Can a 10-Minute Questionnaire Identify Significant Psychological Issues in Patients With Temporomandibular Joint Disease?

PURPOSES: For patients with disc displacement disorders (DDDs), psychiatric illness increases the risk of worsening postsurgical pain, postoperative delirium, postoperative incomplete recovery, and worse postoperative life quality. This study provides a fast and practical protocol to evaluate psychological conditions of patients with DDDs of the temporomandibular joint (TMJ) in clinical care. MATERIALS AND METHODS: The populations under investigation in this cross-sectional study included patients with DDD who received treatment from October 2012 through June 2016. Variables included age, gender, education level, and TMJ (Axis I) and psychological (Axis II) evaluations. The 13-item protocol of Axis II evaluations contained a 5-item Brief Symptom Rating Scale (BSRS-5), a pain visual analog scale (VAS; 1 item), major life events (3 items), suicidal risk (3 items), and substance use (1 item). Analysis of variance, χ2 test, and multivariate logistic regression were used for analyses. RESULTS: Of 177 patients, 75.14% were women (mean age, 37.46 ± 14.06 yr). Pain VAS scores clearly supported the following ranking of psychosocial discomforts: disc displacement without reduction with limited opening (DDWORWLO) > disc displacement without reduction without limited opening > disc displacement with reduction. Pain VAS and BSRS-5 correlated with 5 variables in Axis I (trismus, acute TMJ pain, chronic awake bruxism, chronic sleep bruxism, and deep bite). The DDD study indicated that 9.6% of patients required urgent referrals to mental health resources (MHRs) for their moderate and high suicidal risk DDD and 77% required nonurgent referrals to MHRs for their psychiatric morbidity. CONCLUSIONS: This study found that patients with DDD showed a prevalence of suicidal ideation and mean BSRS scores that were higher for anxiety, hostility, depression, interpersonal hypersensitivity, and insomnia than in the general population. Patients with trismus or acute TMJ pain could have a higher pain VAS score; chronic awake bruxism could involve greater hostility and lower depression; chronic sleep bruxism could increase sensitivity to interpersonal interactions; and deep bite could involve a higher anxiety level. DDWORWLO produced the highest pain VAS score in patients with DDD. The 13-item Axis II evaluations can offer useful clues for oral and maxillofacial surgeons and other specialists to collaborate with MHRs.

Effect of Flat-Plane Splint Vertical Thickness on Disc Displacement Without Reduction: A Retrospective Matched-Cohort Study.

PURPOSE: The efficacy of occlusal splints for treating temporomandibular disorders (TMDs) remains controversial. This study aimed to evaluate and compare the effectiveness of flat-plane splints (FPSs) with a vertical thickness of 3 mm (VT3) and 5 mm (VT5) in treating disc displacement without reduction (DDWOR). MATERIALS AND METHODS: This retrospective matched-cohort study selected the study participants from 400 TMD patients treated in the Department of Oral and Maxillofacial Surgery of Tainan Sin-Lau Hospital, Tainan, Taiwan, between August 2013 and July 2015. The thickness of occlusal splints was the predictor variable. The outcome variables included joint crepitus sound, deviation of the mandible during opening, TMD-associated headache, myofascial pain with referral, temporomandibular joint (TMJ) arthralgia, and maximum assisted opening. The case and control groups were matched 1:1 by propensity scoring to ensure that there were no statistical differences in the categorical variables and continuous variables. The analysis used χ2 tests, t tests, and multiple regression analyses. RESULTS: We allocated 162 patients into 2 groups, with 81 patients each: VT3 group and VT5 group. Both VT3 FPSs and VT5 FPSs effectively improved the DDWOR. At 12 months after treatment, the VT5 group showed remarkable improvement in joint crepitus sound and TMJ arthralgia compared with the VT3 group. No statistical differences in other TMJ-associated symptoms such as deviation of the mandible during opening, TMD-associated headache, and myofascial pain with referral were observed between the 2 groups. CONCLUSIONS: Both VT3 and VT5 FPSs can effectively improve various clinical symptoms of DDWOR. We suggest that VT5 FPS treatment for at least 1 year is a suitable option for DDWOR patients with joint crepitus sound and TMJ arthralgia. For DDWOR patients without joint crepitus sound and TMJ arthralgia, there are no differences between the VT3 and VT5 FPSs.

Comparison Between Acupuncture and Biofeedback as Adjunctive Treatments for Primary Insomnia Disorder.

