Validity of temporomandibular disorder examination procedures for assessment of temporomandibular joint status

Association between clinical symptoms and MRI image findings in symptomatic temporomandibular joint (TMJ) disease: A systematic review

To evaluate the association between clinical signs and symptoms of temporomandibular joint (TMJ) and magnetic resonance image (MRI) findings in patients with temporomandibular disorders (TMD). Relevant articles on humans over 18 years of age were obtained from five databases (Ovid MEDLINE, PubMed, Scopus, Web of Science, and Google Scholar) up to August 2022. Risk of bias assessment was completed using the Joanna Briggs Institute critical appraisal tools. The GRADEpro (Grading of Recommendations, Assessment, Development, and Evaluation) instrument was applied to assess the level of evidence across studies in a GRADE Summary of Findings table. In total, 22 studies were included in this systematic review. Of these, 11 studies highlighted that joint pain was positively associated with particular MRI findings: joint effusion, bone marrow edema, disk displacement with/without reduction, and condylar erosion. Masticatory muscle pain was found to have a strong positive correlation with disk displacement in four studies. Five studies found no significant association between MRI findings and masticatory muscle pain. Range of motion and MRI findings were examined in six studies. Limited mouth opening was found to be correlated with disk displacement in five studies. Of the 11 studies evaluating the correlation between joint noise and MRI findings, eight reported a significant association between disk displacement and TMJ noise. The results suggested that patients with joint pain and limited range of motion may benefit from MRI. Patients exhibiting primarily muscle pain are unlikely to benefit clinically from MRI. Future studies with improved quality are warranted.

Sleep, Caffeine, BMI, and Pressure Pain Threshold in Temporomandibular Disorder Patients: An Observational Study

BACKGROUND

Temporomandibular disorders (TMDs) represent a multifactorial condition involving a multitude of symptoms of the temporomandibular joint that emanates a series of distress. Understanding the relationship between these lifestyle factors and pain perception in TMD patients is essential for optimizing their management and care. This study delves into the intricate interplay between sleep, caffeine consumption, body mass index (BMI), and the potential effect on pressure pain threshold (PPT) values among individuals with TMDs.

MATERIALS AND METHODS

This is an observational study. Data were collected from a convenient sample of female patients at a single center in Riyadh city, between the ages of 20 and 50 years. The variables collected were based on an operator-designed questionnaire, the symptom questionnaire, and the Diagnostic Criteria for Temporomandibular Joint Disorders (DC/TMD).

RESULTS

A total of 139 participants were included in the study, appraising the occurrence of TMD and pain as per reports of caffeine intake and sleep duration. The observed outcomes indicate that the amount of sleep has a significant effect on the PPT values in TMD patients. This study highlights the substantial impact of sleep duration on lowering PPT values in individuals with TMDs. The findings highlight the importance of considering sleep duration and caffeine intake in the comprehensive management of TMD patients. There was no effect of BMI on this particular sample.

CONCLUSION

This study shows a positive correlation between sleep and pain and TMD, caffeine, and pain. A deeper understanding of these relationships could pave the way for more effective pain management strategies and personalized treatment approaches tailored to the unique needs of TMD patients. BMI had no effect.

Cross-cultural Adaptation of Oral and Maxillofacial Frailty Assessment Tools for Geriatric Population of Kerala

AIM

The aim of this study is to translate the oral and maxillofacial frailty index (OMFI) into Malayalam, culturally adapt it, and test its reliability and validity in the Kerala geriatric population.

MATERIALS AND METHODS

OMFI was translated, culturally adapted, and validated in Malayalam using a methodological and cross-sectional study design. The Malayalam version of OMFI underwent full linguistic validation and was tested on 200 patients at Amritakripa Hospital in Kalpetta. Principal component analysis with varimax rotation was used for exploratory factor analysis, and Cronbach's alpha was used to assess reliability.

RESULTS

Two-hundred patients were recruited in this study. Participants ranged in age from 60 to 83 years; mean age was 68 years (SD: 15.21). In total 55.5% were male participants, and 30.5% were belonging to upper middle class as per the Kuppuswami scale. Only 12% of the participants were living alone. Kaiser-Meyer-Olkin was found to be 0.583, and Bartlett's test of sphericity was significant with a Chi-square test value of 1003.469. A principal axis factor analysis conducted on 20 items with orthogonal rotation (varimax). OMFI Malayalam version (5 items) had a good internal consistency (Cronbach's alpha = 0.751). Item-total correlations were reviewed for the items of OMFI.

