Reliability and validity of Axis I of the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) with proposed revisions.

The research diagnostic criteria for temporomandibular disorders (RDC/TMD) have been employed internationally since 1992 for the study of temporomandibular muscle and joint disorders (TMD). This diagnostic protocol incorporates a dual system for assessment of TMD for Axis I physical diagnoses as well as Axis II psychological status and pain-related disability. Because the reliability and criterion validity of RDC/TMD had not yet been comprehensively characterised, the National Institute of Dental and Craniofacial Research funded in 2001 the most definitive research to date on the RDC/TMD as a U01 project entitled, 'Research Diagnostic Criteria: Reliability and Validity'. The results of this multi-site collaboration involving the University of Minnesota, the University of Washington, and the University at Buffalo were first reported at a pre-session workshop of the Toronto general session of the International Association of Dental Research on 2 July 2008. Summaries of five reports from this meeting are presented in this paper including: (i) reliability of RDC/TMD Axis I diagnoses based on clinical signs and symptoms; (ii) reliability of radiographic interpretations used for RDC/TMD Axis I diagnoses; (iii) reliability of self-report data used for RDC/TMD Axis I diagnoses; (iv) validity of RDC/TMD Axis I diagnoses based on clinical signs and symptoms; and (v) proposed revisions of the RDC/TMD Axis I diagnostic algorithms.

Longitudinal Stability of Common TMJ Structural Disorders.

The longitudinal course of temporomandibular joint (TMJ) disc displacement (DD) and degenerative joint disease (DJD) has never been conclusively described with magnetic resonance imaging and computed tomography, respectively. This 8-y observational study's objective was to assess the longitudinal stability of DD and DJD among 401 subjects. The Validation Project provided baseline measures; follow-up was performed in the TMJ Impact Project. With magnetic resonance imaging, 2 radiologists rendered a consensus diagnosis of normal/indeterminate, DD with reduction, or DD without reduction. Computed tomography consensus diagnoses included normal/indeterminate, grade 1 DJD, or grade 2 DJD. Radiologist reliability was assessed by kappa; a Hui-Walter model was used to estimate, after accounting for diagnostic disagreement, the frequency of diagnostic progression and reversal. Permutation tests were used to test the statistical influence of concurrent baseline diagnoses on diagnostic changes at follow-up. Of 789 baseline joint-specific soft tissue diagnoses of DD, 598 (76%) joints showed no change; 109 (14%) demonstrated progression; and 82 (10%) had reversal. Of 794 joints with baseline joint-specific hard tissue diagnoses of DJD, progression was observed in 122 (15%) joints, no change in 564 (71%), and reversal in 108 (14%). Radiologist reliability (kappa) was 0.73 (95% CI, 0.64 to 0.83) for DD and 0.76 (95% CI, 0.68 to 0.83) for DJD. After accounting for the influence of diagnostic disagreement, progression of hard tissue diagnoses in the right TMJ occurred in 15.2% of subjects (95% CI, 10.5% to 20.8%) and reversal in 8.3% (95% CI, 4.9% to 12.3%); results were similar for soft tissue diagnoses and the left TMJ. Concurrent baseline soft tissue diagnoses were associated with hard tissue diagnostic changes at follow-up ( P < 0.0001). Baseline hard tissue diagnoses showed no statistical association with soft tissue changes at follow-up ( P = 0.11). Longitudinally, 76% of baseline TMJ soft tissue diagnoses and 71% of the baseline hard tissue diagnoses remained stable. Diagnostic reversal and progression were confirmed for both soft and hard tissues.

Oral manifestations of chronic graft-v-host disease.

Sixty patients were studied 180 to 500 days after allogeneic marrow transplantation to determine if late oral abnormalities were associated with the presence of chronic graft-v-host disease (GVHD). Lip and intraoral mucosal surfaces were evaluated for color, keratinization, atrophy, and erythema. Subjective complaints of oral pain and xerostomia were also recorded. Abnormalities were scored on a scale of 0 to 3 and tested for association with GVHD by chi 2 test. Oral manifestations most strongly associated with chronic GVHD included atrophy and erythema or lichenoid lesions of the buccal and labial mucosa and oral pain. Oral manifestations resembled several naturally occurring autoimmune disorders. Recognition of these changes can aid in the clinical diagnosis and assessment of established chronic GVHD.

