Occurrence and Predictors of Postoperative Preauricular and Masticatory Muscle Pain Symptoms After Surgical Removal of Third Molars: A Single-Blind Randomized Controlled Trial Comparing Dental Assistants Supporting the Mandible and the Restful Jaw Device.

BACKGROUND: During third molar removal, the mandible is supported by a dental assistant (DA) to counter downward forces during surgery, and with sedation, to maintain airway patency. The Restful Jaw device (PEP Design; Saint Paul) provides this support instead of the DA. PURPOSE: This study compared the occurrence of postoperative preauricular and masticatory muscle pain symptoms (PMMPS) between the device and DAs providing mandibular support, using two outcome measures. Secondary aims identify predictors of outcome and providers' opinions of the device. STUDY DESIGN, SETTING, SAMPLE: In this multisite, single-blind, two-arm parallel randomized trial, participants without preoperative PMMPS had surgical removal of third molars, with sedation and bite blocks were randomly assigned to manual support or the device. EXPOSURE VARIABLE: The exposed group was randomly assigned to the device and the nonexposed group to manual support. MAIN OUTCOME VARIABLE(S): The primary outcome was patient-reported PMMPS. Two secondary outcomes were pain assessed with the temporomandibular disorder Pain Screener and providers' views on the device. Outcomes were assessed at 1-, 3-, and 6-month postsurgery. COVARIATES: The covariates are baseline demographics (eg, sex), clinical characteristics (eg, eruption status), and third molar surgeries. ANALYSES: For occurrence of pain, generalized estimating equations assessed differences between groups. Logistic regression analysis assessed predictors of pain at 1 month, per the Screener. The level for statistical significance was 5%. RESULTS: Enrollment was 86 and 83 participants in the device and DA groups, respectively. The average age was 20.8 years; the majority were female (65%) and Caucasian (66%). The retention rate was ≥95.9%. The groups did not differ significantly for occurrence of pain using the primary and secondary outcome measures at any follow-up (P ≥ .46). Fully impacted molars were associated with occurrence of pain (odds ratio = 3.44; 95% confidence interval 1.49-7.92; P = .004). CONCLUSION AND RELEVANCE: Occurrence of pain using the primary and secondary outcome measures did not differ significantly between groups at any follow-up and was associated with removal of fully impacted third molars. Four out of five surgeons reported wanting to use the device on a regular basis when performing this procedure in sedated patients.

Acute and Chronic Temporomandibular Disorder Pain: A critical review of differentiating factors and predictors of acute to chronic pain transition.

AIMS: The aims of this critical review were to: (i) assess the factors that differentiate acute from chronic temporomandibular disorders (TMD) pain; (ii) assess the risk factors associated with the transition from acute to chronic TMD pain; and (iii) summarize and appraise the studies. METHOD: The databases used were MEDLINE, Embase, and Cochrane Database of Systematic Reviews. Eligible studies included articles comparing acute to chronic TMD pain, and cohort studies assessing the risk factors implicated in the transition from acute to chronic TMD pain. RESULTS: Seven articles were selected: one case-control study, three cross-sectional studies, and three cohort studies. These studies found that psychological factors were more common in chronic than acute TMD pain patients; however, these factors did not increase the transition risk in the multivariable model. Myofascial and baseline pain intensity were associated with the transition from acute to chronic TMD pain at a 6-month follow-up. Due to methodological weaknesses in the available literature, more research is required to establish the risk factors implicated in the transition from acute to chronic TMD pain. CONCLUSION: This review found some evidence that myofascial pain is associated with the transition risk from acute to chronic TMD pain at a 6-month follow-up and that pain intensity at baseline is associated with more intense TMD pain 6 months later. There is insufficient evidence to draw conclusions about the role of demographics and psychological disorders as independent risk factors.

Diagnostic accuracy of panoramic radiography and MRI for detecting signs of TMJ degenerative joint disease.

