Increase in stress contributes to impaired jaw function in juvenile idiopathic arthritis: a two-year prospective study.

BACKGROUND: Stress in patients with Juvenile Idiopathic Arthritis (JIA) has been found to be associated with orofacial pain, psychological distress, jaw dysfunction and loss of daily activities in a cross-sectional study. The aim of this study was to investigate the relations between stress and change of stress over time versus changes in orofacial pain, psychosocial factors and jaw function over a two-year period in patients with JIA. METHODS: This is a two-year prospective follow-up study involving 40 JIA patients. At baseline (2015) the median age was 12 years and at two-year follow up (2018) 14 years. The JIA patients were examined clinically and with questionnaires at baseline and follow-up with the diagnostic criteria for temporomandibular disorders (DC/TMD) and completed the same set of DC/TMD questionnaires regarding orofacial pain symptoms and psychosocial factors. RESULTS: Change in stress was associated with change in catastrophizing, psychological distress as well as limitation in general function and jaw function. CONCLUSIONS: This study emphasizes the importance of maintaining a low stress level in patients with JIA since an increase in stress level over a two-year period seems to impair jaw function as well as psychological distress and catastrophizing.

Diagnostic criteria for temporomandibular disorders-INfORM recommendations: Comprehensive and short-form adaptations for adolescents.

BACKGROUND: The Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for use in adults is in use worldwide. Until now, no version of this instrument for use in adolescents has been proposed. OBJECTIVE: To present comprehensive and short-form adaptations of the adult version of DC/TMD that are appropriate for use with adolescents in clinical and research settings. METHODS: International experts in TMDs and experts in pain psychology participated in a Delphi process to identify ways of adapting the DC/TMD protocol for physical and psychosocial assessment of adolescents. RESULTS: The proposed adaptation defines adolescence as ages 10-19 years. Changes in the physical diagnosis (Axis I) include (i) adapting the language of the Demographics and the Symptom Questionnaires to be developmentally appropriate for adolescents, (ii) adding two general health questionnaires, one for the adolescent patient and one for their caregivers and (iii) replacing the TMD Pain Screener with the 3Q/TMD questionnaire. Changes in the psychosocial assessment (Axis II) include (i) adapting the language of the Graded Chronic Pain Scale to be developmentally appropriate for adolescents, (ii) adding anxiety and depression assessment that have been validated for adolescents and (iii) adding three constructs (stress, catastrophizing and sleep disorders) to assess psychosocial functioning in adolescents. CONCLUSION: The recommended DC/TMD, including Axis I and Axis II for adolescents, is appropriate to use in clinical and research settings. This adapted first version for adolescents includes changes in Axis I and Axis II requiring reliability and validity testing in international settings. Official translations of the comprehensive and short-form to different languages according to INfORM requirements will enable a worldwide dissemination and implementation.

Diagnostic criteria for temporomandibular disorders-INfORM recommendations: Comprehensive and short-form adaptations for children.

BACKGROUND: The Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) are used worldwide in adults. Until now, no adaptation for use in children has been proposed. OBJECTIVE: The aim of this study was to present comprehensive and short-form adaptations of Axis I and Axis II of the DC/TMD for adults that are appropriate for use with children in clinical and research settings. METHODS: Global Delphi studies with experts in TMDs and in pain psychology identified ways of adapting the DC/TMD for children. RESULTS: The proposed adaptation is suitable for children aged 6-9 years. Proposed changes in Axis I include (i) adapting the language of the Demographics and the Symptom Questionnaires to be developmentally appropriate for children, (ii) adding a general health questionnaire for children and one for their parents, (iii) replacing the TMD Pain Screener with the 3Q/TMD questionnaire and (iv) modifying the clinical examination protocol. Proposed changes in Axis II include (i) for the Graded Chronic Pain Scale, to be developmentally appropriate for children, (ii) adding anxiety and depression assessments that have been validated in children and (iii) adding three constructs (stress, catastrophising and sleep disorders) to assess psychosocial functioning in children. CONCLUSION: The recommended DC/TMD, including Axis I and Axis II, for children aged 6-9 years, is appropriate for use in clinical and research settings. This adapted the first version for children includes changes in Axis I and Axis II changes requiring reliability and validity testing in international settings. Official translations to different languages according to INfORM requirements will enable a worldwide dissemination and implementation.

