Intra- and inter-examiner reliability for diagnostic criteria of temporomandibular disorders (DC/TMD) - axis 1: assessment in a sample of students

Objective: The aim of this study was to analyze the intra- and inter-examiner reliability when using the DC/TMD axis 1 and verify the replicability and validity of the data obtained.Methods: The sample comprised 30 volunteers (students) of the Instituto Universitário de Ciências da Saúde Norte (Portugal). The calibration process consisted of a volunteer selection, theoretical and practical training, data collection, and agreement calculation. Examiners received proper previous training. Three dental practitioners applied the questionnaire (T1) and re-examined all the participants one week later (T2). To measure the degree of inter and intra-examiner agreement, multiple Kappa coefficients were obtained when nominal or ordinal variables were involved. When the correspondence between quantifiable variables was assessed, Pearson correlation coefficients and their statistical significance were replicated.Results: Regarding opening patterns, a strong overall agreement was obtained, only showing discrepancies in left-assisted and unassisted maximum openings (from -0.034 to -0.370 and -0.630 to -0.933, respectively). A high level of inter-examiner agreement during TMJ noise during the opening assessment was obtained, only displaying variations in clicks (Kappa -0.423 to 0.757). Protrusion movement showed negative kappa and weaker agreement of all measurements (Kappa between -0.034 and -0037). Small discrepancies were obtained from palpation assessment (left lateral pole- Kappa -0.034).Conclusion: There was no discernible and persistent difference in the amount of agreement among the three examiners, demonstrating that all three examiners were capable of participating in data collecting by employing the DC/TMD questionnaire. The findings indicated nearly perfect intra- and inter-examiner concordance scores.

Pain paper 2b: classification of orofacial pain and an update on assessment and diagnosis.

The classification of chronic orofacial pain remains a contentious area. However, more recently, with the clarification of pain mechanisms and improved understanding of the underlying neurophysiology and modulation factors, there is more clarity of the possible division of pain conditions. Interestingly, the pathophysiology provides a basis for classification that has more clinical relevance. The principles of assessing and managing patients with pain have modified significantly, in line with recent improved understanding of the affective and emotional components in pain behaviour and suffering. Clinical Relevance: This paper aims to provide the dental and medical teams with a review of the classification of trigeminal pain with an overview of how to assess and diagnose patients with trigeminal pain.

Assessment of mandibular movements in 10 to 15 year-old patients with and without temporomandibular disorders

El objetivo del presente trabajo fue establecer valores de referencia de movimientos mandibulares en niños de 10-15 años sin disfunción; compararlos con los de pacientes de la misma edad con trastornos temporomandibulares (TTM) y con los hallados anteriormente en un grupo menor de 11 años sinTTM. Niños de ambos sexos que acudieron a la Cátedra Odontología Integral Niños de UBA en 2013 y cuyos responsables brindaron consentimiento fueron evaluados con CDI/TTM por odontopediatras estandarizados (Kappa 0.88) conformándose 3 grupos en función del resumen diagnóstico; C: sin TTM, Ia: con dolor miofacial e Ib: dolor con limitación de la apertura bucal, para el análisis de las siguientes variables: edad, sexo y movimientos mandibulares. La muestra quedó constituida por169 pacientes de 12.5±1.76 años. El 62.36 por ciento no presentó TTM (C) y en el 37.27 por ciento se estableció un diagnóstico de trastorno muscular (29.58 por ciento Ia y 7.69 por ciento Ib). En C se registraron lossiguientes valores en mm: Apertura máxima no asistida: 48.28±6.14; Lateralidad derecha 8.78±2.50; izquierda: 9.60±2.64; Protrusión: 4.94±2.58 y Sobremordida: 2.98 ± 2.5sin variaciones en relación al sexo, pero con diferencias en los registros de todos los movimientos comparados con losobtenidos en dentición mixta. (p=0.0001). El análisis de los valores medios de los movimientos mandibulares entre los 3 grupos sólo reveló diferencias para la apertura máxima no asistida (p= 0.0317). En relación al sexo, los TTM fueron másfrecuentes en niñas siendo significativa la diferencia entre C e Ia (p=0.019). En los niños sin disfunción se estableció unaapertura máxima promedio de 48.28±6.14mm, observándose valores inferiores en los pacientes con TTM. Los movimientos mandibulares en pacientes pediátricos sin TTM mostrarondiferencias significativas en función del tipo de dentición y la edad...

