Achieved competences in temporomandibular disorders/orofacial pain: a comparison between two dental schools in Europe.

AIMS: The aim was to study achieved competences in temporomandibular disorders (TMD)/orofacial pain (OP) at two universities by comparing student's knowledge and understanding, satisfaction with their education and confidence in their clinical competences of TMD/OP. METHODS: The study was conducted in collaboration between Malmö University, Sweden­which uses problem-based learning­and the University of Naples Federico II, Italy­which uses traditional educational methods. Final-semester dental students responded to a self-report questionnaire regarding their knowledge and understanding, interpretation of cases histories, clinical experience, satisfaction and confidence in clinical examination, management and treatment evaluation. RESULTS: No significant difference was found between the students regarding knowledge and understanding. Eighty-seven per cent of the Malmö students and 96% of the Naples students met the criterion on achieved competence. Malmö students had a higher per cent of correct diagnoses than Naples students in the interpretation of case histories. Overall, Malmö students reported most clinical experience and higher confidence than Naple students. CONCLUSIONS: The main findings were that students from Malmö and Naples were, similar in knowledge and understanding of TMD/OP and in satisfaction with their clinical competences. However, Malmö students perceived more confidence in clinical management of patients with TMD/OP. This may reflect that, besides the theoretical part of the programme, a sufficient level of clinical exposure to patients with TMD/OP is essential to gain competences in TMD/OP.

Long-term effectiveness of a prefabricated oral appliance for myofascial pain.

The long-term effectiveness of a prefabricated oral appliance (R) was compared with a stabilisation appliance (S) in patients with myofascial pain. Sixty-five patients diagnosed with myofascial pain at two centres for Stomatognathic Physiology in Sweden and Finland were included in a randomised controlled trial using Research Diagnostic Criteria for Temporomandibular Disorders, with history questionnaires and clinical examinations performed by blinded examiners at baseline and at 6- and 12-month follow-ups. Patients were randomly assigned either to the R or the S group. Treatment outcome was measured according to IMMPACT for four chronic pain outcome domains: pain intensity, overall improvement, physical functioning and emotional functioning. Physical functioning was classified for Graded Chronic Pain severities and assessed by the Jaw Functional Limitation scale. Emotional functioning composed of scores of non-specific physical symptoms and depression. There were no differences between groups at baseline. At both follow-ups, all outcome domains showed significant within-group improvement, without significant differences between groups. At 12 months, 72% of all patients reported a 30% reduction in worst pain and 63% of the patients a 50% reduction in worst pain. Overall improvement 'better' to 'symptom-free' was observed in 81% in the R and 64% in the S group at the 12-month follow-up. Graded Chronic Pain, Functional Limitation of the Jaw, non-specific physical symptoms and depression showed statistically significant reduction at 12-month follow-up. Results support the hypothesis that the effectiveness of the prefabricated appliance is similar to that of the stabilisation appliance in the long-term when treating patients with myofascial pain.

Dentists reflect on their problem-based education and professional satisfaction.

AIM: To determine the way in which Malmö University dental graduates perceive their problem-based dental education and evaluate their professional satisfaction. METHOD: The first five cohorts (graduating in years 1995-1999) of the problem-based curriculum were invited to participate. Of 166 graduates, 77% responded to a questionnaire comprising 20 questions on aspects of their dental education, professional situations and interest in postgraduate education. They were asked to rank their perception of their dental education and satisfaction with their professional situation on a visual analogue scale (VAS) with endpoints ranging from 'Not at all' (1) to 'Very well' (10). For other statements, the markings were made on a Likert scale from 1 (not important/not satisfied) to 5 (very important/very satisfied). There were also open-ended questions. RESULTS: Most respondents perceived their education to prepare them well for a career in dentistry (median score VAS 8), and 90% rated above six on a VAS for their professional satisfaction as dentists. Importance and satisfaction were highly correlated with principles of the curriculum: holistic view, oral health, lifelong learning, integration between theory and clinic, and clinical competence. Forty-five per cent of the graduates noted the problem-based learning approach as the most valuable asset of their education, and 19% cited training in oral surgery as a deficit. Of the respondents, 77% expressed interest in specialist training and 55% in research education. CONCLUSION: Problem-based education was perceived to prepare graduates well for their profession, and their professional satisfaction was high.