Diagnostic criteria for temporomandibular disorders in children and adolescents: An international Delphi study-Part 2-Development of Axis II.

BACKGROUND: Unlike the psychosocial assessment established for adults in the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD), a standardised psychosocial assessment for children and adolescents with TMD complaints has not yet been established. OBJECTIVES: To develop a new standardised instrument set to assess the psychosocial functioning in children and adolescents by adapting the psychosocial status and pain-related disability (Axis II) of the adult DC/TMD and by including new instruments. METHODS: A modified Delphi method was used to survey 23 international TMD experts and four international experts in pain-related psychological factors for consensus regarding assessment tools for psychosocial functioning and pain-related disability in children and adolescents. The TMD experts reviewed 29 Axis II statements at round 1, 13 at round 2 and 2 at round 3. Agreement was set at 80% for first-round consensus level and 70% for each of the second and third rounds. The psychological experts completed a complementary Delphi survey to reach a consensus on tools to use to assess more complex psychological domains in children and adolescents. For the psychological experts, the first round included 10 open-ended questions on preferred screening tools for depression, anxiety, catastrophising, sleep problems and stress in children (ages 6-9 years old) and adolescents (ages 10-19 years old) as well as on other domains suggested for investigation. In the second round, the psychological experts received a 9-item questionnaire to prioritise the suggested instruments from most to least recommended. RESULTS: The TMD experts, after three Delphi rounds, reached consensus on the changes of DC/TMD to create a form to evaluate Axis II in children and adolescents with TMD complaints. The psychological experts added tools to assess depression and anxiety, sleep disorders, catastrophising, stress and resilience. CONCLUSION: Through international expert consensus, this study adapted Axis II of the adult DC/TMD to assess psychosocial functioning and pain-related disability in children and adolescents. The adapted Axis II protocols will be validated in the target populations.

Diagnostic criteria for temporomandibular disorders (DC/TMD) for children and adolescents: An international Delphi study-Part 1-Development of Axis I.

BACKGROUND: Since in children and adolescence prevalence is assessed mainly on self-reported or proxy-reported signs and symptoms; there is a need to develop a more comprehensive standardised process for the collection of clinical information and the diagnosis of TMD in these populations. OBJECTIVE: To develop new instruments and to adapt the diagnostic criteria for temporomandibular disorders (DC/TMD) for the evaluation of TMD in children and adolescents. METHOD: A modified Delphi method was used to seek international consensus among TMD experts. Fourteen clinicians and researchers in the field of oro-facial pain and TMD worldwide were invited to participate in a workshop initiated by the International Network for Orofacial Pain and Related Disorders Methodology (INfORM scientific network) at the General Session of the International Association for Dental Research (IADR, London 2018), as the first step in the Delphi process. Participants discussed the protocols required to make physical diagnoses included in the Axis I of the DC/TMD. Thereafter, nine experts in the field were added, and the first Delphi round was created. This survey included 60 statements for Axis I, and the experts were asked to respond to each statement on a five-item Likert scale ranging from 'Strongly disagree' to 'Strongly agree'. Consensus level was set at 80% agreement for the first round, and at 70% for the next. RESULTS: After three rounds of the Delphi process, a consensus among TMD experts was achieved and two adapted DC/TMD protocols for Axis I physical diagnoses for children and adolescents were developed. CONCLUSION: Through international consensus among TMD experts, this study adapted the Axis I of the DC/TMD for use in evaluating TMD in children and adolescents.