The objective of this study was to determine the diagnostic accuracy of panoramic radiography and magnetic resonance imaging (MRI) for detection of signs of temporomandibular joint (TMJ) degenerative joint disease (DJD). Panoramic radiography and bilateral MRI and computed tomography (CT) of the TMJs were performed for 705 subjects. Three calibrated board-certified radiologists who were blinded to the clinical findings interpreted all images. The diagnoses of DJD established using the panoramic radiographs and MRIs were compared to the reference standard diagnoses derived from the CTs. DJD was defined as the presence of at least 1 of the following 4 signs: a subcortical cyst, surface erosion, osteophyte formation, or generalized sclerosis. The target values for sensitivity and specificity were 70% or greater and 95% or greater, respectively. Compared to the reference standard CTs, the panoramic radiographs had the following sensitivity and specificity values: subcortical cysts, 14% and 100%, respectively; erosion, 20% and 100%, respectively; osteophytes, 12% and 100%, respectively; and sclerosis, 33% and 100%, respectively. The MRIs achieved the following sensitivity and specificity values: subcortical cysts, 32% and 100% respectively; erosion, 35% and 99% respectively; osteophytes, 71% and 98%, respectively; and sclerosis, 50% and 100%, respectively. The radiologists' interexaminer reliability was slight (κ = 0.16) when using panoramic radiographs, moderate (κ = 0.47) when using MRIs, and substantial when using CTs (κ = 0.71) for diagnosis of signs of DJD. Panoramic radiographs and MRIs had below-target sensitivity but above-target specificity in detecting all CT-depicted signs of DJD with the exception of osteophytes, for which MRIs demonstrated adequate diagnostic accuracy. Use of CT for diagnosis of TMJ DJD is recommended to avoid the false-negative findings that can occur if panoramic radiographs and MRIs are used.

Exploration of dimensionality and psychometric properties of the Pittsburgh Sleep Quality Index in cases with temporomandibular disorders.

BACKGROUND: This study assessed the dimensional structure of sleep quality with the Pittsburgh Sleep Quality Index (PSQI) and investigated its psychometric properties in cases with temporomandibular disorders (TMD). METHODS: A convenience sample of 609 TMD cases (age: 37.1 ± 13.1 yrs, 18-67 yrs, 85% female) of the multi-center Validation Project meeting Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) and with sufficient PSQI data were included in this study. To investigate PSQI scores' dimensionality, exploratory factor analysis was used. Factors were identified using the Scree plot. To investigate internal consistency, Cronbach's alpha was calculated. Analyses were separately performed for TMD cases with (N = 496) and TMD cases withouta pain-related diagnosis (N = 113). RESULTS: The mean PSQI score for all TMD cases was 7.1 ± 4.0 units, range: 0-19. The exploratory factor analysis identified one factor for cases with at least one pain-related TMD diagnosis as well as one factor for cases with a pain-free TMD diagnosis that explained 41% of the variance in cases with pain-related TMD and 37% in cases with pain-free TMD. Internal consistency for PSQI scores was alpha of 0.75 in cases with pain-related TMD, alpha of 0.66 in cases with pain-free TMD and alpha = 0.75 for all TMD cases. CONCLUSIONS: Sleep quality in TMD patients is a unidimensional construct and can therefore be represented by one summary score; a finding that is in line with previous reports in TMD patients.

A Controlled Study of Biopsychosocial Differences Observed in Masticatory Myalgia With and Without Pain Referral.

AIMS: To assess differences in biopsychosocial factors between participants with masticatory myofascial pain with referral (MFPwR), with myalgia without referral (Mw/oR), and community controls without TMDs. METHODS: Study participants were diagnosed with MFPwR (n = 196), Mw/oR (n = 299), or as a non-TMD community control (n = 87) by two calibrated examiners at each of three study sites. Pain chronicity, pain on palpation of masticatory muscle sites, and pressure pain thresholds (PPT) at 12 masticatory muscle, 2 trigeminal, and 2 nontrigeminal control sites were recorded. Psychosocial factors assessed included anxiety, depression, and nonspecific physical symptoms (Symptom Checklist-90 Revised); stress (Perceived Stress Scale); and health-related quality of life (Short Form Health Survey). Comparisons among the three groups were adjusted for age, sex, race, education, and income using multivariable linear regression. The significance threshold was set at P = .017 (.05 / 3) for subsequent pairwise comparisons. RESULTS: Compared to the Mw/oR group, the MFPwR group had significantly greater pain chronicity, number of painful muscle sites, anxiety, depression, nonspecific physical symptoms, and impaired physical health (P < .017). The MFPwR group also had significantly lower PPTs for masticatory sites (P < .017). Both muscle pain groups differed significantly from the non-TMD community control group for all outcome measures (P < .017). CONCLUSION: These findings support the clinical utility of separating MFPwR from Mw/oR. Patients with MFPwR are more complex from a biopsychosocial perspective than Mw/oR patients, which likely affects prognosis and supports consideration of these factors in case management.

