxel sizes in the detection of TMJ osteoarthritic changes. The mean visual analog scale response did, however, differ significantly between the two groups (P = .02).

CONCLUSIONS

Despite no improvement in diagnostic efficacy with a smaller voxel size, perceived image quality is consistently higher for images with greater spatial resolution.

No significant differences between conservative interventions and surgical interventions for TMJ disc displacement without reduction

DATA SOURCES

The Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase and Scopus databases were searched. In addition reference lists of relevant review articles, textbook chapters and seven relevant journals were hand searched.

STUDY SELECTION

Randomised or quasi-randomised controlled trials in patients with clinical and/or radiological diagnosis of acute or chronic DDwoR undergoing any form of conservative or surgical intervention were considered. The primary outcomes were TMJ pain intensity and unassisted/active maximum mouth opening (MMO).

DATA EXTRACTION AND SYNTHESIS

Study selection, data abstraction and quality assessment were conducted independently by two authors. The Cochrane risk of bias tool was used for the quality assessment. Data analysis was based on Cochrane statistical guidelines. For dichotomous data, the estimates of effect of an intervention were expressed as risk ratios (RR) together with 95% confidence intervals (CI). For continuous data, mean differences (MD) with 95% CI were used.

RESULTS

Twenty studies involving a total of 1305 patients were included. Twelve studies were considered to be at high risk of bias with eight being at unclear risk of bias. There was a high degree of clinical heterogeneity among the studies included. Twenty-one comparisons were made among interventions. Meta-analyses were carried out for four comparisons. In most comparisons made there were no statistically significant differences between interventions relative to primary outcomes at short- or long-term follow-up.

CONCLUSIONS

Most interventions appear to alleviate DDwoR symptoms, with no significant differences between non-invasive conservative interventions and minimally invasive or invasive surgical interventions. Given the paucity of evidence and the difficulty in interpreting the minimal clinically important difference, this finding suggests that patients with DDwoR probably should be initially managed with the most minimal and least invasive intervention. Escalation to more invasive treatment should occur only in the face of objective clinical need. This, however, should be interpreted in the context of a review based mostly on single studies of unclear to high risk of bias. Future well-conducted research may change or confirm this.

Report of the National Institutes of Health task force on research standards for chronic low back pain

OBJECTIVES

Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed nonspecific and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus. The purpose of this article is to disseminate the report of the National Institutes of Health (NIH) task force on research standards for cLBP.

METHODS

The NIH Pain Consortium charged a research task force (RTF) to draft standards for research on cLBP. The resulting multidisciplinary panel developed a 3-stage process, each with a 2-day meeting.

RESULTS

The panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimal data set to describe research subjects (drawing heavily on the Patient Reported Outcomes Measurement Information System methodology); reporting "responder analyses" in addition to mean outcome scores; and suggestions for future research and dissemination. The Pain Consortium has approved these recommendations, which investigators should incorporate into NIH grant proposals.

CONCLUSIONS

The RTF believes that these recommendations will advance the field, help to resolve controversies, and facilitate future research addressing the genomic, neurologic, and other mechanistic substrates of cLBP. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes. We expect the RTF recommendations will become a dynamic document and undergo continual improvement.

Evaluation of pain regression in patients with temporomandibular dysfunction treated by intra-articular platelet-rich plasma injections: a preliminary report

OBJECTIVE

The objective of this study was to evaluate the regression of temporomandibular pain as a result of intra-articular injections of platelet-rich plasma (PRP) to patients with temporomandibular joint dysfunction previously subjected to prosthetic treatment.

MATERIALS AND METHODS

The baseline study material consisted of 10 patients, both males and females, aged 28 to 53 years, previously treated due to painful temporomandibular joint dysfunction using occlusal splints. All patients were carried out to a specialist functional assessment of the dysfunction using the Polish version of the RDC/TMD questionnaire axis I and II. Intra-articular injections were preceded by a preparation of PRP. The injection sites were determined by the method used during arthroscopic surgical procedures. Following aspiration, 0.5 mL of plasma was injected into each temporomandibular joint.

RESULTS

The comparison of the intensity of pain during all examinations suggests a beneficial effect of the procedure being performed as the mean VAS score was 6.5 at examination I, 2.8 at examination II, and 0.6 at examination III.