CONCLUSION

The OMFI Malayalam version demonstrated acceptable validity and reliability and can be used to screen the oral frailty of the geriatric population in Kerala.

CLINICAL SIGNIFICANCE

As Kerala is having highest geriatric population in India, we need to assess the oral frailty burden of Kerala. This study provided the first measure to assess the oral frailty in elderly in Kerala.

The importance of multisection sagittal and coronal magnetic resonance imaging evaluation in the assessment of temporomandibular joint disc position

OBJECTIVES

The aim of this study was to evaluate diagnoses of temporomandibular (TMJ) disc displacement by comparing evaluations done on the basis of central sagittal scans only, the most often used in temporomandibular disorder (TMD) patients, with a multisection evaluation done with both sagittal and coronal scans.

MATERIALS AND METHODS

Multisection MRI analysis of 382 TMJs was conducted in 191 patients with disc displacement according to RDC/TMD criteria. Disc position in the intercuspal position (IP) was assessed two times using two different methods. The first method involved a TMJ disc position evaluation on the central slide in the oblique sagittal plane only. In the second method, the TMJ disc position was assessed on all oblique sagittal and coronal images. McNemar's χ² test was used to evaluate the differences between the sensitivities of two methods.

RESULTS

The first method (central oblique sagittal scans assessment) identified 148 TMJs (38.7%) with normal disc position compared with 89 TMJs (23.3%) with normal disc position found by the second method (all oblique sagittal and coronal scans assessment). The sensitivity of analysis in both planes was significantly higher than in the sagittal plane only (p < 0.001).

CONCLUSIONS

The multisection analysis in the sagittal and coronal plane allows to distinguish the correct disc position from disc displacement and thus improve evaluation of TMJ internal derangement.

CLINICAL RELEVANCE

The multisection sagittal and coronal images should be recommended as a standard in MRI of the TMJ disc displacement in patients with TMD to avoid false-negative diagnoses.

Development of an Oral and Maxillofacial Frailty Index: A preliminary study

OBJECTIVE

The purpose of this study is to develop an index to measure oral and maxillofacial frailty in older adults as an acceptable screening tool.

METHODS

Three hundred adults (aged ≥ 50 years) participated in this study by telephone interview. Ten candidate items for the Oral and Maxillofacial Frailty Index (OMFI) and 20 matched detailed items for oral and maxillofacial functions were asked. Information about sociodemographic and oral health-related variables was also obtained. The test-retest reliability of the 10 candidate items was determined. Correlations of the 10 candidate items with the 20 detailed items or sociodemographic and oral health-related variables were analysed to test the validity of the candidate items. To suggest optimal items for the OMFI, five different models with different numbers of items were constructed and evaluated based on their associations with main variables.

RESULTS

The overall internal consistency of the 10 candidate items was .704, and the Cronbach's alpha value of each item was .23-.55. The test-retest reliability was excellent. There were significant correlations between the 10 candidate and 20 matched detailed items. The score of the 10 candidate items was significantly different according to gender, education level and oral health-related variables. The final five items for the OMFI were difficulties in chewing, the necessity of water when eating dry food, difficulties in jaw or tongue movements, difficulties in speaking or pronunciation and difficulties in facial expression.

CONCLUSIONS

The five items could be used as a screening tool for evaluating oral and maxillofacial frailty in older adults.

Condylar repair and regeneration in adolescents/young adults with early-stage degenerative temporomandibular joint disease: A randomised controlled study

BACKGROUND

Anterior repositioning splint (ARS) can facilitate regenerative condylar remodelling.

OBJECTIVE

To determine the effect of ARS on osseous condylar changes in adolescents/young adults with early-stage degenerative joint disease (DJD).

METHODS

Sixty-nine patients with early-stage temporomandibular joint (TMJ) DJD based on the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) and cone beam computed tomography (CBCT) imaging were recruited and randomly allocated to two treatment groups: (a) conservative therapy with ARS and (b) conservative therapy without ARS. Subjects with acute TMJ closed-lock had their displaced discs physically reduced by mandibular manipulation prior to ARS therapy. Clinical and CBCT data of 59 patients (86.4% females, mean age 17.95 ± 4.53 years, 67 joints) were attained pre- and at 6 or 12 months post-treatment. Osseous changes after treatment were categorised into (a) progressed, (b) unchanged, (c) repaired (remodelled without new bone formation) and (d) regenerated (remodelled with new bone formation). Statistical analysis including chi-square test, independent samples t test or Mann-Whitney U test was conducted.