Practitioner/Practice- and Patient-Based Factors Contributing to Dental Practitioner Treatment Recommendations for Patients with Pain-Related TMDs: Findings from the National Dental PBRN.

AIMS: To document National Dental Practice-Based Research Network (PBRN) practitioner treatment recommendations for patients with painful temporomandibular disorders (TMDs) and to identify practitioner/practice- and patient-related factors contributing to treatment recommendations made at the initial clinical visit. METHODS: This prospective single-sample cohort study formed groups based on treatment recommendations made by 185 dental practitioners who treated 1,901 patients with painful TMDs. At the baseline visit, which this article describes, practitioners provided patients with their diagnoses and a treatment plan and then completed a comprehensive questionnaire. RESULTS: Self-care, an intraoral appliance, medication, and practitioner-recommended jaw exercises were the most frequently recommended treatments. Practitioners recommended multiple treatments to most patients. TMD signs, symptoms, and diagnoses were primary considerations in treatment planning, but the practitioner's expectations for improvement were only significant for intraoral appliances and self-care. Female practitioners and those with expertise in TMDs more frequently recommended patient-directed and multidisciplinary treatments compared to their counterparts. CONCLUSIONS: Practitioners used a wide range of treatments for patients with few consistent patterns. The propensity to use TMD signs, symptoms, and diagnoses when making treatment recommendations suggests a tendency to conceptualize patients using the biomedical model. Infrequent referral to nondental providers suggests a lack of availability of these providers, a misunderstanding of the complexity of TMDs, and/or discomfort with assessment of psychosocial factors. Implications include the need for comprehensive training in the assessment and management of TMD patients during dental school and participation in TMD continuing education courses following evidence-based guidelines.

Diagnostic criteria for headache attributed to temporomandibular disorders.

AIMS: We assessed and compared the diagnostic accuracy of two sets of diagnostic criteria for headache secondary to temporomandibular disorders (TMD). METHODS: In 373 headache subjects with TMD, a TMD headache reference standard was defined as: self-reported temple headache, consensus diagnosis of painful TMD and replication of the temple headache using TMD-based provocation tests. Revised diagnostic criteria for Headache attributed to TMD were selected using the RPART (recursive partitioning and regression trees) procedure, and refined in half of the data set. Using the remaining half of the data, the diagnostic accuracy of the revised criteria was compared to that of the International Headache Society's International Classification of Headache Diseases (ICHD)-II criteria A to C for Headache or facial pain attributed to temporomandibular joint (TMJ) disorder. RESULTS: Relative to the TMD headache reference standard, ICHD-II criteria showed sensitivity of 84% and specificity of 33%. The revised criteria for Headache attributed to TMD had sensitivity of 89% with improved specificity of 87% (p < 0.001). These criteria are (1) temple area headache that is changed with jaw movement, function or parafunction and (2) provocation of that headache by temporalis muscle palpation or jaw movement. CONCLUSION: Having significantly better specificity than the ICHD-II criteria A to C, the revised criteria are recommended to diagnose headache secondary to TMD.

Influence of temple headache frequency on physical functioning and emotional functioning in subjects with temporomandibular disorder pain.

AIMS: To investigate the relationship of headache frequency with patient-reported physical functioning and emotional functioning in temporomandibular disorder (TMD) subjects with concurrent temple headache. METHODS: The Research Diagnostic Criteria for TMD (RDC/TMD) Validation Project identified, as a subset of 614 TMD cases and 91 controls (n = 705), 309 subjects with concurrent TMD pain diagnoses (RDC/TMD) and temple headache. The temple headaches were subdivided into infrequent, frequent, and chronic headache according to the International Classification of Headache Disorders, second edition (ICHD-II). Study variables included self-report measures of physical functioning (Jaw Function Limitation Scale [JFLS], Graded Chronic Pain Scale [GCPS], Short Form-12 [SF-12]) and emotional functioning (depression and anxiety as measured by the Symptom Checklist-90R/SCL-90R). Differences among the three headache subgroups were characterized by increasing headache frequency. The relationship between ordered headache frequency and physical as well as emotional functioning was analyzed using linear regression and trend tests for proportions. RESULTS: Physical functioning, as assessed with the JFLS (P < .001), SF-12 (P < .001), and GCPS (P < .001), was significantly associated with increased headache frequency. Emotional functioning, reflected in depression and anxiety, was also associated with increased frequency of headache (both P < .001). CONCLUSION: Headache frequency was substantially correlated with reduced physical functioning and emotional functioning in subjects with TMD and concurrent temple headaches. A secondary finding was that headache was precipitated by jaw activities more often in subjects with more frequent temple headaches.