MRI assessment of temporomandibular disorders: an approach to diagnostic and therapeutic setting.

AIMS: The aim of this study was to evaluate the relationship between the clinical and the radiological data obtained by magnetic resonance imaging (MRI) in patients with temporomandibular disorder (TMD). METHODOLOGY: The study group included 17 patients with symptoms of TMDs. The radiological assessments before and after therapy was evaluated by MRI; in the clinical analysis, signs and associated symptoms have been assessed. RESULTS: With MRI before therapy, we were able to distinguish the specific type of TMD that each patient had. At the end of the treatment, a general improvement of the clinical status was noticed; MRI, however, showed the permanence of several degrees of condyle-disc incoordination in some patients. CONCLUSIONS: Certainly TMDs can be diagnosed without MRI; nevertheless, MRI gives us the possibility to obtain objective data of the patients concerned. Symptoms recorded during a clinical evaluation cannot be the only terms of diagnosis; MRI provides objective data in the diagnostic and post-therapy phases.

Profiling the clinical presentation of diagnostic characteristics of a sample of symptomatic TMD patients.

BACKGROUND: Temporomandibular disorder (TMD) patients might present a number of concurrent clinical diagnoses that may be clustered according to their similarity. Profiling patients' clinical presentations can be useful for better understanding the behavior of TMD and for providing appropriate treatment planning. The aim of this study was to simultaneously classify symptomatic patients diagnosed with a variety of subtypes of TMD into homogenous groups based on their clinical presentation and occurrence of comorbidities. METHODS: Clinical records of 357 consecutive TMD patients seeking treatment in a private specialized clinic were included in the study sample. Patients presenting multiple subtypes of TMD diagnosed simultaneously were categorized according to the AAOP criteria. Descriptive statistics and two-step cluster analysis were used to characterize the clinical presentation of these patients based on the primary and secondary clinical diagnoses. RESULTS: The most common diagnoses were localized masticatory muscle pain (n = 125) and disc displacement without reduction (n = 104). Comorbidity was identified in 288 patients. The automatic selection of an optimal number of clusters included 100% of cases, generating an initial 6-cluster solution and a final 4-cluster solution. The interpretation of within-group ranking of the importance of variables in the clustering solutions resulted in the following characterization of clusters: chronic facial pain (n = 36), acute muscle pain (n = 125), acute articular pain (n = 75) and chronic articular impairment (n = 121). CONCLUSION: Subgroups of acute and chronic TMD patients seeking treatment can be identified using clustering methods to provide a better understanding of the clinical presentation of TMD when multiple diagnosis are present. Classifying patients into identifiable symptomatic profiles would help clinicians to estimate how common a disorder is within a population of TMD patients and understand the probability of certain pattern of clinical complaints.

Temporomandibular disorders/myoarthropathy of the masticatory system. Costs of dental treatment and reimbursement by Swiss federal insurance agencies according to the Health Care Benefits Ordinance (KLV).

The goal of the study was to calculate the direct costs of therapy for patients with MAP. This retrospective study included 242 MAP patients treated at the Department of Prosthodontics of the University of Bern between 2003 and 2006. The following parameters were collected from the clinical charts: chief complaint, diagnosis, treatment modalities, total costs, costs of the dental technician, number of appointments, average cost per appointment, length of treatment, and services reimbursed by health insurance agencies. The average age of the patients was 40.4 ± 17.3 years (76.4% women, 23.6% men). The chief complaint was pain in 91.3% of the cases, TMJ noises (61.2%) or limitation of mandibular mobility (53.3%). Tendomyopathy (22.3%), disc displacement (22.4%), or a combination of the two (37.6%) were more often diagnosed than arthropathy alone (7.4%). Furthermore, 10.3% of the MAP patients had another primary diagnosis (tumor, trauma, etc.). Patients were treated with counseling and exercises (36.0%), physiotherapy (23.6%), or occlusal splints (32.6%). The cost of treatment reached 644 Swiss francs for four appointments spread over an average of 21 weeks. In the great majority of cases, patients can be treated with inexpensive modalities. 99.9% of the MAP cases submitted to the insurance agencies were reimbursed by them, in accordance with Article 17d1-3 of the Swiss Health Care Benefits Ordinance (KLV) and Article 25 of the Federal Health Insurance Act (KVG). The costs of treatment performed by dentists remain modest. The more time-consuming services, such as providing information, counseling and instructions, are poorly remunerated. This aspect should be re-evaluated in a future revision of the tariff schedule.

