Diagnostic criteria for temporomandibular disorders (DC/TMD): interexaminer reliability of the Finnish version of Axis I clinical diagnoses

Inter-examiner reliability of the Chinese version of Axis I diagnoses of the diagnostic criteria for temporomandibular disorders

OBJECTIVE

To evaluate the inter-examiner reliability of the Chinese version of the Axis I diagnoses of the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) and to compare the consistency between clinical diagnoses and magnetic resonance imaging (MRI).

METHODS

Sixty-seven individuals were evaluated by three TMD specialists, and 49 underwent MRI examination. Cohen's Kappa coefficient (κ) was used to evaluate the inter-examiner reliability and the consistency between clinical diagnoses and MRI manifestations.

RESULTS

Diagnostic agreement was good to excellent for pain and disc displacement with or without reduction (κ = 0.659-1.000). Agreement between clinical diagnoses and MRI findings was fair to good (κ = 0.400).

CONCLUSION

Inter-examiner diagnostic reliability using the Chinese version of the DC/TMD Axis I instruments was excellent, especially for arthrogenic TMDs.

Risk factors associated with symptoms of temporomandibular disorders among women with hypermobile Ehlers-Danlos syndrome: Questionnaire-based study in Finland and Sweden

BACKGROUND

Generalized joint hypermobility as a characteristic feature of Ehlers-Danlos syndromes (EDS) is among the factors contributing to temporomandibular disorders (TMD).

OBJECTIVE

To evaluate the prevalence of TMD symptoms and their risk factors among women born in Sweden or Finland who were 27- to 78-year-olds with diagnosed hypermobile EDS (hEDS).

METHODS

A cohort of women with confirmed hEDS (n = 185) was constructed from the members of the National EDS Associations in both countries. Based on questionnaire data, frequency of independent variables in terms of socio-demographic, general health and oral health-related factors, comorbid symptoms and psychological distress for self-reported TMD symptoms as the dependent variables, were calculated first. Prevalence ratios (PR) and their 95% confidence interval (95% CI) were estimated for the association between independent and dependent variables.

RESULTS

Nearly all participants reported TMD symptoms (98%) with TMD pain (95%), TMJ clicking (90%) and jaw fatigue (80%) as the most common symptoms and TMJ crepitation (63%) and luxation (44%) as the least common symptoms. Risk factors for TMD among 27- to 50-year-olds participants were Finland as a country of birth, living alone and self-reported worst pain in the body (not the joints). The respective risk factors among the 51- to 78-year-olds were Finland as a country of birth, family history of EDS, tinnitus and regularly taking contraceptives.

CONCLUSIONS

Among adult women with confirmed hEDS, socio-demographic and health-related factors and comorbid symptoms were significantly associated with TMD but with differences regarding age group. Therefore, management of TMD requires a multidisciplinary approach among the affected.

Do TMJ MRI diagnosis support clinical examination diagnosis following DC/TMD criteria?

PURPOSE

The Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) has been validated as a clinical diagnostic guideline with high-sensitivity and -specificity in identifying TMDs. The purpose of this study was to evaluate the agreement between DC/TMD diagnoses and magnetic resonance imaging (MRI) diagnoses in patients with TMD.

METHODS

A prospective cohort study was conducted on patients with TMD. The predictor variable was the clinical diagnosis of TMD based on DC/TMD criteria. The outcome variable was the MRI diagnosis of TMD. The diagnoses used for both the predictor variable and the outcome variable were the same. They were normal, disc displacement with reduction (DDWR), DDWR with intermittent locking, disc displacement without reduction (DDWOR) with limited opening, DDWOR without limited opening, degenerative joint disease, and subluxation. Age and gender of the patients and number of joints evaluated were covariates. Each subject had clinical examination performed by two independent Oral and Maxillofacial Surgeons. All subjects had a bilateral temporomandibular joint (TMJ) MRI performed which was evaluated by a radiologist. The correlation between the clinical and MRI diagnoses was calculated using Cohen's kappa value with a P value of <.05 considered significant.

RESULTS

A total of fifty patients (100 TMJs) were enrolled with 38 females and 12 males. The mean ages were 31.92 and 31.75 years, respectively, with a total of 100 TMJs analyzed. Internal derangement was clinically identified in 76% of the joints and with MRI in 69% of joints. The Cohen's kappa value between DC/TMD and MRI diagnoses was found to be κ = 0.720 (P < .01). The respective sensitivity and specificity in determining disc position clinically for DDWR was 1 and 0.96; for DDWR with intermittent locking 0.78 and 0.91; for DDWOR with limited opening 0.9 and 0.98; for DDWOR without limited opening 1 and 0.9; for degenerative joint disease 0.63 and 0.97 and for subluxation 0.28 and 1.00.