Context • Insomnia affects from 5% to 35% of the general population worldwide. Primary insomnia disorder is the most frequently diagnosed, sleep-related disorder. Pharmacological treatments remain the most widely used treatments for insomnia. Nonpharmacological treatments for primary insomnia disorder have been found to be effective. Objective • This study intended to determine the appropriateness of acupuncture and biofeedback as adjuncts to medication for primary insomnia disorder. Design • The research team designed a randomized, controlled study. Setting • The study took place in a psychosomatic clinic at a regional general hospital in southern Taiwan. Participants • Participants were patients at the clinic with primary insomnia disorder who had never received prior hypnotic medication or alternative treatments. Intervention • All participants received 10 mg of zolpidem. The participants were divided into 3 groups: (1) acupuncture adjunctive to zolpidem (AAZ) group- 18 patients received 1 acupuncture session weekly; (2) biofeedback adjunctive to zolpidem (BAZ) group- 17 patients received 1 biofeedback session weekly; and (3) control (OZ) group-14 patients received only zolpidem. Patients visited the clinic 1 ×/wk for 4 wk, at baseline and on days 7, 14, and 21 of the intervention. Outcome Measures • The Pittsburgh Sleep Quality Index (PSQI) was used to measure outcomes. Treatment success was defined as a final PSQI score of ≤5. The generalized estimating equation (GEE) was used for statistical analysis. Results • Using analysis of variance, the reduction in the PSQI scores were (1) 3.72 for the AAZ group, (2) 2.00 for the BAZ group, and (3) 2.29 for the OZ group (P = .28). The GEE analysis indicated no differences in the therapeutic effects among the 3 groups: P = .37 for the AAZ group vs the OZ group and P = .07 for the BAZ group vs the OZ group, when the PSQI of the OZ group was set to 0. The AAZ group had a significantly higher score than the OZ group for the sleep duration domain (B = 3.01, P < .001), whereas the BAZ group had a significantly higher score than the OZ group on the sleep disturbance domain (B = 6.78, P < .001). Higher scores indicate more difficulty in a domain. Conclusions • The change in the PSQI score and the success rate were better in the acupuncture group. The heterogeneity in primary insomnia disorder might mean that different therapeutic compositions are needed.

Temporal relationship between dysthymia and temporomandibular disorder: a population-based matched case-control study in Taiwan.

BACKGROUND: Numerous studies have reported a relationship between depression and temporomandibular disorders (TMD), but the conclusions remain undefined. The aim of this article was to examine the temporal relationship between depression and TMD. METHODS: In this retrospective matched case-control study, we recruited all samples from a randomsample sub-dataset of one million insured individuals for the year 2005 (Longitudinal Health Insurance Database (LHID2005)). All beneficiaries were enrolled in the National Health Insurance (NHI) programme in Taiwan. We used propensity scoring and matched the case and control groups (1:1) by ten confounding factors to detect the effect of different types of depression on TMD. RESULTS: The positive correlative factors of TMD included the total number of times medical advice was sought for an unspecified anomaly of jaw size plus malocclusion (TTSMA-JS, p = 0.045), the total number of times medical advice was sought for an anxiety state (TTSMA-AS, p = 0.000), and the total number of times medical advice was sought for a panic disorder (TTSMA-P, p = 0.009). Dysthymia (synonymous with chronic depression) had an effect on TMD. The odds ratio (OR) of dysthymia for TMD measured by multiple logistic regression was 1.91 (p = 0.008) after adjusting for demographic factors, psychiatric comorbidities, and maxillofacial confounders. CONCLUSIONS: This study demonstrated the established temporal relationship between dysthymia and TMD. The inclusion of a psychiatrist on the TMD management team is appropriate.

Reducing Trismus After Surgery and Radiotherapy in Oral Cancer Patients: Results of Alternative Operation Versus Traditional Operation.

PURPOSE: In patients with oral cancer, trismus (maximum interincisal opening [MIO] <35 mm) can develop as a result of surgery and radiotherapy. The aim of this study was to provide an alternative operation to both eradicate oral cancer and prevent postsurgical trismus. MATERIALS AND METHODS: In our retrospective cohort study of oral cancer patients who underwent operations during 2010 to 2014, the predictor variable was the type of operation (alternative operation or traditional operation) and the outcome variable was MIO. All of the cases were allocated by 2 periods: the traditional operations were performed from 2010 to 2011, and the alternative operations were performed from 2011 to 2014. All patients received marginal mandibulectomy, anterolateral thigh free flap, and adjuvant radiotherapy or concurrent chemoradiotherapy. In addition to traditional marginal mandibulectomy, the alternative operation included ipsilateral coronoidectomy and myotomy of the temporalis muscle insertion, masseter muscle, and medial pterygoid muscle. MIO was measured at 10 time points. The adjusted variables included demographic data, diagnostic parameters, treatment, and response. RESULTS: Of the 36 male patients with oral cancer, 16 were placed in the alternative operation group (AOG; mean age, 53.5 ± 11.9 years) and 20 were placed in the traditional operation group (TOG; mean age, 50.7 ± 7.1 years). Regarding the outcome indicator of patient MIO, the preoperative MIO in the AOG was on average 7.5 mm shorter than that in the TOG (P < .01), but it was consistently superior to the MIO in the TOG after the operation. Multivariate analysis of variance showed that patients in the AOG were more likely to have postoperative non-trismus. CONCLUSIONS: The alternative operation exhibited superior postoperative MIO values and similar postoperative complication rates. For the prevention of trismus, it is practical to perform the combined operation simultaneously, cutting all ipsilateral jaw closing muscles and the coronoid process and eradicating the tumor.

