Provisional restorations (Part 2).

This chapter will emphasise the need to: 1) Provide a provisional restoration following tooth preparation to protect the pulp; secure positional stability, function and aesthetics; and maintain gingival health; 2) Consider using long-term provisional restorations to assess aesthetic, occlusal and periodontal changes before embarking on definitive restorations; 3) Distinguish between preparations for conventional and adhesive restorations when providing provisional restorations; 4) Determine in advance the type of provisional restorations and materials to be used, ideally, while treatment planning; 5) Be aware of materials for making provisional restorations and how to control potential hazards; and 6) Make provisional restorations to a high standard to ensure a predictable restorative outcome.

Provisional restorations (Part 1).

This chapter will emphasise the need to: 1) Provide a provisional restoration following tooth preparation to protect the pulp; secure positional stability, function and aesthetics; and maintain gingival health; 2) Consider using long-term provisional restorations to assess aesthetic, occlusal and periodontal changes before embarking on definitive restorations; 3) Distinguish between preparations for conventional and adhesive restorations when providing provisional restorations; 4) Determine in advance the type of provisional restorations and materials to be used, ideally, while treatment planning; 5) Be aware of materials for making provisional restorations and how to control potential hazards; and 6) Make provisional restorations to a high standard to ensure a predictable restorative outcome.

Pain Part 6: Temporomandibular Disorders.

TMDs are a complex collection of conditions which can have a significant impact on an individual's quality of life. The aetiology, diagnosis and management of TMDs will be described in this article with the hope of increasing a general dental practitioner's knowledge of these problems, thus helping them to institute simple, initial, conservative therapies for such patients. Diagnosis of TMDs can be simplified by following recent published clinical diagnostic criteria such as those outlined in this article. CPD/CLINICAL RELEVANCE: Pain and functional disturbances related to TMDs are common and require simple and pragmatic interventions for most patients. After providing a diagnosis, reassure patients that they do not have a sinister disease, and explain that the condition is usually self-limiting.

OHIP-TMDs: a patient-reported outcome measure for temporomandibular disorders.

OBJECTIVES: This research aims to assess the test-retest reliability, the face, content and known groups validity, and responsiveness to change, of OHIP-TMDs, a 22-item TMDs-specific version of the Oral Health Impact Profile (OHIP). METHODS: Test-retest reliability - A group of patients with TMDs (n = 20) was administered OHIP-TMDs twice before initial consultation with a 2-week interval. Face and content validity - Content validity index assessments were undertaken with professionals and patients. Known groups validity - Participants (n = 76) with confirmed Axis 1 RDC/TMD diagnoses completed OHIP-TMDs prior to TMDs treatment. Their responses were compared, using inferential statistics, with those of age- and gender-matched controls. Responsiveness to change - Using the same 76 participants, a comparison was made of OHIP-TMDs with OHIP-49 (order of administration randomized) both at baseline and 3 months after starting treatment. RESULTS: OHIP-TMDs showed good test-retest reliability ICC [2,1] 0.805 (95% CI: 0.565, 0.918); good face and content validity; significant differences (P < 0.001) between controls and participants demonstrating known groups validity. Its responsiveness to change was similar to OHIP-49. CONCLUSIONS: OHIP-TMDs is an appropriate biopsychosocial, patient-centred, outcome measure for assessing QOL in patients with TMDs. It is less than half the length of OHIP-49 and contains proportionately more items relevant to TMDs.

Does the mode of administration of the Oral Health Impact Profile-49 affect the outcome score?