CONCLUSION

The DC/TMD clinical examination performed well in all types of disc displacement but is less reliable in detecting the presence of degenerative disc diseases and subluxation.

Comparison of Axis II psychosocial assessment methods of RDC/TMD and DC/TMD as part of DC/TMD-FIN phase II validation studies in tertiary care Finnish TMD pain patients

BACKGROUND

The Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) and Diagnostic Criteria for TMD (DC/TMD) include Axis II instruments for psychosocial assessment.

OBJECTIVES

The aims were to compare the Finnish versions of Axis II psychosocial assessment methods of the RDC/TMD and DC/TMD and to study their internal reliability.

METHODS

The sample comprised 197 tertiary care referral TMD pain patients. The associations between RDC/TMD [Graded Chronic Pain Scale (GCPS) 1.0, Symptom Check List 90-revised (SCL-90R)] and DC/TMD (GCPS 2.0, Patient Health Questionnaire-9 (PHQ-9), PHQ-15) assessment instruments were evaluated using Spearman correlation coefficients, Wilcoxon Signed Rank s, chi-squared test and gamma statistics. The internal reliability and internal inter-item consistency of SCL-90-R, PHQ-9, PHQ-15 and Generalized Anxiety Disorder-7 (GAD-7) were evaluated using Cronbach's alpha coefficient values.

RESULTS

The DC/TMD and RDC/TMD Axis II psychosocial instruments correlated strongly (p < .001). GCPS 1.0 and GCPS 2.0 grades were similarly distributed based on both criteria. The RDC/TMD psychological instruments had a higher tendency to subclassify patients with more severe symptoms of depression and non-specific physical symptoms compared to DC/TMD. The internal reliability and internal inter-item consistency were high for the psychological assessment instruments.

CONCLUSION

The Finnish versions of the RDC/TMD and DC/TMD Axis II psychosocial instruments correlated strongly among tertiary care TMD pain patients. Furthermore, the Axis II psychological assessment instruments indicated high validity and internal inter-item consistency and are applicable in Finnish TMD pain patients as part of other comprehensive specialist level assessments, but further psychometric and cut-off evaluations are still needed.

Interexaminer reliability of the German version of the DC/TMD

AIM

Verification of the interrater reliability of axis I diagnoses of the German version of the DC/TMD. The hypothesis was that the DC/TMD protocol yields comparable results, if examiner instructions are closely followed.

MATERIAL AND METHODS

A culturally equivalent German translation of the DC/TMD was developed. During a 1-day calibration workshop at the University of Heidelberg, three examiners were trained by the DC/TMD Training and Calibration Center. According to the calibration guidelines, 16 models (11 cases, five non-cases) were examined by four experienced TMD specialists. Reliability was calculated with reference to the reference standard examiner as percentage agreement and kappa coefficients for DC/TMD diagnoses and intraclass correlation coefficients (ICCs) for findings.

RESULTS

Excellent reliability was achieved for the diagnoses myalgia, myofascial pain with referral, arthralgia, headache attributed to TMD, disc displacement (DD) with reduction, DD without reduction without limited opening (κ = 0.85…1.00). Degenerative joint disease was diagnosed with substantial agreement (κ = 0.64), DD with reduction with intermittent locking and DD without reduction with limited opening were not present in our sample. Overall percentage agreement was 94%-100% for all diagnoses.

CONCLUSION

The German version of the DC/TMD shows very good reliability and can be recommended for the use in clinical and research settings.

The effectiveness of the masseteric nerve block compared with trigger point injections and dry needling in myofascial pain

OBJECTIVE

To compare the efficacy of three different treatment methods in the management of myofascial pain: masseteric nerve block (MNB), trigger point injection with local anesthetic (LA), and dry needling (DN).

METHODS

Forty-five patients diagnosed with myofascial pain and trigger points in masseter muscles were treated with MNB (n = 15), DN (n = 15), and trigger point injection with LA (n = 15). Pain on palpation (PoP), pain on function (PoF), and maximum mouth opening (MMO) scores were measured and compared before the injections and all follow-ups after the injections.

RESULTS

MMO values were significantly increased in each group. The decrease in PoF values was statistically significant between the groups at 12 weeks (baseline time period).

DISCUSSION

Results of the present study indicate that MNB was not as effective as trigger point injection with local anesthetic or dry-needling in the management of masticatory myofascial pain.

