Traumatic onset of temporomandibular disorders: positive effects of a standardized conservative treatment program

Prevalence of Temporomandibular Disorders Based on a Shortened Symptom Questionnaire of the Diagnostic Criteria for Temporomandibular Disorders and Its Screening Reliability for Children and Adolescents Aged 7-14 Years

The prevalence and adequacy of diagnostic approaches for temporomandibular disorders (TMD) in children and adolescents are still matters of debate. This study aimed to determine the prevalence of TMD and oral habits in children and adolescents aged 7-14 years and evaluate the consistency between self-reported TMD symptoms and clinical findings using a shortened Axis I of Diagnostic Criteria for TMD (DC/TMD). Children (aged 7-10) and adolescents (aged 11-14) of both sexes were invited to participate in this study (n = 1468). Descriptive statistics for all observed variables and Mann-Whitney U-Tests for the clinical examination were performed. A total of 239 subjects participated in the study (response rate 16.3%). The self-reported prevalence of TMD was found to be 18.8%. The most frequently reported oral habit was nail biting (37.7%), followed by clenching (32.2%) and grinding (25.5%). Self-reported headache increased with age, while clenching and grinding decreased. Based on the answers to the DC/TMD Symptom Questionnaire, subgroups of asymptomatic and symptomatic participants (n = 59; 24.7%) were established and randomly selected for the clinical examination (f = 30). The shortened Symptom Questionnaire showed a sensitivity of 0.556 and a specificity of 0.719 for pain during the clinical examination. Although the Symptom Questionnaire exhibited high specificity (0.933), its sensitivity (0.286) for temporomandibular joint sounds was low. Disc displacement with reduction (10.2%) and myalgia (6.8%) were the most common diagnoses. In conclusion, the self-reported prevalence of TMD in children and adolescents in this study was comparable to that reported in the literature for adults. However, the accuracy of the shortened Symptom Questionnaire as a screening tool for TMD-related pain and jaw sounds in children and adolescents was found to be low.

The relationship of whiplash injury and temporomandibular disorders: a narrative literature review

OBJECTIVE

The purpose of this article is to offer a narrative review and discuss the possible relationship between temporomandibular disorders (TMDs) and whiplash injuries.

METHODS

Databases from 1966 to present were searched including PubMed; Manual, Alternative, and Natural Therapy Index System; and Cumulative Index for Nursing and Allied Health Literature. Search terms used included whiplash injury, temporomandibular disorders and craniomandibular disorders. Inclusion criteria consisted of studies on orofacial pain of a musculoskeletal origin addressing the following topics: posttraumatic temporomandibular disorder (pTMD) incidence and prevalence, mechanism of injury, clinical findings and characteristics, prognosis (including psychologic factors). Excluded were studies of orofacial pain from nontraumatic origin, as well as nonmusculoskeletal causes including neurologic, vascular, neoplastic, or infectious disease.

RESULTS

Thirty-two studies describing the effects of whiplash on TMD were reviewed based on inclusion/exclusion criteria. The best evidence from prospective studies indicates a low to moderate incidence and prevalence. Only 3 studies addressed mechanism of injury theories. Most studies focusing on clinical findings and characteristics suggest significant differences when comparing pTMD to idiopathic/nontraumatic patients. Regarding prognosis, most studies suggest a significant difference when comparing pTMD to idiopathic/nontraumatic TMD patients, with pTMD having a poorer prognosis.

CONCLUSIONS

There is conflicting evidence regarding the effects of whiplash on the development of TMD. Furthermore, because of lack of homogeneity in the study populations and lack of standardization of data collection procedures and outcomes measured, this review cannot conclusively resolve the controversies that exist concerning this relationship. This review of the literature is provided to clarify the issues and to provide useful clinical information for health care providers managing TMD such as doctors of chiropractic, physical therapists, dentists, and medical doctors.

Radiographic and clinical features of temporomandibular dysfunction in patients following indirect trauma: A retrospective study

OBJECTIVES

Patients developing temporomandibular dysfunction (TMD) following a motor vehicle accident (MVA) have been reported to respond poorly to standard TMD treatment compared with TMD patients who have not sustained an MVA. The purpose of this study was to determine clinical and radiographic differences between post-MVA and nontrauma TMD patients and to determine whether radiographic findings in post-MVA patients undergoing litigation show more severe anatomical changes than post-MVA patients not undergoing litigation.

STUDY DESIGN

One hundred thirty-six files with magnetic resonance imaging (MRI) and/or bone scan studies of TMD patients were randomly drawn (54 post-MVA and 82 nontrauma TMD).