The roles of beliefs, catastrophizing, and coping in the functioning of patients with temporomandibular disorders.

Pain-related beliefs, catastrophizing, and coping have been shown to be associated with measures of physical and psychosocial functioning among patients with chronic musculoskeletal and rheumatologic pain. However, little is known about the relative importance of these process variables in the functioning of patients with temporomandibular disorders (TMD). To address this gap in the literature, self-report measures of pain, beliefs, catastrophizing, coping, pain-related activity interference, jaw activity limitations, and depression, as well as an objective measure of jaw opening impairment, were obtained from 118 patients at a TMD specialty clinic. Controlling for age, gender, and pain intensity, significant associations were found between (1) pain beliefs and activity interference, depression, and non-masticatory jaw activity limitations, (2) catastrophizing and activity interference, depression, and non-masticatory jaw activity limitations, and (3) coping and activity interference and depression. Controlling for age, gender, pain intensity, and the other process variables, significant associations were found between (1) beliefs and activity interference and depression, and (2) catastrophizing and depression. No process variable was associated significantly with the objective measure of jaw impairment. The results suggest that for patients with moderate or high levels of TMD pain and dysfunction, beliefs about pain play an important role in physical and psychosocial functioning.

Radioprotection by WR-2721 of gamma-irradiated rat parotid gland: effect on gland weight and secretion at 8-10 days post irradiation.

Changes in rat parotid salivary gland weight and functional parameters were evaluated at 8 to 10 days post irradiation in WR-2721 protected and non-protected animals following exposure to a single 15.3 Gy dose of Cs-137 radiation to the head. Glandular fluid secretory capacity was assessed by maximum flow rate, total volume of saliva and duration of secretion following pilocarpine stimulation. Protection against radiomucositis was also evaluated indirectly by daily monitoring of food and water intake, body weight and paraoral symptomatology. WR-2721 provided a significant degree of protection for all glandular functional parameters as well as gland weight. Relative protective factors (RPF) were computed for irradiated protected and non-protected animals compared to their sham-irradiated, pair-fed controls. The calculated RPFs were: Gland weight 1.9, maximum flow rate 2.9, volume of saliva 2.1 and duration of secretion 2.1 for a mean "relative protection" of 2.25. Substantial protection against radiomucositis in protected animals was evident by a progressive gain in body weight and lack of oral signs and symptoms as compared to non-protected animals. Protection against radiomucositis and preservation of residual parotid gland secretory capacity as determined by functional parameters suggests that WR-2721 may be of significant benefit in alleviating oral symptoms and maintaining salivary gland function for patients receiving radiotherapy for head and neck tumors.

Disordered salivary immunoglobulin secretion and sodium transport in human chronic graft-versus-host disease.

Whole saliva samples and lip biopsies were collected from 12 allogeneic bone marrow transplant recipients who developed extensive chronic graft-versus-host disease (GVHD) and from 10 healthy allogeneic and syngeneic recipients without GVHD. Six of ten biopsies from patients with chronic GVHD had lichenoid stomatitis or sialadenitis, or both, with sialodochitis. Seven of nine biopsies from patients free of chronic GVHD were entirely normal, and two had either mild glandular or mucosal changes. Salivary gland involvement in chronic GVHD was associated with decreased or absent levels of salivary IgA and inorganic phosphate, decreased salivary flow rates, and increased concentrations of salivary sodium, albumin, and IgG. The most striking abnormalities were found in patients with histologic evidence of sialadenitis. In contrast, marrow transplant recipients without chronic GVHD had normal salivary immunoglobulin and electrolyte levels. Secretory IgA deficiency may contribute to the frequent sinobronchial infections observed in patients with chronic GVHD.

The predictive value of elevated labial saliva sodium concentration: its relation to labial gland pathology in bone marrow transplant recipients.