Short-term treatment of a resilient appliance in TMD pain patients: a randomized controlled trial.

To investigate the short-term efficacy of a resilient appliance in patients with temporomandibular disorders (TMD) suffering from pain, a randomized, controlled trial was performed in 80 recruited TMD pain patients. They were randomly allocated to one of two groups: treatment with a resilient appliance or treatment with a hard, palatal, non-occluding appliance. The primary treatment outcome measure was judged positive when patients' TMD pain at worst, according to the Visual Analog Scale (VAS), decreased by at least 30%. One additional treatment outcome was reduction of characteristic pain intensity. Number needed to treat was measured on the basis of primary treatment outcome at 10 weeks. At baseline, patient characteristics and TMD pain did not differ between the groups. There were no significant differences between groups regarding a 30% reduction in VAS-reported TMD pain at worst at 10 weeks' follow-up; 61% in the treatment group and 46% in the control group. After 6 and 10 weeks of treatment, CPI decreased in both groups. Number needed to treat was 9.1 for both the resilient and the control appliance therapy during 10 weeks. There was no statistically significant difference between the resilient appliance and the non-occluding control appliance in reducing TMD pain from a short-term perspective.

Salivary cortisol and IgA levels in patients with myofascial pain treated with occlusal appliances in the short term.

In many studies, the endocrinological response of individuals to different kinds of stresses has been tested. There seems to be widespread agreement that stress, depression, disability and dysfunctional illness behaviors are critical aspects of patients suffering from symptoms like pain, arising out of temporomandibular disorders (TMD). We aimed to explore treatment-induced changes in salivary cortisol, IgA and flow rate values in TMD patients suffering from myofascial pain. Temporomandibular disorders patients (n = 39) were randomized into two groups and treated with two different occlusal appliances. Perceived stress regarding family, work, economy, relationships, general health and stress in general was evaluated at baseline according to a verbal scale. Paraffin-stimulated saliva samples were collected before treatment and during follow-up at 6 and 10 weeks. Flow rate was measured immediately after the saliva collection while salivary cortisol and IgA were determined from samples stored at -70 degrees C. No clear association between reported stress and cortisol or IgA values could be observed at baseline. At 10 weeks follow-up, 92% of the patients felt 'better, much better, symptom-free' and no difference was found between the two appliance groups. Cortisol, IgA and flow rate values showed no systematic between appliance groups' differences. All salivary parameters showed interindividual differences but stayed intra-individually on a similar level throughout the study and no statistically significant changes could be observed when comparing before and after treatment levels. To conclude, there were no treatment-induced changes in saliva parameters despite successful appliance therapy in myofascial pain patients.

Undergraduates' and graduates' perception of achieved competencies in temporomandibular disorders and orofacial pain in a problem-based dental curriculum in Sweden.

AIMS: Aims of this study were to assess undergraduates' and graduates' perceptions of their education by documenting their attitudes and investigating acquired competencies in temporomandibular disorders (TMD) and orofacial pain (OP). METHODS: In 2006, 141 undergraduates (in semesters 1, 6, and 10 of a 5-year dental programme) and 60 graduates of 2000 and 2001 were invited to fill in questionnaires designed for their levels. The four questionnaires contained open-ended questions, closed-ended questions, and questions requiring a scaled response on an 11-point numerical rating scale (NRS). Questions covered personal experience of pain, attitudes toward TMD/OP, clinical competencies, and satisfaction with their education. Participants rated importance of and satisfaction with clinical competencies on a 5-point scale. RESULTS: The importance of understanding TMD/OP patients was rated high (NRS 9-10) and attitudes to given statements about TMD/OP patients were positive. In general, perception of clinical competencies increased with level of education. Mean scores for importance of and satisfaction with clinical competencies of 10th semester undergraduates and graduates were above 4.0. Median graduate satisfaction with undergraduate education in TMD/OP patient management was high (NRS 9). All but one graduate had treated patients with TMD/OP. One-third of the responding graduates expressed a wish for additional training, such as in pharmacological treatment and evaluation of treatment outcome. CONCLUSION: In general, the perception of acquired clinical competencies in TMD and OP increased with level of education, and the importance of, and satisfaction with, training was highly rated. Positive attitudes toward these kinds of patients were expressed at all levels.