CONCLUSION

Application of the intra-articular injections of platelet-rich plasma into the temporomandibular joints has a positive impact on the reduction of the intensity of pain experienced by patients treated for temporomandibular joint dysfunction.

Comparison of TMJ vibration frequencies under different joint conditions

OBJECTIVE

To compare 10 Hz wide segments of the 0 to 1000 Hz frequency distributions of vibrations recorded from five stages of internally deranged and asymptomatic temporomandibular joints (TMJs).

METHODS

TMJ vibrations were recorded from 236 patients with five stages of TMJ dysfunction: (1) reducing partial disc displacement (PDDR, n=39); (2) acute reducing complete disc displacement (A-DDR, n=39); (3) chronic reducing complete disc displacement (C-DDR, n=55); (4) un-adapted, non-reducing, complete disc displacement (DDUA, n=57); and (5) well adapted, non-reducing, complete disc displacement (DDWA, n=46). A totally asymptomatic control group with quiet TMJs (AQ, n=43) and a group with vibrating TMJs (AWV, n=93), but otherwise asymptomatic were also recorded. Frequency distributions were calculated for each group using discrete Fourier transform methods in 10 Hz increments (0-10 Hz, 10-20 Hz,…, 990-1000 Hz). The 10 Hz segments were compared between the seven groups using Student's t test with Bonferroni adjustment.

RESULTS

There were significant differences (P<0.05) in all 21 comparisons for the three segments between 80 Hz and 110 Hz, in 20 of 21 comparisons between 180 and 200 Hz, in 19 of 21 comparisons between 110 and 180 Hz and between 50 and 80 Hz.

DISCUSSION

The segments of the frequency distributions from 80 to 110 Hz provided the best differentiation between all seven groups.

Report of the NIH Task Force on Research Standards for Chronic Low Back Pain

Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed non-specific and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus. Therefore, NIH Pain Consortium charged a Research Task Force (RTF) to draft standards for research on cLBP. The resulting multidisciplinary panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimum dataset to describe research participants (drawing heavily on the PROMIS methodology); reporting "responder analyses" in addition to mean outcome scores; and suggestions for future research and dissemination. The Pain Consortium has approved the recommendations, which investigators should incorporate into NIH grant proposals. The RTF believes that these recommendations will advance the field, help to resolve controversies, and facilitate future research addressing the genomic, neurologic, and other mechanistic substrates of chronic low back pain. We expect that the RTF recommendations will become a dynamic document and undergo continual improvement.

PERSPECTIVE

A task force was convened by the NIH Pain Consortium with the goal of developing research standards for chronic low back pain. The results included recommendations for definitions, a minimum dataset, reporting outcomes, and future research. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes.

Clinical orofacial characteristics associated with risk of first-onset TMD: the OPPERA prospective cohort study

Case-control studies have documented clinical manifestations of chronic temporomandibular disorder (TMD), whereas clinical predictors of TMD development are largely unknown. We evaluated 41 clinical orofacial characteristics thought to predict first-onset TMD in a prospective cohort study of U.S. adults aged 18 to 44 years. During the median 2.8-year follow-up period, 2,737 people completed quarterly screening questionnaires. Those reporting symptoms were examined and 260 people were identified with first-onset TMD. Univariate and multivariable Cox regression models quantified associations between baseline clinical orofacial measures and TMD incidence. Significant predictors from baseline self-report instruments included oral parafunctions, prior facial pain and its life-impact, temporomandibular joint noises and jaw locking, and nonspecific orofacial symptoms. Significant predictors from the baseline clinical examination were pain on jaw opening and pain from palpation of masticatory, neck, and body muscles. Examiner assessments of temporomandibular joint noise and tooth wear facets did not predict incidence. In multivariable analysis, nonspecific orofacial symptoms, pain from jaw opening, and oral parafunctions predicted TMD incidence. The results indicate that only a few orofacial examination findings influenced TMD incidence, and only to a modest degree. More pronounced influences were found for self-reported symptoms, particularly those that appeared to reflect alterations to systems beyond the masticatory tissues.

PERSPECTIVE

OPPERA's prospective cohort study identifies predictors of first-onset TMD comprising self-reported orofacial symptoms and examination findings. The results suggest a complex pattern of TMD etiology that is influenced by disorders locally, in masticatory tissues, and systemically, in pain-regulatory systems.