Labial minor gland salivary flow rate and sodium concentration were analyzed in relation to 1) histologic findings in labial biopsy specimens and 2) the occurrence of chronic graft-versus-host disease (GVHD) in patients who received bone marrow transplants. Biopsy specimens and samples were obtained from 61 recipients of marrow transplants (including three twins) 51 to 1,260 days post transplantation. Labial saliva sodium concentrations were elevated in some patients, and these increases were associated with inflammation and destruction of minor salivary gland acini and ducts by chronic GVHD or other factors. The predictive value of the salivary sodium changes in evaluating labial salivary gland pathologic changes was 91 per cent, and the sensitivity was 74 per cent. Thus, if a transplant recipient is found to have an elevated labial saliva sodium level, then the probability that he has pathologic labial gland changes is 91 per cent. When analyses were restricted to include only patients who received no irradiation during transplantation, then elevated labial saliva sodium concentration was significantly associated with the occurrence of chronic GVHD. The sensitivity of this relationship was 42 per cent, but the predictive value was 100 per cent. Thus, if a nonirradiated transplant recipient is found to have an elevated labial saliva sodium concentration, then it is virtually certain that he has chronic GVHD. We found no significant changes in labial saliva flow rates in these bone marrow transplant recipients.

Use of human minor salivary glands in basic and applied secretion research.

Previous findings from studies utilizing human labial and palatine minor salivary glands are reviewed. These studies took histopathological, biochemical, and ultrastructural approaches, and focused on control and diseased glands. Disease-oriented summarization are used, and control results are discussed in the context of disease-related findings. Findings are reviewed separately for electrolytes, macromolecules, and ultrastructure. In control subjects, minor gland salivary electrolyte concentrations are dependent on flow rate, and this dependence may be altered by diseases such as cystic fibrosis as well as by inflammatory situations such as graft-versus-host disease. There is also evidence that salivary electrolyte secretion processes are not similar in labial and palatine minor glands. Studies of salivary macromolecular composition are reviewed for control subjects and for patients with graft-versus-host disease and Sjögren's syndrome. The findings indicate that the macromolecular contents of labial and palatine gland saliva are similar, but that both are significantly different from that for major gland saliva. Finally, studies attempting to measure disease-related changes in intracellular composition are reviewed. It is concluded that the minor salivary glands are important models for the study of exocrine gland physiology and pathophysiology in man.

Sialochemistry of whole, parotid, and labial minor gland saliva in patients with oral lichen planus.

This study was undertaken to determine whether oral lichen planus in otherwise healthy patients is associated with sialochemical abnormalities. Unstimulated and stimulated whole saliva, stimulated parotid saliva, and stimulated labial minor gland saliva were collected from 25 patients with oral lichen planus and from 25 age- and sex-matched controls. Flow rate and salivary concentrations of immunoglobulins A and G, albumin, amylase, lysozyme, lactoferrin, and total protein were determined by standard analytical techniques. Concentrations of inorganic components including sodium, potassium, calcium, chloride, and phosphate were also measured. No significant differences were found between the lichen planus patients and the controls. These findings do not support an association between oral lichen planus and salivary dysfunction in otherwise healthy patients.

Oral topical doxepin rinse: analgesic effect in patients with oral mucosal pain due to cancer or cancer therapy.

Oral mucositis is a treatment limiting toxicity of cancer therapy. The purpose of this study was to assess the impact of doxepin oral rinse in the management of oral mucosal pain in cancer patients. Forty-one cancer patients with oral mucosal pain were provided a solution of doxepin (0.5%) for oral rinsing. Oral pain was assessed prior to rinsing, and following rinsing for 4 h using a visual analogue scale (VAS). Adverse effects were recorded. Doxepin rinse resulted in a reduction of pain intensity of more than 50%, with pain relief extending for more than 3 h with pain not returning to baseline 4 h after rinsing. The rinse was tolerated by patients with mucosal damage, and had acceptable taste, and infrequent mucosal stinging with use. Some patients reported sedation after use, likely due to systemic absorption. The results of this single dose trial suggest that topical doxepin rinse has significant ability to provide clinically significant pain relief in patients with mucosal damage with an extended duration of effect.