Recommendations by the EACD for examination, diagnosis, and management of patients with temporomandibular disorders and orofacial pain by the general dental practitioner.

The Council of the European Academy of Craniomandibular Disorders charged the Educational Committee with the task of establishing Guidelines and Recommendations for the examination, diagnosis, and management of patients with temporomandibular disorders and orofacial pain by the general dental practitioner. It was not their purpose to present a thorough and critical review of the vast amount of literature available but to summarize the at-present generally accepted clinical approach. These recommendations are based as much as possible on scientific evidence and on sound clinical judgment in cases where only partial evidence or contradictory data were found.

Treatment of craniomandibular disorders in children and young adults.

A group of 99 children and young adults referred to a Swedish oral health sciences center were retrospectively evaluated regarding symptoms, signs, diagnoses, treatment, and treatment outcome. The most common symptoms in this patient group were headaches (52%), temporomandibular joint clicking (49%), pain at chewing (47%), and pain at wide mouth opening (46%). Common diagnoses were anterior disc displacement (32%) and craniomandibular disorders of muscular origin (16%). After treatment, 91% of the children and young adults reported themselves to be better or free of symptoms. A treatment modality often used was the occlusal splint, and it was concluded that using conservative methods led to good treatment outcomes in this patient group.

Treatment outcome in patients with craniomandibular disorders of muscular origin: a 7-year follow-up.

The outcome of different treatment modalities after 7 years was investigated in a selected group of 50 patients with craniomandibular disorders of muscular origin. To minimize the possible effects of selection on the clinical material, the selected treatment group was compared to a consecutive group of patients in terms of age, gender, intensity/duration of pain, and socioeconomic profile. Both groups were comparable in most respects, but the selected group had a longer duration and a higher intensity of pain at baseline. There were more men in the consecutive group than in the selected group. A combined treatment approach resulted in a better outcome than single treatments. Sixty-five percent of all patients in the selected group reported improvement at the 7-year follow-up. All of the 19 patients who received counseling combined with different occlusal treatments improved. Forty-three percent of the patients treated otherwise showed improvement. Patients who were aware of stress responded better to treatment.

Clinical follow-up with different disc positions.

A clinical follow-up of 45 previously symptomatic patients with arthrographically diagnosed TMJ disc positions was performed at least 1 year (average, 4 years 4 months) after treatment. The patients were divided into three groups according to disc position: (1) superior disc position, n = 5; (2) anterior disc displacement with reduction, n = 17; and (3) anterior disc displacement without reduction, n = 23. Ninety-two percent of the patient were treated conservatively. Seventy percent of the patients reported being symptom-free or improved. The frequency of joint clicking did not change considerably, but the amount of crepitating sounds increased markedly. No difference was found regarding treatment outcome between the anterior disc displacement groups with and without reduction.

Prevalence of functional disturbances and diseases of the stomatognathic system in 15-18 year olds.

Three hundred and nine teenagers were interviewed and clinically examined in an stomatognathic epidemiological study of young people aged 15-18 in Malmö, Sweden. The youngsters were randomly selected. Forty-one per cent (41%) claimed symptoms, 16% recurrent headaches and 17% had noticed clicking sounds from the temporomandibular joints. At least one of following parafunctions: grinding, clenching, lip- and cheek-biting, nailbiting were stated by 74% of the young adults. Occlusal interferences were found in 83% and mediotrusion interferences in 77%. More than half (55%) of the young people exhibited temporomandibular joint muscles tender on palpation and 34% stated that they experienced pain on palpation of the temporomandibular joints. It is concluded that there is a higher prevalence of symptoms among the young adults than among children (Nilner & Lassing 1981).

The influence of stabilisation appliance therapy and other factors on the treatment outcome in patients with temporomandibular disorders of arthrogeneous origin.