Fear of Movement and Catastrophizing in Participants with Temporomandibular Disorders.

AIMS: To assess differences in catastrophizing and kinesiophobia in relation to areas of pain and somatic symptoms among participants with temporomandibular disorders (TMDs) and controls. METHODS: In total, 401 participants (333 women, 68 men, mean age: 45.8 years) in the TMJ Impact Project were examined in accordance with the Diagnostic Criteria for TMD, including clinical examination (Axis I) and psychosocial assessment (Axis II) augmented with imaging of the temporomandibular joint (TMJ). Of these, 218 participants had a painful TMD pain diagnosis, 63 had a nonpainful TMD diagnosis, and 111 had no TMD. Nine participants had missing data. Participants completed the Pain Catastrophizing Scale, Tampa Scale for Kinesiophobia, Areas of Pain figure, and the Patient Health Questionnaire-15 for assessing somatic symptoms. RESULTS: Compared to controls, participants with TMD pain showed higher levels of catastrophizing (P = .017), kinesiophobia (P < .001), areas of pain (P < .001), and somatic symptoms (P < .001). Participants with nonpainful TMD showed a higher level of kinesiophobia (P < .001) than controls. There was a positive correlation between catastrophizing and kinesiophobia for participants with TMD pain (r = 0.33, P < .001) and nonpainful TMD (r = 0.42, P < .001). DISCUSSION: The results suggest more fear of movement, as well as an association between catastrophizing and fear of movement, in participants with TMD pain and in participants with nonpainful TMD compared to controls. Assessment and management of fear of movement as well as catastrophizing may be useful as part of individualized treatment strategies for patients with TMD.

Management of painful temporomandibular disorders: Methods and overview of The National Dental Practice-Based Research Network prospective cohort study.

BACKGROUND: Patients often seek consultation with dentists for temporomandibular disorders (TMDs). The objectives of this article were to describe the methods of a large prospective cohort study of painful TMD management, practitioners' and patients' characteristics, and practitioners' initial treatment recommendations conducted by The National Dental Practice-Based Research Network (the "network"). METHODS: Participating dentists recruited into this study treated patients seeking treatment for painful TMDs. The authors developed self-report instruments based on well-accepted instruments. The authors collected demographics, biopsychosocial characteristics, TMD symptoms, diagnoses, treatments, treatment adherence, and painful TMDs and jaw function outcomes through 6 months. RESULTS: Participating dentists were predominately White (76.8%) and male (62.2%), had a mean age of 52 years, and were general practitioners (73.5%) with 23.8% having completed an orofacial pain residency. Of the 1,901 patients with painful TMDs recruited, the predominant demographics were White (84.3%) and female (83.3%). Patients' mean age was 44 years, 88.8% self-reported good to excellent health, and 85.9% had education beyond high school. Eighty-two percent had pain or stiffness of the jaw on awakening, and 40.3% had low-intensity pain. The most frequent diagnoses were myalgia (72.4%) and headache attributed to TMDs (51.0%). Self-care instruction (89.4%), intraoral appliances (75.4%), and medications (57.6%) were recommended frequently. CONCLUSIONS: The characteristics of this TMD cohort include those typical of US patients with painful TMDs. Network practitioners typically managed TMDs using conservative treatments. PRACTICAL IMPLICATIONS: This study provides credible data regarding painful TMDs and TMD management provided by network practitioners across the United States. Knowledge acquired of treatment recommendations and patient reports may support future research and improve dental school curricula.

Septic arthritis associated with closed intra-articular fracture: a case series.