OBJECTIVE: To determine if there are differences in outcome scores if the Oral Health Impact Profile-49 (OHIP-49) is delivered by two different modes of administration (manual-self complete versus telephone interview). METHODS: Patients with chronic periodontitis (n=83, 54% females and 46% males, mean age 49.1±9.5 years) completed the OHIP-49 using two modes of administration (manual self-complete and telephone interview) in a randomly assigned order, with a minimum washout period of 2 weeks between modes, both episodes occurring prior to any periodontal treatment being provided. To assess convergent validity, after each mode of administration, the patients were additionally asked a global question about their oral health-related quality of life (OHRQoL). RESULTS: Median OHIP-49 scores recorded by manual self-complete (median 36 [IQR=20-70]) were significantly higher than those recorded by telephone interview (median 27 [IQR=11-61]) (p<0.01). The global question was well correlated to the OHIP domains, but did not reveal any evidence of an order effect such as was seen with OHIP-49 itself (which showed a higher impact on OHRQoL during the first administration in either mode). CONCLUSIONS: The mode of administration (manual-self complete versus telephone interview) did substantially influence the OHIP-49 scores in patients with chronic periodontitis. The OHRQoL differed between the two modes of administration, with significantly higher scores (indicating poorer OHRQoL) when the questionnaire was manually self-completed. CLINICAL SIGNIFICANCE: The mode of administration of quality of life questionnaires such as OHIP-49 could potentially affect the outcome scores derived. This study investigated whether there is a difference in outcome scores if OHIP-49 is delivered via manual self-complete or by telephone interview in patients with chronic periodontitis. We found that there was a significant difference between the two modes: manual self-completion by the patients yielded significantly higher scores than completion by telephone interview. It is therefore important to be consistent in the mode of completion of OHIP-49, as mixing modes could introduce additional error into clinical studies that utilise this instrument.

The Oral Health Impact Profile: ranking of items for temporomandibular disorders.

The study aimed to rank the Oral Health Impact Profile (OHIP-49) items by relevance to temporomandibular disorders (TMD). A modified version of the OHIP-49 was completed by 110 patients with TMD and by age- and gender-matched TMD-free individuals. Patients were diagnosed using the Research Diagnostic Criteria (RDC) for TMD. The modified OHIP included a reference to the 'jaw' and a 1-month reference period. The difference in item prevalence for problems reported fairly/very often (FOVO) between the two groups was calculated for each OHIP item. The FOVO prevalence differences were ranked to reveal the most relevant problems for TMD. Patients' total OHIP scores were higher (60.6, SD = 31.6) than those of controls (17.1, SD = 18.1). Patients scored higher on all items, with 41 items showing a statistically significant difference between the patient score and the control score. The patient-control difference in FOVO item prevalence varied considerably between different items, ranging from 1 to 67%. Substantial differences were noted between patients and controls for a number of specific items, including those relating to pain and physical impact. Smaller differences across most items were also noted, even those not expected to have an impact. The OHIP provides a starting point for a measure of TMD treatment outcome, once items less attributable to TMD are excluded.

Temporomandibular disorder patients' journey through care.

UNLABELLED: Temporomandibular disorders (TMDs) are a common group of chronic disorders (illnesses) that health care providers can find difficult to diagnose and explain. Similar difficulties in the diagnosis of other chronic conditions have been shown to have a negative impact on health. An understanding of TMD patients' experiences and journey through care could indicate time points and strategies to help patients. OBJECTIVE: To develop a robust empirically derived map of TMD sufferers' journey through care. METHODS: A qualitative study using semi-structured interviews was undertaken using a purposive sample of patients with TMDs. Analysis followed the principles of the constant comparative method where data collection and thematic analysis occurred concurrently and continued until data saturation (n = 29). RESULTS: The experiences of patients could be grouped into three key stages: genesis of problem, seeking help in primary care and secondary care intervention. A wide variety of negative effects were described throughout these stages. An empirically derived map of the patients' reported journey through care emerged. CONCLUSIONS: The experiences of patients with TMDs mirror experiences of other types of chronic illness. Mapping the journey through care for TMDs highlights the potential for interaction between the stages of the journey and the individual's illness. It may be possible to target interventions at specific stages on the map to help minimize the psychosocial effects of TMDs.

The effect on cast post dimensions of casting investment and airborne particle abrasion.

Cast posts can sometimes prove difficult to seat fully during fitting. This study compared two different liquid/water dilutions for phosphate bonded investment and the effect of controlled airborne particle abrasion on resulting post diameter. After measuring polymeric post patterns (n = 18), 3 groups were invested using concentrated solution and 3 groups using dilute solution. After casting they were weighed and remeasured then exposed to airborne particle abrasion. Both solutions produced oversized cast posts. Mean diameter reduction during airborne particle abrasion was 8 microm/10s taking an average of 41s to reach precast size. Where a post pattern fits tightly, airborne particle abrasion for 70s should reduce the casting sufficiently to accommodate the cement lute.