The Use of Solid-Phase Concentrated Growth Factors for Surgical Defects in the Treatment of Dysplastic Lesions of the Oral Mucosa.

PURPOSE: Use of the skin graft and artificial dermis to reconstruct a defect after the excision of dysplastic lesions of the oral mucosa has been practiced for years. The purpose of this case series was to introduce a novel resolution-that is, an operating procedure using solid-phase concentrated growth factors (SPCGFs) to reconstruct oral mucosa defects-and observe the postoperative results and evaluate its clinical effects. MATERIALS AND METHODS: In this consecutive serial case study of patients with oral dysplastic lesions who underwent operations from April 2015 through July 2015, the primary endpoint of the study was to observe the clinical wound-healing profile at 1 week, 3 weeks, 3 months, and 6 months postoperatively. The secondary endpoint was to observe maximal interincisal opening (MIO) and wound pain preoperatively and at 1 and 3 days, 1 and 3 weeks, and 3 and 6 months postoperatively. The minimum follow-up was 8 months, and the longest was 1 year. RESULTS: All sites had healed with complete epithelialization after 3 weeks postoperatively. All patients had a wound-healing score no higher than 3 at 3 weeks postoperatively. The preoperative MIO was 52 ± 4.64 mm and the 6-month postoperative MIO was 49.2 ± 3.03 mm. No patient reported further pain from 3 weeks postoperatively. No recurrence of the lesion was found at or after the 6-month follow-up period. CONCLUSION: The results of this study show that the use of SPCGFs to reconstruct oral mucosa defects is feasible and practical. The efficacy of SPCGFs needs to be verified by additional studies with higher-level evidence bases in the future.

Suicide and the Elderly During the COVID-19 Pandemic: An Overview of Different Suicide Theories.

OBJECTIVE: To expand knowledge during the coronavirus disease 2019 (COVID-19) pandemic with regard to suicide prevention among the elderly population by providing recommendations for interview strategies using 3 suicide theories. METHODS: Two hypothetical geriatric suicide cases (1 low lethality and 1 high lethality) are presented and categorized according to 3 suicide theories: interpersonal theory of suicide, three-step theory of suicide, and hopelessness theory of depression. RESULTS: In crisis intervention, the clinician's interview must match the intrinsic belief of the suicide attempter to enable engagement and rapport. Use of different aspects of the 3 suicide theories can be useful but are dependent on the emergent nature of the attempt. CONCLUSION: The need for identification and treatment of those with mental health issues, especially among the elderly population, and collaborative multidiscipline management teams is increasing during the current global pandemic. Specific interview strategies are needed when engaging with elderly suicidal patients. Suicide prevention in elderly patients is worthy of strong public attention.

Gender Disparity in the Risk of Hypertension in Subjects With Major Depressive Disorder.

Objects: The aim of our study was to investigate whether major depressive disorder (MDD) increased the risk of hypertension using propensity score matching (PSM) in patients with MDD in Taiwan. Methods: In this study, we recruited all samples from a random sample sub-dataset of one million insured individuals from 2005. A total of 743,114 outpatients were included in our study. We used PSM (nearest neighbor matching) stratified by age, hospital level, insurance amount, and Charlson Comorbidity Index score. Results: The hazard ratio (HR) of hypertension was significantly greater in the male MDD outpatients (HR = 1.116, P = 0.004) than in the female MDD outpatients (HR = 0.93, P = 0.02). Using PSM, we selected 27,988 outpatients with hypertension and 27,988 outpatients without hypertension for a nested case-control study. In this analysis, female outpatients with MDD (relative risk = 0.852) had lower risks of hypertension. Male outpatients without/with MDD (relative risk = 1.987/3.018) showed a synergistic interaction with gender in which male patients had a higher risk of hypertension in a multiplicative model. Furthermore, MDD appeared to have an interaction effect with gender (HR = 1.82, P < 0.001) in the proportional hazards model analysis. Antidepressant use also increased the risk of hypertension (HR = 1.16, P < 0.001). Conclusions: There was gender disparity in the risk of hypertension in subjects with MDD. MDD outpatients who used antidepressants had a higher risk of suffering from hypertension. A large-scale, population-based study is warranted to generalize these results in the future.