Validation of a web-based version of the Craniofacial Pain and Disability Inventory

OBJECTIVE

To translate and cross-culturally adapt the Craniofacial Pain and Disability Inventory (CF-PDI) into Chinese and, to evaluate measurement properties of the web-based version of the CF-PDI.

METHODS

The Chinese version (CF-PDI/C) was first produced according the guidelines. Then, the web-based version of CF-PDI/C (eCF-PDI/C) was developed by our team and a third-party survey provider. The eCF-PDI/C was distributed to patients with painful temporomandibular disorders (TMD) with or without headache to evaluate its psychometric properties. The reliability of the eCF-PDI/C was detected by internal consistency and test-retest reliability. The validity of the measure was performed through construct validity and convergent validity.

RESULTS

A total of 206 patients were recruited. The Cronbach's α value and the intraclass correlation coefficients (ICC) value of the eCF-PDI/C was .912 and .82, respectively. Following exploratory factor analysis (EFA), three factors were extracted, accounting for 77.153% of the total variation. With regard to the convergent validity, the measure evidenced a good relationship with the global health question.

CONCLUSIONS

The eCF-PDI/C displays good reliability and validity through rigorous performance tests. This can be recommended for use among patients with painful TMD with or without headache.

Sex hormones in association with general joint laxity and hypermobility in the temporomandibular joint in adolescents-results of the epidemiologic LIFE child study

OBJECTIVES

The aim of this cross-sectional study was to investigate whether sex hormones (testosterone, oestradiol, sex-hormone-binding globulin = SHBG) are associated with general joint laxity (GJL) and hypermobility or derangements of the temporomandibular joint (TMJ) in adolescents.

METHODS

Within the LIFE Child study, 970 adolescents (10-18 years) were included. GJL was assessed using the Beighton test. Maximum mouth opening (MMO) and clinical clicking sounds as signs of disc displacement (DD) in the TMJ were assessed according to the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD). Serum levels of sex hormones were assessed using standardised laboratory analyses.

RESULTS

Hypermobile joints were found in 54.9% (N = 532) of the sample; females were more affected than males (61.4% vs. 51.8%, P < 0.001). Using logistic regression analyses, the odds ratio (OR) for having >1 hypermobile joints increased to 1.15 (95% confidence interval [CI]: 1.04-1.27) in males and 1.09 (95% CI: 1.02-1.17) in females per 10 units of the SHBG serum level, compared to those without hypermobile joints-after controlling for the effect of age, adjusted BMI, pubertal development (Tanner scale), testosterone as well as oestradiol levels. Female subjects with >1 hypermobile joints showed a higher OR (1.89; 95% CI: 1.05-3.43) for having clinical clicking sounds in the TMJ and a 3.28 times higher OR (95% CI: 1.44-7.44) for MMO ≥ 55 mm.

CONCLUSIONS

We observed age- and gender-independent associations of higher SHBG serum levels with GJL in adolescents. Moreover, hypermobile female adolescents show a more frequent hypermobility of the TMJ and clinical signs of DD.

Prevalence of temporomandibular disorders (TMD) among Finnish prisoners: cross-sectional clinical study

OBJECTIVE

The aim of the present study was to evaluate the prevalence of self-reported temporomandibular disorders (TMD) symptoms and clinically diagnosed TMD among Finnish prisoners.

MATERIAL AND METHODS

Altogether 100 prisoners from the Pelso Prison, Vaala, Finland, underwent dental and TMD clinical examinations performed by a calibrated and well-trained dentist. Symptom Questionnaire and clinical examination according to a Finnish pre-final version of the DC/TMD (Diagnostic Criteria for Temporomandibular Disorders) Axis I protocol were used to evaluate the prevalence of TMD sub-diagnoses.

RESULTS

The most common TMD symptoms were facial pain (54.0%), temporomandibular joint noises (43.0%) and headache (37.0%). The prevalence of joint-related TMD diagnoses was four and a half times higher than diagnoses attributed with pain (76.0% vs. 17.0%). The most common TMD diagnoses were degenerative joint disease (33.0%) and disc displacement with reduction (33.0%).

CONCLUSIONS

The prevalence of self-reported TMD symptoms and clinical assessed TMD, especially join-related TMD diagnoses, is high among Finnish prisoners. Examination and treatment of TMD should become a common practice also in prison dental care.

Validation of the Centrality of Pain Scale in Chinese-Speaking Patients with Painful Temporomandibular Disorders

OBJECTIVE

The present study aimed to validate the Centrality of Pain Scale (COPS) for use in Chinese patients with painful temporomandibular disorders (TMDs).