Adapting the diagnostic definitions of the RDC/TMD to routine clinical practice: a feasibility study.

UNLABELLED: The Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) is a well-known diagnostic tool for clinical trials on TMD. OBJECTIVES: This study aims to assess the reliability, validity and feasibility of a new method of physically diagnosing temporomandibular disorders (TMD), designed for routine clinical use. This version, known as Clinical Examination Protocol-TMD (CEP-TMD), was compared to the gold standard original RDC/TMD. METHODS: A total of 49 subjects (41 referred TMD patients and 8 symptom free subjects) were examined using both RDC/TMD and CEP-TMD versions. Three examiners, with varying levels of experience in diagnosing TMD, worked in pairs. Each member of a pair saw the same patient twice, once for the RDC/TMD and once for the CEP-TMD examination. The examination order was randomized. Each patient's examinations alternated between examiners to reduce the memory effect. Examinations could yield single, multiple or no diagnosis. Kappa statistics were calculated to estimate reliability. RESULTS: There was substantial overall agreement between the CEP-TMD and the RDC/TMD (kappa=0.70). Intra-examination agreements were substantial in both RDC/TMD (kappa=0.70) and CEP-TMD (kappa=0.90). For examination and diagnosis, the CEP-TMD was almost 3 min faster than the RDC/TMD (p<0.05). CONCLUSIONS: It was concluded that the CEP-TMD's diagnosis is comparable to the RDC/TMD thus providing a convenient and intuitive approach for dentists to physically diagnose TMD in clinical practice. The well-established RDC/TMD remains the gold standard for research diagnosis of TMD.

Psychosocial profiles of diagnostic subgroups of temporomandibular disorder patients.

The purpose of the study was to examine whether patients' psychosocial profiles differ depending on if the location of pain is in the masticatory muscles, the temporomandibular joint, or both. Eligible participants were 491 consecutive patients examined according to the research diagnostic criteria for temporomandibular disorders (RDC/TMD). Among these a total of 225 adult TMD patients had at least one pain-related TMD diagnosis and were therefore included in this study and completed the multidimensional pain inventory (MPI). Patients diagnosed with myogenous pain only (n = 103), patients with joint pain only (n = 56), and patients with both (n = 66) were compared with respect to depression, somatization, jaw disability, pain intensity and chronicity, and MPI scores and profiles. The MPI profiles were analyzed using a multivariate analysis of variance and Hotelling's T(2) test. Although patients with joint pain were significantly more impaired in jaw function, no significant differences in depression, in somatization or in the 11 scales of the MPI were observed. The location of pain in TMD patients is not a major factor for the prediction of psychosocial profiles. Therefore, clinical TMD diagnoses alone form an insufficient basis for tailored behavioural or psychological management.

A method for clinically defining "improvers" in chronic pain studies.

AIMS: To test a measurement model based on clinicians' assessments of patient data that allows simple and confident clinical validation of any statistical or numerical technique designed to separate patients improving with treatment from those who are not, particularly for pain that shows large daily variation. METHODS: Diaries using daily visual analog scales (VAS) of pain intensity were obtained from 39 patients treated for chronic temporomandibular disorders. Three experienced clinicians visually assessed 39 VAS/time graphs. Criteria indicating improvement (general trend, height and apparent frequency of graph spikes) evolved over 3 assessments. The third assessment defined improvers visually. Numeric analyses considered the difference between first and last months of treatment for mean, area under the curve (AUC), and maximum VAS scores. Thresholds of 40%, 50%, or 60% pain reduction defined improvement numerically. Aggregate sensitivity and specificity was compared with visual definition to find the optimal threshold. RESULTS: Patients were defined visually as improvers, nonimprovers, and borderline cases. Interexaminer reliability for identifying improvers was good (k = 0.79). Mean VAS and AUC were highly correlated (r = 0.999). The optimal threshold of mean and maximum VAS relative to visual definition was 50% pain reduction. Cases defined as improvers by both mean and maximum agreed best with the visual definition (sensitivity 90%, specificity 84%). CONCLUSION: Visual assessment of VAS demonstrates distinct pain/time patterns that can validate numeric definition of complex pain recovery. No single numeric method can be guaranteed to give a clinically valid outcome.