Effect of arthrocentesis plus platelet-rich plasma and platelet-rich plasma alone in the treatment of temporomandibular joint osteoarthritis: A retrospective matched cohort study (A STROBE-compliant article).

Although the research on using platelet-rich plasma (PRP) for temporomandibular joint osteoarthritis (TMJ-OA) has advanced, no unified standards exist for determining the joint use of arthrocentesis and the injection dose and frequency of PRP. This study aimed to compare the efficacy of 2 TMJ-OA treatment approaches, arthrocentesis plus platelet-rich plasma (A+PRP) and PRP alone, and attempted to provide another potential treatment option with a single injection of 2 mL of high-concentration and high-purity PRP.This retrospective matched cohort study enrolled 208 patients who were treated for temporomandibular disorders (TMDs) in the Department of Oral and Maxillofacial Surgery of Tainan Sin-Lau Hospital between August of 2013 and January of 2016, from which 90 patients were selected for the final analysis. The predictor variables were treatment outcome indicators, including joint crepitus sounds, TMD-associated headache, jaw range of motion <6 mm, myofascial pain with referral, temporomandibular joint (TMJ) arthralgia, pain when chewing most foods, and maximum assisted opening (MAO). The data were analyzed using χ tests, t tests, and multiple regression analyses.Among the 90 patients, 30 were assigned into the A+PRP group, and 60 were included in the PRP group. A matching method was used to ensure no statistically significant differences in the categorical and continuous variables between the 2 groups. After treatment, both the A+PRP and PRP groups showed improvements in TMJ-OA. The 2 treatment groups did not show statistically significant differences in the symptom improvement rates of joint crepitus sounds, reparative remodeling, and TMJ arthralgia. However, compared with PRP alone, the A+PRP treatment demonstrated superior performance in improving TMD-associated headache, jaw range of motion <6 mm, myofascial pain with referral, and pain when chewing most foods.Both A+PRP and PRP treatments can effectively improve multiple symptoms of TMJ-OA. Based on the results from this study, we recommend a single injection with 2 mL of high-concentration and high-purity PRP for TMJ-OA treatment. For patients with TMJ-OA accompanied by other clinical symptoms, including TMD-associated headache, jaw range of motion <6 mm, myofascial pain with referral, and pain when chewing most foods, a treatment approach using arthrocentesis prior to a PRP injection can achieve a higher efficacy.

Dysthymia increases the risk of temporomandibular disorder: A population-based cohort study (A STROBE-Compliant Article).

Numerous studies have investigated the relationship between depression and temporomandibular disorders (TMD), but the conclusions remain vague. The aim of this study was to examine the causal effect between depression and TMD.The reporting of this study conforms to the STROBE statement. In this retrospective cohort study, all samples were recruited from a representative subdataset of 1 million insured persons for the year 2005 Longitudinal Health Insurance Database, who were randomly selected from all beneficiaries enrolled in the National Health Insurance program of Taiwan. We used a propensity score and stratified 926,560 patients into 2 groups (propensity1 = 588,429 and propensity2 = 338,131) and 4 cohorts (propensity1 with depression = 18,038, propensity1 without depression = 570,391, propensity2 with depression = 38,656, propensity2 without depression = 299,475) to detect the development of TMD among the depressive and nondepressive patients between 2004 and 2013.The positive correlative factors of TMD included female, total number of times seeking medical advice (TTSMA) for anxiety state, TTSMA for generalized anxiety disorder, TTSMA for mandible fracture, and TTSMA for unspecified anomaly of jaw size. The propensity2 group was represented by elder and female-predominant patients who used more psychiatric health resources. Among 3 types of depression, only dysthymia (so-called chronic depression) had a causal impact on TMD in the propensity 2 group. In the propensity 2 group, the hazard ratio of dysthymia for TMD measured by Cox's regression was 1.64 (95% confidence interval 1.28-2.09), after adjusting for demographic factors, psychiatric comorbidities, and maxillofacial confounders. The first-onset mean time of TMD as the consequence of dysthymia was 3.56 years (sd = 2.74, min = 0.08, median = 2.99, max = 9.73).This study demonstrates that dysthymia increases the risk of TMD in elderly and female-predominant patients who use more psychiatric health resources.