Internet-based treatment for adolescents with symptomatic temporomandibular joint disc displacement with reduction. A randomized controlled clinical trial.

OBJECTIVE: To evaluate treatment outcome of a jaw exercise (JE) intervention program combined with an information/counselling program (IC) vs. information/counselling alone. MATERIALS AND METHODS: A clinical sample of 83 adolescents, experiencing painful clicking or catching/locking of the jaw, and diagnosed with symptomatic disc displacement with reduction according to RDC/TMD, were randomly assigned to JE/IC or IC program. Both programs were internet-delivered. The adolescents were examined clinically at baseline, at a 2-month mid-evaluation, and at 4months posttreatment by examiners blinded to which programs the adolescents were assigned to. RESULTS: The JE/IC group showed significantly more improvements of painful catching/locking (p = .017), eating ability (p = .006) and of their jaw function limitation (p = .026) compared to the IC group. Significantly more adolescents in the JE/IC group also reported a ≥50% improvement of the catching/locking of the jaw with pain (p = .024) and for eating ability (p = .034) based on a severity index. Treatment method credibility and satisfaction were also significantly higher in the JE/IC group. CONCLUSION: The internet-delivered JE/IC program showed a better outcome compared to IC alone. The former is thus a feasible and cost-effective treatment for adolescents with symptomatic disc displacement with reduction.

The course of pain intensity and frequency of adolescents treated because of temporomandibular disorders: A long-term follow-up.

OBJECTIVES: To evaluate the course of pain intensity and frequency related to temporomandibular disorders (TMDs) 15 years (range 5-21 years) after having received TMD treatment as adolescents due to frequent (at least once a week) TMD pain in two controlled trials. MATERIALS AND METHODS: In the first trial, subjects (n = 122) were randomly allocated to either information only, received in a control condition (Co), or information and an occlusal appliance (OA) versus relaxation therapy (RT). In the second trial, including 64 subjects, nonresponders to OA or RT were subsequently allocated to the alternate treatment (ST). All study participants having completed the trials (n = 167) were invited to a long-term follow-up evaluations, with a response rate of 69.5% (n = 116). Patient-reported outcomes of TMD-related frequency and intensity were appraised relative to baseline data and short-term outcomes as observed in the two trials by use of general linear mixed model and generalized estimation equation statistics. RESULTS: A significantly higher proportion of participants treated with OA and in the combined RT/Co condition than those in the ST group, reported a frequency level of TMD pain less than once week at post-treatment and the long-term follow-up. Adolescents treated with OA showed significantly lower TMD pain intensity levels post-treatment than those in the other two treatment conditions. While no difference between the OA and the RT/Co conditions was found in the long-term follow-up, participants in these two conditions were significantly more improved than those in the ST group. CONCLUSION: Adolescents treated with an OA clearly showed better outcome with regard to intensity and frequency in a long-term follow-up of TMD pain than those treated with RT and ST for nonresponders. These latter individuals need special clinical attention and more effective supplementary treatment methods to be developed.

Orofacial pain in juvenile idiopathic arthritis is associated with stress as well as psychosocial and functional limitations.

BACKGROUND: The aim of this study was to investigate relations between psychosocial factors, signs and symptoms of orofacial pain and jaw dysfunction in patients with juvenile idiopathic arthritis (JIA). METHODS: Forty-five patients with JIA (median age 12 years) and 16 healthy matched controls (median age 13 years) were examined according to the diagnostic criteria for temporomandibular disorders (DC/TMD). The subjects answered the DC/TMD questionnaires regarding psychosocial factors (pain intensity, pain-related disability, depression, stress, catastrophizing, pain locations and jaw function). RESULTS: JIA patients with orofacial pain had higher degree of stress, depression, catastrophizing and jaw dysfunction compared to subjects without. In turn, these factors were associated with orofacial pain intensity. Also, patients with orofacial pain had higher systemic inflammatory activity. CONCLUSIONS: Orofacial pain in patients with JIA is associated with stress, psychological distress, jaw dysfunction and loss of daily living activities. Pain intensity seems to be the major pain aspect related to these factors. In addition, systemic inflammatory activity appears to be an important factor contributing to orofacial pain in JIA.