How to make a well-fitting stabilization splint.

UNLABELLED: This article demonstrates a clinical step-by-step approach to constructing stabilization splints. These splints can be invaluable for many restorative procedures and for TMD management. To help the busy practitioner, we have included tips on trouble shooting problems encountered during splint fitting. CLINICAL RELEVANCE: Knowledge of how to make a stabilization splint is a welcome addition to the dental practitioner's armamentarium.

Functional and psychosocial impact related to specific temporomandibular disorder diagnoses.

OBJECTIVES: Comparing the level of impaired oral health-related quality of life (OHRQoL) in patients with a specific temporomandibular disorder (TMD) diagnosis to general population subjects unaffected by TMD to derive the unique functional and psychosocial impact due to TMD. METHODS: A sample of 471 consecutive treatment seeking adult patients with at least one physical (axis I) TMD diagnosis according to the research diagnostic criteria for temporomandibular disorders (RDC/TMD) was included in this study. OHRQoL was measured using the oral health impact profile (OHIP). To derive functional and psychosocial impact due to TMD mean OHIP scores were calculated from adult subjects of a regional population sample without any RDC/TMD axis I diagnosis (N=135) from which a subgroup without any sign/symptom according to the Helkimo-index (N=35) was derived. These means were subtracted from mean OHIP scores of the TMD patients. RESULTS: All TMD patients with a single axis I diagnosis presented much higher impaired OHRQoL (OHIP means: 27.5-56.2) compared to general population subjects (9.7 in subjects without any TMD sign/symptom and 14.8 in those without RDC/TMD axis I diagnosis). Group I diagnosis (myofascial pain) showed the highest OHRQoL impact with the lowest in patients with group II diagnosis (disc displacement). Patients with two pain-related diagnoses had significantly higher impaired OHRQoL than patients with a single one (58.9 versus 49.2, p=0.03). CONCLUSIONS: All TMD axis I diagnoses have significant impact on OHRQoL. Subjects with pain-associated conditions present higher scores than those without pain. Patients with two pain-related diagnoses have more impaired OHRQoL than subjects with one diagnosis.

Developments in denture teeth to prevent softening by food solvents.

The effect of various food-simulating solvents on the hardness of denture teeth after varying storage times, using a Martens hardness test was determined. Martens hardness (HM) was assessed at baseline and during storage up to 1 month in distilled water (DW), peppermint oil (PO), heptane (HT) and 75% ethanol (ET) for four commercially-available denture teeth; Vivodent (VIV), Double-cross-linked Postaris (DCL), Orthosit (ORT), Candulor porcelain (POR) and two polymer based experimental denture teeth: Experimental 1 (EXP1); a hybrid nanocomposite with two different sized silanated filler particles and Experimental 2 (EXP2); containing an organic copolymer based upon urethanedimethacrylate and polymethyl methacrylate. Hardness [mean (sd)] at baseline was: VIV 142 (1), DCL 142 (1), ORT 209 (9), POR 2926 (101), EXP1 285 (11), and EXP2 146 (12). One-way ANOVA using Tukey's test on polymer-based materials showed that the hardness values of ORT and EXP1 were significantly higher than those of VIV, DCL and EXP2 (P < 0.05). Moreover, EXP1 had a significantly higher hardness value than ORT (P < 0.05). Except for EXP1, all polymer based materials showed a significant drop in hardness after storage in ET (P < 0.05). Specimens stored in water, heptane and peppermint oil showed minor fluctuations in hardness, which were not statistically significant.

Oral health-related quality of life in patients with temporomandibular disorders.