Effects of specific antibodies on the interaction between the fungus Candida albicans and human oral mucosa.

Host-parasite interactions were studied in four groups: non-infected controls; infected carriers of Candida albicans without evidence of candidiasis; subjects with acute candidiasis; and subjects with chronic candidiasis. Specific anti-candida antibodies were demonstrated in saliva from subjects of all four groups; the titres reflected the degree of antigenic stimulation, being significantly higher in candidiasis than in controls or infected carriers. The adherence of C. albicans to buccal epithelial cells was not significantly different in a given saliva, regardless of whether the assay was carried out with autologous C. albicans and epithelial cells or with a stock strain in a standardized assay. Therefore, the standard assay was used to study the effects of specific salivary antibodies on adherence. A significant inverse correlation was found between salivary IgA anti-candida antibodies and the adherence of C. albicans to buccal epithelial cells, suggesting that IgA antibodies can inhibit adherence of candida to the oral mucosa. In some instances, removal of antibodies led to a significant increase in adherence; however, often this was not the case, indicating that some but not all of the antibodies present were capable of inhibiting the adherence of C. albicans to epithelial cells.

Topical cyclosporine in a bioadhesive for treatment of oral lichenoid mucosal reactions: an open label clinical trial.

Oral lichenoid reactions may present as chronic symptomatic mucosal reactions. Lichen planus-like reactions include those associated with drug reactions, graft-versus-host disease after bone marrow transplantation, and idiopathic lichen planus. The mainstay of management is topical steroids; in resistant cases, topical and systemic corticosteroids may be used. We evaluated the use of cyclosporine administered in an adhesive hydroxypropyl cellulose base in patients with oral lichenoid reactions that remained active despite the prior use of high-potency topical steroids and in some cases despite the combined use of topical and systemic immunosuppression. Signs and symptoms of ulcerative oral graft-versus-host-disease improved more than 50% in three of four patients with oral graft-versus-host disease treated with the addition of topical cyclosporine. However, in patients with persistent oral lichen planus less effect was seen with 7 of 14 patients demonstrating a partial reduction in signs and symptoms. The topical use of cyclosporine in a bioadhesive base may represent a useful adjunctive approach in management of oral lichenoid reactions, although dose escalation and placebo-controlled studies are needed.

Comparison of clinical and magnetic resonance imaging diagnosis in patients with disk displacement in the temporomandibular joint.

OBJECTIVE: The purpose of this study was to validate the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) for the diagnostic subgroup of disk displacement with reduction, with magnetic resonance imaging used as a gold standard. STUDY DESIGN: The diagnoses from the clinical examination of 78 joints in 39 patients, each with disk displacement with reduction in at least one TMJ, were compared with magnetic resonance imaging diagnoses. The readers of the magnetic resonance images were blinded to the clinical diagnoses. The data analysis included kappa statistics and calculation of predictive values. RESULTS: The predictive value of the RDC/TMD for disk displacement with reduction was 0.65. For disk displacement alone-the movement of the disk on opening not being considered-the predictive value was 0.92. The diagnostic agreement between RDC/TMD and magnetic resonance imaging diagnoses for all joints examined was 53.8%. Most of the disagreement was due to false negative clinical diagnoses for asymptomatic joints. CONCLUSIONS: A positive RDC/TMD examination is predictive for internal derangement but not reliable with regard to the type of disk displacement; such examination is therefore of limited value in determining the true disk position and its functional movements.

A survey of preceived oral health needs of homebound patients.

1. While almost 60 percent of all patients reported dental needs, it is assumed that actual needs were in fact considerably higher. Problems relating to dentures were the most freqeuntly expressed complaint. 2. A strong relation existed between the ability of homebound patients to get to a dentist and the time elapsed since last dental visit. Number of teeth was a significant determinant in frequency of seeking care. Persons with teeth or dentures sought treatment more often than those who were edentulous. Pain was the only variable for which a difference was noted between the two groups in the effect on time of last dental visit. 3. The study revealed an inaccessibility of dental care for the majority of patients confined to their homes. Ability to get to the dentist was identified as a major barrier to care for the homebound. The delivery of dental services to such patients in their immediate surroundings, by specially trained dental professionals using mobile units, must therefore be seriously considered as a means for improving access to care for this population.