RESULTS

Patients with post-MVA TMD demonstrated significantly more orofacial pain complaints but significantly less disk displacements on MRI (47.5% post-MVA vs. 69.2% control; P = .03). Litigating post-MVA patients had significantly more nonreducing disks than the nonlitigating group (37.7% litigating vs. 7.7% nonlitigating; P = .05).

CONCLUSION

Based on these findings, it is suggested that treatment limited to the temporomandibular joints (TMJs) in post-traumatic TMD patients may fail without consideration that pain may originate in structures other than the TMJs. Within the post-MVA group, the more severe anatomical changes were found in the litigating patients, suggesting that some of their symptoms are associated with anatomical changes.

Third-molar extraction as a risk factor for temporomandibular disorder

BACKGROUND

Although third-molar extraction is common in the U.S., there are few reports on the relationship between third-molar extraction and temporomandibular disorder (TMD). The aim of this study was to investigate this potential association.

METHODS

The authors enrolled study subjects on their 15th birthdays and followed them continuously for a minimum of five years. The authors ascertained exposure (third-molar extraction) and outcome (TMD) via electronic dental insurance records. A survival analysis design estimated the relative risk of experiencing TMD after third-molar extraction. They considered sex, dental care utilization and other potentially confounding variables in the analyses.

RESULTS

A total of 34,491 subjects met the inclusion criterion. Fifty percent of all subjects had third molars removed by the age of 20 years, and 391 subjects had claims indicating TMD. The adjusted relative risk of experiencing TMD after third-molar extraction was 1.6 (95 percent confidence interval, 1.3 to 2.0). Calculation of the population risk indicated that 23 percent of all TMD cases in this age group might be due to third-molar extraction.

CONCLUSIONS

Third-molar extraction appears to be a risk factor for TMD.

CLINICAL IMPLICATIONS

Dental providers should be aware of the risk of experiencing TMD related to third-molar extraction and take measures to minimize trauma to the joint during extraction.

Efficacy of an early intervention for patients with acute temporomandibular disorder-related pain: a one-year outcome study

BACKGROUND

The authors conducted a randomized clinical trial to evaluate the efficacy of a biopsychosocial intervention for patients who were at high risk (HR) of progressing from acute to chronic temporomandibular disorder (TMD)-related pain.

METHODS

The authors classified subjects' risk using a predictive algorithm and randomized them into an early-intervention (EI) or a nonintervention (NI) group. The EI included cognitive behavioral skills training and biofeedback. The authors assessed pain and psychosocial measures at intake and at a one-year follow-up. Subjects' self-reported pain levels were measured on an analog scale and as a response to palpation.

RESULTS

At one year, EI-group subjects had significantly lower levels of self-reported pain and depression. At one year, more NI-group subjects than EI-group subjects had utilized health care for jaw-related pain. NI-group subjects were 12.5 times as likely to have a somatoform disorder, more than seven times as likely to have an anxiety disorder, and 2.7 times more likely to have an affective disorder at one year, compared with EI-group subjects.

CONCLUSIONS

EI-group subjects had reduced pain levels, improved coping abilities and reduced emotional distress at one year.

CLINICAL IMPLICATIONS

The TMD-related pain experience is complex and requires early identification with a biopsychosocial EI to achieve maximal, sustainable results.

Update on burning mouth syndrome: overview and patient management

Burning Mouth Syndrome (BMS) is a chronic pain syndrome that mainly affects middle-aged/old women with hormonal changes or psychological disorders. This condition is probably of multifactorial origin, often idiopathic, and its etiopathogenesis remains largely enigmatic. The present paper discusses several aspects of BMS, updates current knowledge, and provides guidelines for patient management. There is no consensus on the diagnosis and classification of BMS. The etiopathogenesis seems to be complex and in a large number of patients probably involves interactions among local, systemic, and/or psychogenic factors. In the remaining cases, new interesting associations have recently emerged between BMS and either peripheral nerve damage or dopaminergic system disorders, emphasizing the neuropathic background in BMS. Based on these recent data, we have introduced the concepts of "primary" (idiopathic) and "secondary" (resulting from identified precipitating factors) BMS, since this allows for a more systematic approach to patient management. The latter starts with a differential diagnosis based on the exclusion of both other orofacial chronic pain conditions and painful oral diseases exhibiting muco-sal lesions. However, the occurrence of overlapping/overwhelming oral mucosal pathologies, such as infections, may cause difficulties in the diagnosis ("complicated BMS"). BMS treatment is still unsatisfactory, and there is no definitive cure. As a result, a multidisciplinary approach is required to bring the condition under better control. Importantly, BMS patients should be offered regular follow-up during the symptomatic periods and psychological support for alleviating the psychogenic component of the pain. More research is necessary to confirm the association between BMS and systemic disorders, as well as to investigate possible pathogenic mechanisms involving potential nerve damage. If this goal is to be achieved, a uniform definition of BMS and strict criteria for its classification are mandatory.