BACKGROUND: Osteomyelitis in the setting of closed fractures is a recognized association in the literature, but to our knowledge, septic arthritis after a closed intra-articular fracture has not yet been reported. METHODS: We conducted a retrospective review of 3 cases of septic arthritis after closed intra-articular fractures of the proximal phalanx of the great toe, distal tibia, and distal humerus. RESULTS: The patients presented with fever, erythema, pain, and elevated infectious indices. All patients had a delay in diagnosis of up to 10 days. On diagnosis, all patients underwent open irrigation and debridement and were treated with organism-specific antibiotics for Staphylococcus aureus or Streptococcus pneumoniae. One patient required metatarsophalangeal joint arthrodesis, whereas the other 2 patients returned to full function after a prolonged treatment course. CONCLUSIONS: Septic arthritis after closed intra-articular fracture is a rare clinical condition and requires prompt diagnosis and treatment. LEVEL OF EVIDENCE: Level IV.

The Research Diagnostic Criteria for Temporomandibular Disorders. I: overview and methodology for assessment of validity.

AIMS: The purpose of the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Validation Project was to assess the diagnostic validity of this examination protocol. The aim of this article is to provide an overview of the project's methodology, descriptive statistics, and data for the study participant sample. This article also details the development of reliable methods to establish the reference standards for assessing criterion validity of the Axis I RDC/TMD diagnoses. METHODS: The Axis I reference standards were based on the consensus of two criterion examiners independently performing a comprehensive history, clinical examination, and evaluation of imaging. Intersite reliability was assessed annually for criterion examiners and radiologists. Criterion examination reliability was also assessed within study sites. RESULTS: Study participant demographics were comparable to those of participants in previous studies using the RDC/TMD. Diagnostic agreement of the criterion examiners with each other and with the consensus-based reference standards was excellent with all kappas > or = 0.81, except for osteoarthrosis (moderate agreement, k = 0.53). Intrasite criterion examiner agreement with reference standards was excellent (k > or = 0.95). Intersite reliability of the radiologists for detecting computed tomography-disclosed osteoarthrosis and magnetic resonance imaging-disclosed disc displacement was good to excellent (k = 0.71 and 0.84, respectively). CONCLUSION: The Validation Project study population was appropriate for assessing the reliability and validity of the RDC/TMD Axis I and II. The reference standards used to assess the validity of Axis I TMD were based on reliable and clinically credible methods.

The Research Diagnostic Criteria for Temporomandibular Disorders. VI: future directions.

The Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Validation Project has provided the first comprehensive assessment of reliability and validity of the original Axis I and II. In addition, Axis I of the RDC/TMD was revised with estimates of reliability and validity. These findings are reported in the five preceding articles in this series. The aim of this article is to present further revisions of Axis I and II for consideration by the TMD research and clinical communities. Potential Axis I revisions include addressing concerns with orofacial pain differential diagnosis and changes in nomenclature in an attempt to provide improved consistency with other musculoskeletal diagnostic systems. In addition, expansion of the RDC/TMD to include the less common TMD conditions and disorders would make it more comprehensive and clinically useful. The original standards for diagnostic sensitivity ( < or = 0.70) and specificity (< or = 0.95) should be reconsidered to reflect changes in the field since the RDC/TMD was published in 1992. Pertaining to Axis II, current recommendations for all chronic pain conditions include standardized instruments and expansion of the domains assessed. In addition, there is need for improved clinical efficiency of Axis II instruments and for exploring methods to better integrate Axis I and II in clinical settings.

The Research Diagnostic Criteria for Temporomandibular Disorders. IV: evaluation of psychometric properties of the Axis II measures.

AIMS: To evaluate the psychometric properties of the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) biobehavioral (Axis II) screening instruments. METHODS: Participants with Axis I TMD diagnoses (n = 626) completed the Axis II instruments (Depression, Nonspecific Physical Symptoms, Graded Chronic Pain) and other instruments assessing psychological distress, pain, and disability at three study sites. Internal consistency, temporal stability, and convergent/discriminant validity of the Axis II measures were assessed. To assess criterion validity of Nonspecific Physical Symptoms and Depression instruments as screeners, 170 participants completed a structured psychiatric diagnostic interview. RESULTS: The Axis II instruments showed very good to excellent internal consistency (Cronbach's alpha coefficients = 0.80 to 0.95). Their convergent (correlation range 0.3 to 0.9) and discriminant (range 0.0 to 0.6) validity were generally supported, although Nonspecific Physical Symptoms was more strongly associated with depressive than with somatic symptoms. Temporal stability was high for characteristic pain intensity (Lin's correlation concordance coefficient [CCC] = 0.91), interference (CCC = 0.89), and chronic pain grade (weighted kappa = 0.87), and fair to good for Depression and Nonspecific Physical Symptoms (CCC = 0.63 to 0.78). The Depression instrument normal versus moderate to severe cutoff point was good at identifying current-year depression and dysthymia diagnoses (sensitivity 87%, specificity 53%). Nonspecific Physical Symptoms did not have high utility for detecting psychiatric disorders (sensitivity 86%, specificity 31%). CONCLUSION: The Axis-II Depression and Graded Chronic Pain instruments have clinically relevant and acceptable psychometric properties for reliability and validity and utility as instruments for identifying TMD patients with high levels of distress, pain, and disability that can interfere with treatment response and course of Axis I disorders.