METHODS

The Centrality of Pain Scale was firstly translated and cross-culturally adapted following international guidelines. In total, 166 patients with TMD were recruited to complete the Chinese version of the COPS (COPS-C). In addition to the COPS-C, the patients were also administered the Pain Catastrophizing Scale (PCS) and the Pain Self-Efficacy Questionnaire (PSEQ). The reliability of the COPS-C was evaluated using internal consistency and test-retest methods. The construct validity of the COPS-C was evaluated using exploratory factor analysis (EFA). Convergent validity was determined by analyzing the correlations between COPS-C scores and the scores of the PCS and PSEQ.

RESULTS

Cronbach's alpha for the total COPS-C score was 0.942. The interitem correlations ranged from 0.356 to 0.901. The intraclass correlation coefficient values of the COPS-C ranged between 0.815 and 0.929. The results of the EFA indicated a one-factor solution for the measure, accounting for 70.4% of the total observed variance. The factor loadings of all items ranged from 0.713 to 0.917. Regarding convergent validity, the COPS-C had moderate correlations with the PCS and the PSEQ.

CONCLUSIONS

The results provide initial evidence that the COPS-C is a reliable and valid measure. It can be used as a suitable instrument for Chinese patients with TMD.

DC/TMD Examiner Protocol: Longitudinal Evaluation on Interexaminer Reliability

Objectives

The objectives of this study were to assess the interexaminer agreement between one "reference" (gold standard) and each of two examiners, using the DC/TMD examination method, Axis I and to evaluate whether a recalibration changed reliability values.

Methods

Participants (4 healthy and 12 TMD patients) in 2013 underwent a clinical examination according to DC/TMDs, Axis I. In 2014, additionally 16 participants (4 healthy and 12 TMD patients) were recruited. Two trainee examiners (one more experienced) and one "reference examiner" (gold standard) at both sessions assessed the participants. Calibration preparation (2013): The clinical protocol was sent to the trainee examiners with a request that its verbal commands should be learned by heart. An eight-hour-course was provided on the day preceding the examination session day. Recalibration preparation (2014): The same examiners in advance to this year's examination session were also asked to recapture the protocol's instructions (verbal commands to be learned by heart) and go through the information from the 2013 course and encouraged to contact by e-mail in case of unclear subjects. At a meeting prior to the examination session, they were also given the opportunities to ask questions. The interexaminer agreements in 2013 and 2014 between the "reference" and each examiner were analysed using Bland-Altman plots, intraclass correlation coefficient, Cohen's kappa, and consistency values.

Results

For the majority of the gathered data, no clear change of agreement between 2013 and 2014 could be observed, and only one muscle zone in 2014 could show any clear difference in agreement between the examiners.

Conclusions

No clear and consistent difference in the level of agreement between the two examiners could be observed, although one was more experienced than the other. Likewise, for most components of the DC/TMD tool, recalibration of examiners did not change the reliability findings.

Validation of the Pain Resilience Scale in Chinese-speaking patients with temporomandibular disorders pain

To validate the Pain Resilience Scale (PRS) for use in Chinese patients with temporomandibular disorders (TMD) pain. According to international guidelines, the original PRS was first translated and cross-culturally adapted to formulate the Chinese version of PRS (PRS-C). A total of 152 patients with TMD pain were recruited to complete series of questionnaires. Reliability of the PRS-C was investigated using internal consistency and test-retest reliability. Validity of the PRS-C was calculated using cross-cultural validity and convergent validity. Cross-cultural validity was evaluated by examining the confirmatory factor analysis (CFA). And convergent validity was examined through correlating the PRS-C scores with scores of 2 commonly used pain-related measures (the Connor-Davidson Resilience Scale [CD-RISC] and the Tampa Scale for Kinesiophobia for Temporomandibular Disorders [TSK-TMD]). The PRS-C had a high internal consistency (Cronbach's alpha = 0.92) and good test-retest reliability (intra-class correlation coefficient [ICC] = 0.81). The CFA supported a 2-factor model for the PRS-C with acceptable fit to the data. The fit indices were chi-square/DF = 2.21, GFI = 0.91, TLI = 0.97, CFI = 0.98 and RMSEA = 0.08. As regards convergent validity, the PRS-C evidenced moderate-to-good relationships with the CD-RISC and the TSK-TMD. The PRS-C shows good psychometric properties and could be considered as a reliable and valid measure to evaluate pain-related resilience in patients with TMD pain.