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.

Orthognathic treatment and temporomandibular disorders: a systematic review. Part 1. A new quality-assessment technique and analysis of study characteristics and classifications.

INTRODUCTION: Orthognathic treatment is undertaken to correct jaw discrepancies and involves a combination of orthodontics and surgery. The effects of orthodontic treatment on temporomandibular disorders (TMD) have been widely debated in the literature, but fewer studies focus on the effects of orthognathic treatment on TMD. METHODS: A systematic review was conducted to (1) determine the percentage of orthognathic patients with signs or symptoms of TMD, (2) establish the range of signs or symptoms, and (3) examine studies that followed patients longitudinally through treatment to determine the effect of orthognathic intervention on TMD symptoms. RESULTS: Of 480 identified articles, 53 were eligible for inclusion in this review. Part 1 of this 2-part article describes the methodology of conducting this review, the difficulties encountered (including the quality-assessment issues), and a narrative analysis of study characteristics and classification methods. Part 2 reports the remaining results, evidence tables, and meta-analyses. CONCLUSIONS: The diversity of diagnostic criteria and classification methods used in the included studies makes interstudy comparisons difficult. There is a definitive need for well-designed studies with standardized diagnostic criteria and classification methods for TMD.

The prevalence of clinical diagnostic groups in patients with temporomandibular disorders.

The aim of this study was to observe the prevalence of diagnostic groups of temporomandibular disorders (TMD) in patients who were referred or sought treatment for TMD and/or orofacial pain in a private clinic. The clinical records of 357 patients were evaluated and selected based on inclusion/exclusion criteria; the mean age was 32 years. A clinical examination was performed and the diagnosis was based on the American Academy of Orofacial Pain criteria. Results showed that 86.8% of patients were women and 93.3% of the patients presented more than one diagnosis. The most frequent chief complaint (n = 216, chi2 = 30.68, p = 0.001) and total diagnosis realized (n = 748, chi2 = 14.14, p = 0.001) were muscle related. We concluded that women seek treatment for dysfunction/disorders of orofacial structures more than men do; patients seeking specialized treatment have more than one diagnosis and muscle dysfunction is more prevalent than intra-articular disorders.

Validity of temporomandibular disorder examination procedures for assessment of temporomandibular joint status.

INTRODUCTION: This hypothesis-generating study was performed to determine which items in the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) and additional diagnostic tests have the best predictive accuracy for joint-related diagnoses. METHODS: One hundred forty-nine TMD patients and 43 symptom-free subjects were examined in clinical examinations and with magnetic resonance imaging (MRI). The importance of each variable of the clinical examination for correct joint-related diagnosis was assessed by using MRI diagnoses. For this purpose, "random forest" statistical software (based on classification trees) was used. RESULTS: Maximum unassisted jaw opening, maximum assisted jaw opening, history of locked jaw, joint sound with and without compression, joint pain, facial pain, pain on palpation of the lateral pterygoid area, and overjet proved suitable for distinguishing between subtypes of joint-related TMD. Measurement of excursion, protrusion, and midline deviation were less important. CONCLUSIONS: The validity of clinical TMD examination procedures can be enhanced by using the 16 variables of greatest importance identified in this study. In addition to other variables, maximum unassisted and assisted opening and a history of locked jaw were important when assessing the status of the TMJ.

Assessment of pain in temporomandibular disorders: the bio-psychosocial complexity.