Critical appraisal of methods used in randomized controlled trials of treatments for temporomandibular disorders.

AIMS: To evaluate the quality of methods used in randomized controlled trials (RCTs) of treatments for management of pain and dysfunction associated with temporomandibular muscle and joint disorders (TMJD) and to discuss the implications for future RCTs. METHODS: A systematic review was made of RCTs that were implemented from 1966 through March 2006, to evaluate six types of treatments for TMJD: orthopedic appliances, occlusal therapy, physical medicine modalities, pharmacologic therapy, cognitive-behavioral and psychological therapy, and temporomandibular joint surgery. A quality assessment of 210 published RCTs assessing the internal and external validity of these RCTs was conducted using the Consolidated Standards of Reporting Trials (CONSORT) criteria adapted to the methods of the studies. RESULTS: Independent assessments by raters demonstrated consistency with a mean intraclass correlation coefficient of 0.63 (95% confidence interval). The mean percent of criteria met was 58%, with only 10% of the RCTs meeting the four most important criteria. CONCLUSIONS: Much of the evidence base for TMJD treatments may be susceptible to systematic bias and most past studies should be interpreted with caution. However, a scatter plot of RCT quality versus year of publication shows improvement in RCT quality over time, suggesting that future studies may continue to improve methods that minimize bias.

The Research Diagnostic Criteria for Temporomandibular Disorders. V: methods used to establish and validate revised Axis I diagnostic algorithms.

AIMS: To derive reliable and valid revised Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis I diagnostic algorithms for clinical TMD diagnoses. METHODS: The multisite RDC/TMD Validation Project's dataset (614 TMD community and clinic cases, and 91 controls) was used to derive revised algorithms for Axis I TMD diagnoses. Validity of diagnostic algorithms was assessed relative to reference standards, the latter based on consensus diagnoses rendered by two TMD experts using criterion examination data, including temporomandibular joint imaging. Cutoff points for target validity were sensitivity > or = 0.70 and specificity > or = 0.95. Reliability of revised algorithms was assessed in 27 study participants. RESULTS: Revised algorithm sensitivity and specificity exceeded the target levels for myofascial pain (0.82, 0.99, respectively) and myofascial pain with limited opening (0.93, 0.97). Combining diagnoses for any myofascial pain showed sensitivity of 0.91 and specificity of 1.00. For joint pain, target sensitivity and specificity were observed (0.92, 0.96) when arthralgia and osteoarthritis were combined as "any joint pain." Disc displacement without reduction with limited opening demonstrated target sensitivity and specificity (0.80, 0.97). For the other disc displacement diagnoses, osteoarthritis and osteoarthrosis, sensitivity was below target (0.35 to 0.53), and specificity ranged from 0.80 to meeting target. Kappa for revised algorithm diagnostic reliability was > or =0.63. CONCLUSION: Revised RDC/TMD Axis I TMD diagnostic algorithms are recommended for myofascial pain and joint pain as reliable and valid. However, revised clinical criteria alone, without recourse to imaging, are inadequate for valid diagnosis of two of the three disc displacements as well as osteoarthritis and osteoarthrosis.

A cross-sectional study of temporomandibular joint coronal plane disk position: imaging reliability and clinical utility.