Prevalence and correlation between TMD based on RDC/TMD diagnoses, oral parafunctions and psychoemotional stress in Polish university students

The aim of the study was to assess the prevalence of temporomandibular disorders (TMD) and oral parafunctions, as well as their correlation with psychoemotional factors in Polish university students. The research was conducted in a group of 456 students (N = 456). The examination form comprised of two parts: survey and clinical examination. The research diagnostic criteria for temporomandibular disorders (RDC/TMD) was used in order to assess TMD. Symptoms of TMD were observed in 246 (54%) students after clinical examination. The largest group involved students with disc displacement (women: 132, 29%; men: 70, 15%). Women (164; 36%) suffered more frequently than men (82; 18%) from problems related to the stomatognathic system (P < 0.05), described themselves as easily excitable and emotionally burdened, and reported symptoms as tightness of the facial and neck muscles (P < 0.05). In 289 (64%) students intraoral symptoms concerning occlusal parafunctions were observed. In 404 (89%) examined students, nonocclusal parafunctions were recorded. A significant correlation between TMD and psychoemotional problems could be detected. TMD symptoms more often concern women. Emotional burden and excitability are factors predisposing muscular disorders.

Temporomandibular disorders among Brazilian adolescents: reliability and validity of a screening questionnaire

Temporomandibular disorders (TMD) screeners assume significant item overlap with the screening questionnaire proposed by the American Academy of Orofacial Pain (AAOP).

OBJECTIVE

To test the reliability and validity of the Portuguese version of AAOP questions for TMD screening among adolescents.

MATERIAL AND METHODS

Diagnoses from Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis I were used as reference standard. Reliability was evaluated by internal consistency (KR-20) and inter-item correlation. Validity was tested by sensitivity, specificity, predictive values, accuracy and receiver operating characteristic (ROC) curves, the relationship between the true-positive rate (sensitivity) and the false-positive rate (specificity). Test-retest reliability of AAOP questions and intra-examiner reproducibility of RDC/TMD Axis I were tested with kappa statistics.

RESULTS

The sample consisted of 1307 Brazilian adolescents (56.8% girls; n=742), with mean age of 12.72 years (12.69 F/12.75 M). According to RDC/TMD, 397 [30.4% (32.7% F/27.3% M)] of adolescents presented TMD, of which 330 [25.2% (27.6% F/22.2% M)] were painful TMD. Because of low consistency, items #8 and #10 of the AAOP questionnaire were excluded. Remaining items (of the long questionnaire version) showed good consistency and validity for three positive responses or more. After logistic regression, items #4, #6, #7 and #9 also showed satisfactory consistency and validity for two or more positive responses (short questionnaire version). Both versions demonstrated excellent specificity (about 90%), but higher sensitivity for detecting painful TMD (78.2%). Better reproducibility was obtained for the short version (k=0.840).

CONCLUSIONS

The Portuguese version of AAOP questions showed both good reliability and validity for the screening of TMD among adolescents, especially painful TMD, according to RDC/TMD.

Report of the NIH task force on research standards for chronic low back pain

Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed nonspecific and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus. Therefore, NIH Pain Consortium charged a research task force to draft standards for research on cLBP. The resulting multidisciplinary panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimum data set to describe research participants (drawing heavily on the Patient Reported Outcomes Measurement Information System methodology); reporting "responder analyses" in addition to mean outcome scores; and suggestions for future research and dissemination. The Pain Consortium has approved the recommendations, which investigators should incorporate into NIH grant proposals. The research task force believes that these recommendations will advance the field, help resolve controversies, and facilitate future research addressing the genomic, neurological, and other mechanistic substrates of cLBP. We expect that the research task force recommendations will become a dynamic document and undergo continual improvement.

PERSPECTIVE

A task force was convened by the NIH Pain Consortium with the goal of developing research standards for cLBP. The results included recommendations for definitions, a minimum data set, reporting outcomes, and future research. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes.

Report of the NIH Task Force on research standards for chronic low back pain

Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed non-specific and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus. Therefore, NIH Pain Consortium charged a Research Task Force (RTF) to draft standards for research on cLBP. The resulting multidisciplinary panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimum dataset to describe research participants (drawing heavily on the PROMIS methodology); reporting "responder analyses" in addition to mean outcome scores; and suggestions for future research and dissemination. The Pain Consortium has approved the recommendations, which investigators should incorporate into NIH grant proposals. The RTF believes that these recommendations will advance the field, help to resolve controversies, and facilitate future research addressing the genomic, neurologic, and other mechanistic substrates of chronic low back pain. We expect that the RTF recommendations will become a dynamic document and undergo continual improvement.