Temporomandibular joint disorders (TMD) affect the joint, the masticatory muscles, or are expressed as a clinical combination of these two factors. The aims of this study were to: (i) identify the clinical and psychosocial factors that aid in the diagnosis and classification of acute and chronic TMD, (ii) determine specific initiating and perpetuating factors which may act as a guide to differentiate between acute and chronic TMD, (iii) identify factors which might predispose to conversion from acute to chronic TMD. Twenty-two patients were examined in the pain clinics at the Eastman Dental Institute. The assessment technique incorporated questionnaires, clinical history and examination including dental panoramic tomography. The results of this pilot study show a significant correlation between mood and enjoyment of life in both groups, mood and relationships in the chronic group, average pain and sleep in the chronic group, average pain and eating-chewing in the chronic group, and phobia for physical disease with trust in clinicians in the chronic group. The bio-psychosocial model of pain is an important appraisal tool. The newly designed TMD Pain Assessment is described with good results.

Evaluation and management of TMDs, Part 1. History, epidemiology, classification, anatomy, and patient evaluation.

The study of temporomandibular disorders has undergone many changes throughout its history. Focus on the structure and function of the TMJ continues to improve our understanding of these complex disorders. A more standardized classification system allows practitioners and researchers to discuss findings in a common language. With improved patient evaluation techniques, the clinician can establish a proper working differential diagnosis and begin focusing attention on treatment planning.

Interobserver variability in assessment of signs of TMD.

PURPOSE: The aim of this report was to study the ability of examiners to measure reliably the clinical signs of temporomandibular disorders (TMD). Four examiners participated in this study of 11 TMD patients and 25 nonpatients. MATERIALS AND METHODS: Vertical and lateral excursions of the jaw were measured using a millimeter ruler. Joint sounds during vertical jaw movements were assessed using digital palpation. The reliability of delivering appropriate degrees of digital pressure to assess masticatory muscle pain was assessed using a manometer after training examiners to exert specified pressures. RESULTS: Intraclass correlation coefficients for the measurement of vertical and protrusive jaw movements were > or = 0.87, which was considered excellent. The intraclass correlation coefficient for measurements of left and right lateral jaw excursions varied between 0.73 and 0.85, which was considered acceptable. The interobserver agreement for detecting the joint sounds showed overall agreement across examiners of 78%. Kappa for every possible pair of examiners varied between .52 and .86 (median .75, interquartile range .18). Reliability for diagnostic categories from the Helkimo index and Research Diagnostic Criteria for Temporomandibular Disorders involving joint noises showed modest reliability. CONCLUSION: Point estimates and measures of spread for reliability measures of single clinical TMD signs as well as combinations of signs into diagnostic categories from the Helkimo index and Research Diagnostic Criteria for Temporomandibular Disorders involving joint noises were sufficient in a group of four examiners.

Temporomandibular disorders and the need for stomatognathic treatment in orthodontically treated and untreated girls.

The aim of this investigation was to study symptoms of temporomandibular disorders (TMD) and headaches longitudinally in girls with Class II malocclusions receiving orthodontic treatment in comparison with subjects with untreated Class II malocclusions and girls with normal occlusion, and to evaluate the need and demand for stomatognathic treatment. The frequency and location of subjective symptoms of TMD and headaches were registered by means of an interview and a questionnaire in three groups of age-matched adolescent girls. Sixty-five Class II subjects received orthodontic fixed straight-wire appliance treatment (Orthodontic group), 58 with Class I malocclusion were orthodontically untreated (Class II group) and 60 had a normal occlusion (Normal group). Individual fluctuations of reported symptoms of TMD were found in all three groups over the 2-year period of the study. Subjects with untreated Class II malocclusions rated their overall symptoms of TMD as more severe than the Orthodontic and the Normal groups. In the Orthodontic group, the prevalence of symptoms of TMD decreased over the 2 years. The overall prevalence of symptoms of TMD was, however, lower in the Normal group than in the other two groups. The need for stomatognathic treatment in the whole sample was estimated to be 13 per cent, while the actual demand was 3 per cent. The large fluctuation of symptoms of TMD over time leads us to suggest a conservative treatment approach when stomatognathic treatment in children and adolescents is considered. The results show that orthodontic treatment did not increase the risk of TMD.