OBJECTIVES: The aim of this study was to assess the reliability, frequency, and clinical significance of temporomandibular joint (TMJ) medial and lateral disk positions, observed in the coronal-oblique plane, to determine their importance in clinical diagnosis and for routine imaging. STUDY DESIGN: This cross-sectional study involved secondary data analysis (clinical and imaging) of 401 participants of the TMJ Impact Study. We used the χ2 statistic to evaluate the associations between coronal disk positions with (1) anterior disk displacements with reduction and without reduction; and (2) familiar TMJ pain resulting from excursive movements and palpation, range of motion, and joint sounds. RESULTS: Anterior disk displacements of any type occurred in 67.5% of joints; in contrast, medial and lateral disk positions occurred in 16% and 24% of joints, respectively. Radiologist reliability was as follows: sagittal posterior band position: right κ = 0.68, left κ = 0.60, average 84% agreement; and medial or lateral disk position: right κ = 0.36, left κ = 0.32, average 70% agreement. Medial and lateral disk positions were associated with sagittal displacements (P < .001). However, there were no associations between medial and lateral disk positions and familiar pain, range of motion, and joint sounds. CONCLUSIONS: Coronal disk position does not contribute to clinical symptomatology or findings and currently lacks sufficient evidence to support its inclusion into standard TMJ imaging protocols or into a clinical diagnostic category.

Electric toothbrush application is a reliable and valid test for differentiating temporomandibular disorders pain patients from controls.

BACKGROUND: Current methods for identifying patients with pain hypersensitivity are sufficiently complex to limit their widespread application in clinical settings. We assessed the reliability and validity of a simple multi-modal vibrotactile stimulus, applied using an electric toothbrush, to evaluate its potential as a screening tool for central sensitization. METHODS: Fourteen female temporomandibular disorders (TMD) subjects with myofascial pain (RDC/TMD Ia or Ib) and arthralgia (RDC/TMD IIIa) were compared to 13 pain-free controls of matched age and gender. Vibrotactile stimulus was performed with an electric toothbrush, applied with 1 pound pressure for 30 seconds in four locations: over the lateral pole of the temporomandibular joint, masseter, temporalis, and mid-ventral surface of forearm. Pain intensity (0-10) was recorded following the stimulus at 0, 15, 30, and 60 seconds. Test-retest reliability was assessed with measurements from 8 participants, taken 2-12 hours apart. Case versus control differentiation involved comparison of area under the curve (AUC). A receiver operating characteristic (ROC) curve was used to determine cutoff AUC scores for maximum sensitivity and specificity for this multi-modal vibrotactile stimulus. RESULTS: Test-retest reliability resulted in an ICC of 0.87 for all 4 pooled sites. ROC-determined AUC cutoff scores resulted in a sensitivity of 57% and specificity of 92% for all 4 pooled sites. CONCLUSION: The electric toothbrush stimulus had excellent test-retest reliability. Validity of the scores was demonstrated with modest sensitivity and good specificity for differentiating TMD pain patients from controls, which are acceptable properties for a screening test.

Critical Commentary 2: Reliability and Validity of the DC/TMD Axis I.

No abstract available.

Effect of Shortened Dental Arch on Temporomandibular Joint Intra-articular Disorders.

AIMS: To investigate whether a shortened dental arch (SDA), as identified by reduced posterior occlusal contacts, is a risk factor for the progression of temporomandibular joint (TMJ) intra-articular disorders (ID), as identified using imaging techniques. METHODS: This multisite, prospective observational study with a mean follow-up period of 7.9 years had a sample of 345 participants with at least 1 temporomandibular disorder (TMD) diagnosis at baseline. SDA was defined as reduced occlusal posterior support due to lack of occlusal intercuspal contacts in the molar region on the left and/or right side. SDA was assessed at baseline and at follow-up with metalized Mylar Tape. The presence or absence of a TMJ ID and the specific TMJ ID diagnoses for baseline and follow-up images were established by a calibrated, blinded radiologist at each of three sites by using bilateral magnetic resonance imaging for soft tissue imaging for disc displacement and by bilateral multidetector computed tomography or cone beam computed tomography for hard tissue imaging for degenerative joint diseases. Wilcoxon rank sum test and linear regression analyses were used to test for an impact of SDA on TMJ ID status. RESULTS: At baseline, TMJ ID status of either side was not significantly affected by the presence of SDA on the ipsilateral or contralateral side of the jaw (all P > .05). Furthermore, the presence or absence of SDA at baseline was also not a significant predictor for progression of the TMJ ID status between baseline and follow-up (all P > .05). CONCLUSION: The findings of this study suggest that there is no significant effect of SDA on progression of TMJ ID.