The aim of this study was to investigate if the difference in treatment outcome between patients provided with a stabilisation appliance and a control appliance was due to the treatment and/or other factors in patients with temporomandibular disorders (TMD) of arthrogeneous origin. Sixty patients were assigned to two equally sized groups: a treatment group, treated with a stabilisation appliance, and a control group given a control appliance. Thirteen possible background variables for the treatment outcome were correlated to changes in severity of temporomandibular joint (TMJ) pain on a verbal scale in the two patient groups. The logistic regression analyses revealed that, after correcting for the background variables, stabilisation appliance treatment was a strong explanatory factor for a positive treatment outcome, with a significance of P = 0.0013 compared to patients belonging to the control group. Background variables of significant importance for the treatment outcome were male sex (positive) (P = 0.0268), and severe or very severe TMJ pain (negative) (P = 0.0034). These findings indicate that not only the treatment with a stabilisation appliance but also sex and the intensity of the TMJ pain before treatment might influence the treatment outcome in patients with TMD of arthrogeneous origin.

Distribution by age and sex of functional disturbances and diseases of the stomatognathic system in 7-18 year olds.

The investigation consisted of 749 randomly selected subjects between 7-18 years of age. The subjects were interviewed for symptoms and oral parafunctions and examined clinically for occlusal interferences, malocclusions and signs of functional disturbances and diseases in the stomatognathic system. The group with one or more symptoms indicated no sex difference but the symptoms showed a gradual increase with age. Recurrent headaches were evenly distributed between the ages, but more commonly reported among girls in the age range 7-14 years. Clickings increased by age and some sex differences were found in the age distribution. Grinding and clenching showed a negative correlation with age. Boys reported clenching more often than girls between 7-14 years of age. Lip-cheek-biting and nailbiting were frequently reported in all ages. Girls in the age group of 15-18 years reported lip-cheek-biting more often than boys of the same age group; who on the other hand reported nailbiting more often. A correlation was found between thumbsucking and anterior open bite.

A longitudinal follow-up of the effect of occlusal adjustment in patients with craniomandibular disorders.

The aim of this study was to evaluate the effect of occlusal adjustment in a prospective longitudinal study. Fifty selected patients with craniomandibular disorders (CMD) including headaches were randomly assigned to a treatment (T) or a control (C) group. Both groups received counselling and occlusal adjustment was performed in T group. Subjective symptoms and clinical findings were registered before and 2 years after treatment. At a follow-up 48% in the T group and 84% in the C group had demanded rescue treatment. Eleven patients in the T group (48%) and 3 patients in the C group (13%) without rescue treatment, reported overall subjective improvement. No difference was found between the groups regarding overall intensity of pain expressed by the visual analogue scale. When all kinds of treatment were taken into account, 70% and 79% of the patients in the T and C group reported overall subjective improvement at follow-up. The conclusions from this study were that in a two-year perspective only single patients improved from counselling alone. A few more patients improved if one more kind of treatment, for example occlusal adjustment, was added to the initial counselling, but the majority of the patients required a comprehensive treatment program.

Prevalence of functional disturbances and diseases of the stomatognathic system in 7-14 year olds.

An epidemiological investigation was carried out in Malmö/Sweden to determine the prevalence of symptoms and signs of functional disturbances and diseases of the stomatognathic system in children aged 7-14. Four-hundred and forty children (440) were randomly selected, interviewed and clinically examined. The interview revealed 36% with symptoms, 15% with recurrent headaches and 13% reported clicking sounds from the temporomandibular joints. Seventy-seven per cent (77%) of the children reported at least one of the following oral parafunctions grinding clenching lip- and cheek-biting, nail-biting or thumb-sucking. In the clinical examination occlusal interferences in RP were found in 79% and mediotrusion interferences in 78%. More than half of the children 64%, claimed pain on palpation of the temporomandibular joint muscles and more than one third (39%) claimed pain on palpation of the temporomandibular joint. It is concluded that children are suffering from diseases and functional disturbances of the stomatognathic system.

Symptoms and signs of temporomandibular disorders before, during and after orthodontic treatment.