Prediction of treatment-seeking behavior in acute TMD patients: practical application in clinical settings.

AIMS: To determine potential differences in predictive models of acute temporomandibular disorder (TMD) patients divided into groups based on the physiologic characteristics of their TMD. METHODS: One hundred seventy-seven acute TMD patients were evaluated with an extensive battery that included biologic and psychosocial measures. Subjects were separated into 3 groups based on a physical exam using the Research Diagnostic Criteria for TMD (RDC): those with a myofascial pain diagnosis, those with either a disc displacement or other joint condition, and those who reported pain but did not receive an RDC Axis I diagnosis. Six months later, it was determined whether patients had sought additional treatment for relief of their symptoms. Treatment-seeking and non-treatment-seeking groups were compared for significant differences, and predictive models were generated to determine the array of variables that best predicted treatment-seeking behavior among each of the 3 classifications of TMD patients used in this study. RESULTS: Among patients with a diagnosis of myofascial pain, gender, Multidimensional Pain Inventory (MPI) interference score, and MPI affective distress score accurately predicted treatment-seeking behavior in 76.1% of the sample. For patients with a diagnosis of disc displacement, arthralgia, arthritis, or arthrosis, the following variables predicted treatment utilization behavior in 93.6% of the sample: race, RDC graded chronic pain, and the introversion scale of the Minnesota Multiphasic Personality Inventory-2. For patients with no RDC Axis I disorder, 80.5% of the sample was accurately classified with regard to treatment-seeking behavior through the use of only the characteristic pain intensity score (i.e., mean of visual analog scale scores for "pain right now," "worst pain," and "average pain"). CONCLUSION: The factors that predict which acute TMD patients are most likely to seek additional treatment vary depending on the physiologic basis of their TMD. This suggests that acute TMD patients may benefit from different modalities of treatment, depending on the type of TMD with which they present.

TMD treatment need in relation to age, gender, stress, and diagnostic subgroup.

Associations between treatment need for temporomandibular disorders (TMD) and age, gender, stress, and diagnostic subgroup were analyzed in an adult Finnish population sample of 506 subjects. When analyzed separately, the association between TMD treatment need and all the studied factors was statistically significant. This finding is in accordance with earlier results. When the studied factors were included into an explanatory model, however, the picture changed. The logistic regression analysis revealed that diagnostic subgroup was the strongest predictor for the TMD treatment need. Total stress score significantly added to the explanatory power of the model, but age and gender did not. The commonplace observation that women show more signs and symptoms of TMD seems to be explainable by their higher stress scores and by the type of symptoms.

Psychosocial and behavioral assessment of patients with temporomandibular disorders: diagnostic and treatment implications.

The literature on chronic pain reveals that several psychosocial and behavioral factors, in addition to physical pathology, play a role in reports of pain and disability. Therefore it is important to assess patients more broadly rather than focus exclusively on physical pathology. Understanding and treatment of temporomandibular disorders has been impeded by the lack of agreement on a classification system with which to make a differential diagnosis. Research supports the appropriateness of a dual-diagnostic approach for temporomandibular disorders based on physical and psychological axes. Treatment should be directed toward the physical diagnoses supplemented by treatment that targets relevant psychosocial characteristics. This approach encourages diagnosticians to think in terms of the two relevant axes and to customize treatment to physical and psychosocial characteristics and thus should foster better outcomes.

Fluctuation of temporomandibular disorders in accordance with two classifications: the Helkimo dysfunction index and treatment need grouping.

We studied the fluctuation of temporomandibular disorders, applying two classifications systems, in a 2-year follow-up study of 411 subjects. In general, the fluctuation was not large. There were no major differences between the two classifications. In our opinion, a decision to treat a patient on the basis of the treatment need grouping would not lead to overtreatment. The study design suffered from the fact that it is not possible to separate the fluctuation of the TMD itself and the fluctuation of its signs and symptoms from each other, owing to the descriptive nature of the diagnosis 'temporomandibular disorder'.