RESULTS

About 85.5% of patients (59/69) completed the study, with 28 subjects (32 joints) in the splint group and 31 (35 joints) in the control group. The occurrence of condylar repair and regeneration was significantly higher with ARS (78.1%/[25/32] of joints) when compared to control group (48.6%/[17/35]) (P < 0.05). Moreover, condylar regeneration was exclusively observed in 50%/(16/32) of joints with ARS. For the 14 joints in splint group that received physical TMJ closed-lock reduction, 85.7%/(12/14) exhibited condylar regeneration. The splint group (3.1%/[1/32]) also had significantly lower incidence of progressive TMJ degeneration than the control (37.1%/[13/35]) (P < 0.001).

CONCLUSION

Condylar repair and regeneration in early-stage TMJ DJD are possible, and ideal spatial disc-condyle relationship appears important. The possibility of restoring TMJ form/structure by ARS therapy presents an attractive area of new basic science and clinical research (Bone defect repair in early osteoarthrosis of temporomandibular joint by joint distraction therapy: A randomized controlled trial/ChiCTR-TRC-14005172).

Inter-tester reliability of selected clinical tests for long-lasting temporomandibular disorders

OBJECTIVE

Clinical tests used to examine patients with temporomandibular disorders vary in methodological quality, and some are not tested for reliability. The purpose of this cross-sectional study was to evaluate inter-tester reliability of clinical tests and a cluster of tests used to examine patients with long-lasting temporomandibular disorders.

METHODS

Forty patients with pain in the temporomandibular area treated by health-professionals were included. They were between 18-70 years, had 65 symptomatic (33 right/32 left) and 15 asymptomatic joints. Two manual therapists examined all participants with selected tests. Percentage agreement and the kappa coefficient (k) with 95% confidence interval (CI) were used to evaluate the tests with categorical outcomes. For tests with continuous outcomes, the relative inter-tester reliability was assessed by the intraclass-correlation-coefficient (ICC3,1, 95% CI) and the absolute reliability was calculated by the smallest detectable change (SDC).

RESULTS

The best reliability among single tests was found for the dental stick test, the joint-sound test (k = 0.80-1.0) and range of mouth-opening (ICC3,1 (95% CI) = 0.97 (0.95-0.98) and SDC = 4 mm). The reliability of cluster of tests was excellent with both four and five positive tests out of seven.

CONCLUSION

The reliability was good to excellent for the clinical tests and the cluster of tests when performed by experienced therapists. The tests are feasible for use in the clinical setting. They require no advanced equipment and are easy to perform.

Disc displacement without reduction: a retrospective study of a clinical diagnostic sign

OBJECTIVE

The purpose of this retrospective study is to evaluate a clinical diagnostic sign for disc displacement without reduction (DDWR), the absence of additional condylar translation during opening compared with protrusion.

METHOD

Thirty-eight electronic axiographic and magnetic resonance imaging (MRI) examinations of the TMJ were analyzed in order to compare the opening/protrusion ratio of condylar translation between non-painful DDWR and non-DDWR.

RESULT

According to the Mann-Whitney U test, the opening/protrusion ratio in non-painful DDWR differs significantly from non-DDWR (p < 0.0001).

DISCUSSION

Among non-painful DDWR, there is no additional condylar translation during opening in comparison with protrusion, and this is probably also the case for DDWR without limited opening, which is a subtype that has not been validated by the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD). Comparative condylar palpation can analyze this sign, and therefore, further comparative investigations between MRI and clinical examination are needed to validate the corresponding clinical test.

Temporomandibular joint vibrations from totally asymptomatic subjects

OBJECTIVE

Precisely characterize the TMJ vibrations of a youthful, adult and completely asymptomatic population.

METHODS

TMJ vibrations were recorded from 237 asymptomatic subjects (163 f, 74 m) at Dayananda Sagar Institute in India. The subjects were selected, examined and informed (WMA Helsinki Declaration). TMJ vibrations were recorded bilaterally during maximal open - close. 6 parameters of the vibrations were analyzed between the left and right sides, between genders and with respect to age.