Temporomandibular disorders: a survey of dentists' knowledge and beliefs.

General dentists and specialists likely to treat TMD were surveyed to gain information on their understanding of TMD causes, diagnosis and treatment. While the role of psychophysiologic factors in the etiology of TMD has been widely acknowledged in the practicing community, there is still a high level of controversy about the pathophysiologic aspects of TMD and appropriate diagnoses and treatment.

Identifying and treating HIV-related oral conditions: a clinical grand rounds approach.

The authors describe an innovative method for teaching dental professionals to differentially diagnose and treat HIV-related oral lesions. The method included a half day of didactic presentations and a half day of clinical grand rounds. The clinical grand rounds featured clinical stations where small groups of practitioners observed HIV oral manifestations and interacted with patients. Their observations were discussed with two dentists expert in diagnosing and managing oral complications of HIV. Videotapes of the patients' oral lesions augmented the discussions.

Oral presentation of Wegener granulomatosis.

Although the mouth is often involved in Wegener granulomatosis, oral lesions as the initial sign are rare. This case report documents the importance of considering Wegener granulomatosis in patients with unique oral lesions. The most common lesion is a friable-granular-hyperplastic gingivitis associated with alveolar resorption and tooth mobility. The disease may remain localized to the mouth for several weeks or months before multiorgan involvement occurs. Gingival enlargement is a direct manifestation of Wegener granulomatosis, and it may be pathognomonic. Failure to recognize the clinical lesions can result in delayed diagnosis and treatment, with potentially fatal results.

Clinical diagnostic criteria for TMD. New classification permits multiple diagnoses.

One of the first to permit multiple diagnoses, this new TMD classification scheme offers guidelines for clinicians and those conducting clinical field studies. The scheme was applied to a TMD population, with control subjects.

Intraligamentary anesthesia: a double-blind comparative study.

Three local anesthetic agents (Xylocaine 2%, Xylocaine 2% with epinephrine 1:50,000, and Marcaine 0.5 with epinephrine 1:200,000) were injected intraorally using an intraligamentary injection technique. The study used a double-blind design and electrical tooth pulp stimulation to examine the duration of pulpal anesthesia. Patterns of recovery from each drug, subjective discomfort associated with each drug, pain of injection, and pain in comparison with local infiltration were also measured. The extent and duration of adjacent soft tissue anesthesia were recorded. Xylocaine 2% with epinephrine 1:50,000 produced the longest pulpal anesthesia. The decay pattern of this particular drug was less abrupt than that of the two others. No difference in discomfort or pain was found across the various drugs. There was no significant difference in pain at injection when intraligamentary anesthesia was compared with local infiltration. Post-injection pain was slightly lower with local infiltration. The extent of soft tissue anesthesia was significantly related to vasoconstrictor levels in the drugs. The study shows that duration of pulpal and soft tissue anesthesia can be tightly controlled by the operator and tailored specifically to planned dental procedures.

The chemotherapeutic management of chronic and persistent orofacial pain.

The use of medication in chronic orofacial pain is not without risk. It is important to be vigilant regarding side effects, including abuse. The treatment of chronic pain can be frustrating and confusing because most patients with pain experience remissions and relapses. The initial report of reduced pain by the patient to any of the treatments that have been attempted may lead to false optimism about the nature of the condition or the potential long-term response to medication. With time the patient may report a reduced response to the medication and suggest either a higher dose or a different medication. In such patients it is important to reexamine the original differential diagnosis. When in doubt, additional consultation with pain centers, other clinicians with experience in managing patients with chronic pain, and consultation with the patient's physician may be needed. If the patient develops an abnormal personality or behavioral profile, referral to a specialist in behavioral medicine may also be needed. The treatment of chronic benign pain should proceed as planned, being careful not to place the patient in an "at-risk position" regarding medications and their effects or side effects.