The relationship between orthodontic treatment and symptoms and signs of temporomandibular disorders (TMD) was studied prospectively and longitudinally in 65 adolescent girls with Class II malocclusion. The subjects received orthodontic fixed appliance treatment with the straight-wire technique combined with or without extractions and were examined for symptoms and signs of TMD before, during, after, and finally one year post-treatment. Both symptoms and signs of TMD showed considerable fluctuations over the three-year period within the individuals. The general tendency was a decreased prevalence of symptoms of TMD over the three years. The prevalence of pain on mandibular movement and tenderness to palpation of the masticatory muscles was significantly less common during and after orthodontic treatment than before. Clinically registered TMJ clicking increased slightly over the three year period. One orthodontic treatment effect when normalizing Class II malocclusions with fixed appliances was a decreased prevalence of functional occlusal interferences. We concluded that the orthodontic treatment either with or without tooth extractions did not increase the risk for TMD or worsen pre-treatment signs of TMD. Subjects with Class II malocclusion and pre-treatment signs of TMD of muscular origin seemed rather to benefit functionally from orthodontic treatment in a three-year perspective.

Masticatory efficiency in individuals with natural dentition.

51 healthy dentate subjects aged between 20 and 60 years were evaluated with regard to their masticatory efficiency using a sieving test. A subjective evaluation of difficulty in chewing different kinds of food was also obtained by means of a questionnaire. The occlusal and restorative status were assessed using specific indices. The masticatory efficiency was shown to be lower with increasing age 20-39 years, mean = 39.8 and 40-60 years, mean = 27.1, respectively (p < 0.05). Males had a statistically significantly higher masticatory efficiency index than females. Multiple regression analysis showed that age, sex, the number of occluding teeth and the orthodontic treatment need index can predict half the variance in masticatory efficiency. It is concluded that it is more appropriate to describe masticatory efficiency with an average value for different age groups.

Long-lasting orofacial pain--a study of 109 consecutive patients referred to a pain group.

The aim was to register and evaluate the orofacial pain condition, with special focus on the equalities/inequalities between the sexes, in consecutive patients referred to the pain group at the Centre for Oral Health Sciences in Malmö, Sweden. The 109 patients, 85 (78%) women and 24 (22%) men, were referred to the pain group during the years 1988 to 1993 and were clinically examined using a standardised procedure. Pain duration of one year or more was experienced by 83% of the patients. The pain onset was related to dental care or toothache by 56% of the patients. Temporomandibular disorders were the most common diagnoses (52%) and were more common among women than among men (p < 0.05). Multiple pain locations were frequently reported, range 1-47 locations, and the women had significantly (p < 0.05) more pain locations than the men. Equalities between the sexes were more frequent than inequalities among patients referred for long-lasting orofacial pain. It can be discussed whether the sex difference in the prevalence of pain of musculoskeletal origin emerges from biological differences or can be explained by different psychosocial circumstances.

TMD before and after correction of dentofacial deformities by orthodontic and orthognathic treatment.

The aims of the study were to investigate the alteration of temporomandibular disorders (TMD) after correction of dentofacial deformities by orthodontic treatment in conjunction with orthognathic surgery; and to compare the frequency of TMD in patients with dentofacial deformities with an age and gender matched control group. TMD were evaluated in 121 consecutive patients (treatment group), referred for orthognathic surgery, by a questionnaire and a clinical examination. 18 months after treatment, 81% of the patients completed a follow-up examination. The control group comprised 56 age and gender matched subjects, of whom 68% presented for follow-up examination. TMD were diagnosed according to research diagnostic criteria for TMD. At baseline examination, the treatment group had a higher frequency of myofascial pain (P=.035) and arthralgia (P=.040) than the control group. At follow-up, the frequencies of myofascial pain, arthralgia and disc displacement had decreased in the treatment group (P=.050, P=.004, P=.041, respectively). The frequency of TMD was comparable in the two groups at follow-up. Patients with dentofacial deformities, corrected by orthodontic treatment in conjunction with orthognathic surgery, seem to have a positive treatment outcome in respect of TMD pain.