RESULTS

Mean vibration intensity was greater for females (p < 0.01) than males. A portion of the frequency spectrum < 300 Hz was also more intense for females (p < 0.022). Females 18 - 20 years old exhibited higher Peak Amplitude than 27 - 30 year olds (p < 0.025) and lower Median Frequency (p < 0.005).

CONCLUSIONS

A significant difference in TMJ vibrations was present between males and females, increased with age in females but not in males.

The relationship between malocclusion, benign joint hypermobility syndrome, condylar position and TMD symptoms

The current study investigated the association between temporomandibular disorders, malocclusion patterns, benign joint hypermobility syndrome and the initial condylar position. One hundred sixty-two subjects were analyzed using the Rocabado Temporomandibular Pain Analysis; Helkimo Index parameters; the Carter-Wilkinson modified test; and a mounting cast with condylar position indicator registration (MPI). The study revealed a significant association between: 1. Delta H, skeletal pattern (p = 0.034); 2. Delta Y, transversal malocclusion (p = 0.04); 3. right and left, Delta Z, right and left posteroinferior synovial pain (p < 0.05); 4. hypermobility scale, gender (p < 0.001), malocclusion pattern (p = 0.021); 5. TMJ function impairment, gender (p = 0.043); 6. sagittal malocclusion pattern, right temporomandibular pain analysis joint (TPAJ) (p = 0.0034); 7. TMJ function impairment, left and right TPAJ (p = 0.007); and 8. mandibular motion, left and right TPAJ (p = 0.035, p = 0.015). The conclusion was that anterior crossbite and condylar displacements in the vertical plane are risk factors in developing TMJ symptoms.

A new instrument for assessing the quality of studies on prevalence

There are numerous scientific articles of studies on the prevalence of disorders with non-standardised examination and diagnostic protocols. Because their quality is heterogeneous, a new instrument has been developed for the assessment of such studies. The new instrument is based mainly on statistical criteria. The points assigned for each of the main criteria according to the information gained from each paper are summed up to form a Total Quality Score (TQS). The interrater reliability of the instrument was tested by employing Kappa and Interrater Correlation Coefficient (ICC) statistics. The latter was assessed on the results of three independent investigators. The new quality instrument appeared to be easy to use, and the instructions were comprehensible. The ICC((2,1)) for the TQS ranged between 0.94 and 1.00 indicating almost perfect agreement between the investigators. The reliability of the new instrument enables its use for scientific review purposes. In this way, its validity will also be tested. The instrument could be adopted for assessment of scientific articles of studies on the prevalence of disorders in many, similar, scientific areas.

Correlation of RDC/TMD axis I diagnoses and axis II pain-related disability. A multicenter study

As part of an ongoing multicenter investigation involving four highly specialized tertiary clinics for temporomandibular disorders (TMD) treatment, retrospective analysis of Research Diagnostic Criteria for TMD (RDC/TMD) axis I and axis II data gathered on clinic and community cases were assessed with a twofold aim: (1) to search for a correlation between axis I diagnoses and axis II pain-related disability, and (2) to identify clinical (axis I) and psychosocial (axis II) predictors of high pain-related disability. Two samples of patients seeking treatment for TMD (clinic cases, N = 1,312) and a sample of general population subjects (community cases, N = 211) underwent a thorough assessment in accordance with the RDC/TMD version 1.0 [1] guidelines to receive both axis I and axis II diagnoses. Spearman's test was performed to assess the level of correlation between axis I diagnoses and Graded Chronic Pain Scale (GCPS) pain-related disability. A stepwise multiple logistic regression model was used to identify the significant associations between 12 clinical and psychosocial predictors and the presence of high pain-related disability. Axis I findings were related with pain-related impairment (GCPS scores) in the overall study sample including both clinic community cases (Spearman correlation = 0.129, p = 0.000), but the results of the correlation analyses performed on the clinic sample alone were not significant (Spearman correlation = -0.018, p = 0.618). Predictors for high disability were related to axis II findings (severe depression and somatization) or psychosocial aspects related to the pain experience (pain lasting from more than 6 months; treatment-seeking behavior), while none of the axis I diagnoses remained in the final logistic regression model. The final model predicted the level of pain-related impairment at a fair level (R(2) = 26.7%). The correlation between axis I diagnoses and pain-related impairment is not significant in the patients populations. Treatment-seeking behavior and other factors related with the pain experience are likely to be more important than the physical findings to determine the degree of psychosocial impairment.