PERSPECTIVE

A task force was convened by the NIH Pain Consortium with the goal of developing research standards for chronic low back pain. The results included recommendations for definitions, a minimum dataset, reporting outcomes, and future research. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes.

Comparison of selected kinematic facebows applied to mandibular tracing

The study focused on the comparison between mechanical and computerized registration methods used by the two selected kinematic facebows. The material consisted of 35 women aged 18 to 35, studied using the Gerber Dynamic Facebow and the computerized ARCUSdigma II axiograph. To compare the devices the condylar path inclination (CPI) was recorded according to the Camper's line, enabling the acquisition of easily comparable values based on which the devices were objectively and subjectively analyzed. Statistics was performed for the obtained data. The study showed that the values for the CPI registrated by the ARCUSdigma II are significantly higher than those obtained by using the Gerber Dynamic Facebow. The significant difference in the records of the CPI is most likely a result of the differences in the registration techniques assumptions. ARCUSdigma II provides the user with more diagnostic options than Gerber Dynamic Facebow. Mechanical facebow handling has a higher risk of hand-measuring errors in tracing procedure. Due to high discrepancy of achieved results from different systems the authors recommend to use articulator compatible with facebow whose measurement has been done.

Expanding the taxonomy of the diagnostic criteria for temporomandibular disorders

There is a need to expand the current temporomandibular disorders' (TMDs) classification to include less common but clinically important disorders. The immediate aim was to develop a consensus-based classification system and associated diagnostic criteria that have clinical and research utility for less common TMDs. The long-term aim was to establish a foundation, vis-à-vis this classification system, that will stimulate data collection, validity testing and further criteria refinement. A working group [members of the International RDC/TMD Consortium Network of the International Association for Dental Research (IADR), members of the Orofacial Pain Special Interest Group (SIG) of the International Association for the Study of Pain (IASP), and members from other professional societies] reviewed disorders for inclusion based on clinical significance, the availability of plausible diagnostic criteria and the ability to operationalise and study the criteria. The disorders were derived from the literature when possible and based on expert opinion as necessary. The expanded TMDs taxonomy was presented for feedback at international meetings. Of 56 disorders considered, 37 were included in the expanded taxonomy and were placed into the following four categories: temporomandibular joint disorders, masticatory muscle disorders, headache disorders and disorders affecting associated structures. Those excluded were extremely uncommon, lacking operationalised diagnostic criteria, not clearly related to TMDs, or not sufficiently distinct from disorders already included within the taxonomy. The expanded TMDs taxonomy offers an integrated approach to clinical diagnosis and provides a framework for further research to operationalise and test the proposed taxonomy and diagnostic criteria.

Multi-dimensionality of chronic pain of the oral cavity and face

Orofacial pain in its broadest definition can affect up to 7% of the population. Its diagnosis and initial management falls between dentists and doctors and in the secondary care sector among pain physicians, headache neurologists and oral physicians. Chronic facial pain is a long term condition and like all other chronic pain is associated with numerous co-morbidities and treatment outcomes are often related to the presenting co-morbidities such as depression, anxiety, catastrophising and presence of other chronic pain which must be addressed as part of management . The majority of orofacial pain is continuous so a history of episodic pain narrows down the differentials. There are specific oral conditions that rarely present extra orally such as atypical odontalgia and burning mouth syndrome whereas others will present in both areas. Musculoskeletal pain related to the muscles of mastication is very common and may also be associated with disc problems. Trigeminal neuralgia and the rarer glossopharyngeal neuralgia are specific diagnosis with defined care pathways. Other trigeminal neuropathic pain which can be associated with neuropathy is caused most frequently by trauma but secondary causes such as malignancy, infection and auto-immune causes need to be considered. Management is along the lines of other neuropathic pain using accepted pharmacotherapy with psychological support. If no other diagnostic criteria are fulfilled than a diagnosis of chronic or persistent idiopathic facial pain is made and often a combination of antidepressants and cognitive behaviour therapy is effective. Facial pain patients should be managed by a multidisciplinary team.