AIMS: To characterize the level of impairment of oral health-related quality of life (OHRQoL) in a temporomandibular disorder (TMD) patient population. METHODS: OHRQoL was measured using the German version of the Oral Health Impact Profile (OHIP-G) in a consecutive sample of 416 patients seeking treatment for their complaints in the masticatory muscles and temporomandibular joints and with at least 1 diagnosis according to the German version of the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). The level of impairment of OHRQoL was characterized by the OHIP summary score mean and its 95% confidence interval. OHRQoL was described for each of the 8 RDC/TMD diagnoses (Axis I) and the RDC/TMD Axis II measures (Graded Chronic Pain Scale [GCPS], jaw disability list, depression, and somatization). These findings were compared with the level of impairment of OHRQoL in the adult general population derived from a national sample (n = 2,026). RESULTS: Among the RDC/TMD Axis I measures, all diagnoses were correlated with much higher impacts compared to the normal population (means for all diagnoses were 32.8 to 53.7 versus 15.8 in the general population). All diagnoses had a similar level of impact except for disc displacement with reduction (which had a lower impact). There were larger differences in mean OHIP-G scores among subgroups of RDC/TMD Axis II measures than among subgroups of RDC/TMD Axis I characteristics. The strongest association was with GCPS, with mean OHIP scores of 33.3 for grade I, 48.1 for grade II, 71.7 for grade III, and 88.5 for grade IV. CONCLUSION: OHRQoL was markedly impaired in TMD patients. The level of OHRQoL varied across diagnostic categories but more across Axis II, ie, the psychosocial axis; the variation was reflected especially in their level of graded chronic pain.

Hardness measured with traditional Vickers and Martens hardness methods.

OBJECTIVE: To determine the differences, if any, between hardness measured with traditional Vickers and Martens hardness test methods on denture teeth under 2, 10 and 50 N loads. METHOD: Hardness of acrylic resin (VIV), composite resin (ORT) and porcelain (POR) denture tooth materials was measured using a traditional Vickers hardness (HV) method and Martens hardness (HM) method at 2, 10 and 50N test loads. Vickers hardness was also calculated from the force-indentation depth curves (HVfid) that were recorded during Martens hardness. Indentation creep of the three test materials was also determined during Martens hardness testing. RESULTS: HM values were the same irrespective of the test force used. However, HV values were different for the three test forces. ANOVA using Tukey's test of the HM data showed that the hardness of POR was significantly higher than VIV or ORT (P<0.001). Moreover, ORT had a significantly higher hardness than VIV (P<0.001). The statistical analysis of HVfid data showed similar results. ANOVA of the HV data showed the hardness of VIV to be significantly higher than ORT (P<0.001) under 2, 10 and 50 N test load. The HV values for POR under 2 and 10 N test load could not be calculated because of inability to measure the indentation diagonals. Under the 50 N load, the hardness of POR was significantly higher than VIV and ORT. POR had a significantly lower creep value than any other material tested while VIV showed a statistically significantly higher creep than ORT. SIGNIFICANCE: This study confirms that the visco-elastic recovery of the materials has a very significant effect on the outcome of the hardness tests of denture teeth and the Martens hardness test method has obvious advantages when testing dental materials.

The treatment of temporomandibular disorders with stabilizing splints in general dental practice: one-year follow-up.

BACKGROUND: The authors evaluated temporomandibular disorder (TMD) outcomes in general dental practice one year after treatment with stabilizing splints (SS) or nonoccluding control splints (CS). METHODS: Seventy-two randomly allocated subjects completed initial treatment. The outcomes measures were a pain visual analog scale (VAS), muscle tenderness, temporomandibular joint (TMJ) tenderness, interincisal opening, TMJ clicks and headaches. After initial treatment, 81 percent of the subjects were found to have been treated satisfactorily. The dentists referred the remaining subjects to a dental hospital. At one year, the authors recalled 52 of the original subjects for evaluation. RESULTS: Improvements after initial treatment were maintained at one year for all outcomes, except for TMJ clicking, which returned to pretreatment levels. Eighty-one percent of the subjects rated their treatment as either good or excellent in reducing jaw pain. The authors found that subjects were aware of more of their TMJ clicks than dentists observed at the one-year clinical examination, but most subjects thought their clicking or the associated pain had been reduced. Fifty-five percent subjects had used their splints in the previous six months, but only 31 percent of these had done so daily. There were no significant differences between splint groups. CONCLUSION: At one year, a good response to TMD treatment in general practice had been maintained, but many subjects still had clicking TMJs. CLINICAL IMPLICATIONS: Trained dentists can manage TMD satisfactorily, with only a small proportion of patients needing specialist attention.