Sensory and affective components of orofacial pain: is it all in your brain?

In this paper, we shall review several chronic orofacial pain conditions with emphasis on those that are essentially refractory to treatment. We shall present a review of current and past literature that describes the various pain phenomena as well as their underlying central mechanisms. New data concerning refractory pain will be used to underscore the importance of central processing of pain, with particular emphasis on neuropsychological and cognitive function and capacity that may play important roles in pain processing and maintenance of the pain state. Further, neurophysiological data showing that the anterior cingulate cortex (ACC) and other structures in the brain may play key roles in modulation of chronic pain will also be discussed. Although peripheral triggering events surely play an important role in initiating pain, the development of chronic and, in particular, refractory pain may depend on changes or malfunctions in the central nervous system. These changes may be quite subtle and require sophisticated approaches, such as functional MRI, to study them, as is now being done. New findings obtained therefore may lead to more rational and reliable treatment for orofacial pain.

Factorial validity of the short-form McGill pain questionnaire (SF-MPQ)

Although widely used, there have been few investigations of the factorial validity of the short-form McGill Pain Questionnaire (SF-MPQ; Melzack, 1987). Confirmatory factor analysis was performed on item responses to the SF-MPQ obtained from 188 patients with chronic back pain. Consistent with the original structure proposed by Melzack (1987), results indicated that the SF-MPQ is best represented by a two-factor solution. However, these findings are contrary to results obtained by Burckhardt and Bjelle (1994) who, using their Swedish version of the SF-MPQ, obtained a three-factor solution. Potential explanations for the disparity between the results of the two studies are explored and recommendations for continuing clinical and research applications are offered.

Predicting completion of a cognitive-behavioral pain management program by initial measures of a chronic pain patient' s readiness for change

OBJECTIVE

There is a need to identify pretreatment patient indicators, which are predictive of the successful enrollment and completion of chronic pain treatment programs. Recent evidence suggests the Pain Stages of Change Questionnaire can predict enrollment and completion of a 10-session cognitive-behavioral pain management program. The purpose of this study is to determine whether the pretreatment Stages of Change Questionnaire can predict patients who would complete a cognitive-behavioral pain treatment program.

DESIGN

Prospective cohort study using logistic regression analyses.

SETTINGS

Patients referred for a 10-session cognitive-behavioral treatment program at a tertiary care multidisciplinary pain clinic or a community-based specialty clinic.

SUBJECTS

Three hundred chronic pain patients (151 in the tertiary setting and 149 in the community-based setting) participated, with 147 of the patients (49%) completing and 153 (51%) patients not completing the 10-session program.

INTERVENTION

Ten-visit cognitive-behavioral program for chronic pain patients.

OUTCOME MEASURE

Completion of program.

RESULTS

The Stages of Change Questionnaire scores could predict completion status chi2 (N = 300, 2 df) = 39.7, p <0.001, (goodness-of-fit test chi2 = 5.69, p = 0.68). Those patients completing the program were slightly older and reported higher levels of pain, depression, and disability than did those patients who did not complete. Low "Precontemplation" score remained the best single predictor, as it identified correctly 61% of the cases patients who completed the program and predicted who would drop out in 65% of the cases.

CONCLUSION

The Stages of Change Questionnaire is a potentially useful tool; however, the current scoring method is insufficient to recommend its use as an inclusion or exclusion criterion for enrollment in a cognitive-behavioral program.

Medical legal considerations in temporomandibular disorders

Dentists commonly see patients with temporomandibular disorders who are involved in litigation, and dentists are occasionally accused of temporomandibular disorder-related negligence. Rapidly changing scientific knowledge must be reflected in dental practice and in the courtroom, where dentists act as experts. In this article, concepts pertaining to assessments of patients with temporomandibular disorders for impairment and disability and concepts pertaining to legal causation are discussed, especially in relation to motor vehicle accidents. Recommendations for avoiding malpractice suits are presented.

Whiplash and temporomandibular disorders: a critical review

Some authors have hypothesized a relationship between rear-impact motor vehicle collisions and subsequent symptoms of neck pain and temporomandibular disorders, or TMD, despite no facial impact. This article examines the TMD aspect in terms of the physiological basis and cultural factors influencing the reporting of such symptoms.