Long-term treatment outcome for adolescents with temporomandibular pain.

OBJECTIVES: This study aims to evaluate long-term, self-perceived outcome in adulthood for individuals treated as adolescents for temporomandibular disorder (TMD) pain in two previous randomized controlled trials (RCTs). MATERIALS AND METHODS: The study included 116 subjects (81% females) treated for frequent TMD pain in two separate RCTs 5-21 (M = 14.8, SD =4.9) years previously. Treatment consisted of occlusal appliance (OA) (n = 41, 35.3%) or relaxation training (RT) combined with information for the control (Co) group (n = 50, 43.1%), both compared to non-responders receiving additional, sequential treatment (ST) in a crossover study (n = 25, 21.6%). Participants answered a questionnaire on their experience of frequency and intensity of TMD pain impaired chewing capacity and daily social activities, help-seeking behaviour and treatment, general health, other pain, and depressive symptoms. RESULTS: Older participants reported lower levels of frequency and intensity of TMD pain, impairment, and depressive symptoms, as well as better general health. Females reported more frequent and more intense TMD pain, greater impairment and more often reported 'other pain' compared to males. Non-responders receiving ST experienced significantly more TMD, and other pain and higher impairment levels compared to other groups. Those treated with an OA had sought additional treatment significantly less often since the RCTs than ST and RT/Co-treated individuals. CONCLUSIONS: Adolescents treated with OA showed somewhat better sustained improvement over the extended follow-up period than those treated with RT/Co. Non-responders to treatment and females exhibited a poorer outcome. These groups need particular attention and extended or different treatments to achieve a better long-term outcome.

Predictors of Clinically Significant Outcome for Adolescents with Temporomandibular Disorders.

AIMS: To evaluate and identify baseline characteristics of the adolescent patients included in two previous randomized controlled trials (RCTs) that may predict a clinically significant outcome after treatment of temporomandibular disorders (TMD) with an occlusal appliance (OA) or relaxation training (RT) in a clinical sample of adolescents. METHODS: This study combined two patient samples from the earlier RCTs for a total of 167 adolescents with frequent TMD pain (once a week or more often), diagnosed according to the Research Diagnostic Criteria for TMD. They were treated with OA, RT, or received information only (control). Outcome (response to treatment vs nonresponse) was assessed using four measures: the Patient Global Impression of Change (PGIC), pain intensity rated on a numeric rating scale (NRS), pain frequency levels, and pain severity levels prospectively recorded in a pain diary. Predictors of outcome were evaluated posttreatment for the whole sample and at 6 months follow-up for participants from the first trial. Associations and differences between groups obtained in the bivariate analyses were further examined in subsequent multivariate logistic regression analyses. RESULTS: At posttreatment, treatment condition (OA being more effective than RT/control), gender (boys being more responsive than girls), arthralgia (predicting lower response), lower levels of somatic complaints (predicting better response), and shorter TMD pain history (predicting better response) emerged as significant predictors of a clinical response. At 6-month follow-up, lower consumption of analgesics and shorter TMD pain history emerged as significant predictors of treatment outcome, while treatment condition approached significance after multivariate analysis. CONCLUSION: This study revealed that treatment condition and gender were the most consistent predictors of a clinically significant outcome across outcome measures in a clinical sample of adolescents with TMD. Treatment with OA reduced TMD pain in the adolescents.

Treating temporomandibular disorders in adolescents: a randomized, controlled, sequential comparison of relaxation training and occlusal appliance therapy.

AIMS: To compare the effects of occlusal appliance therapy (OA) and therapist-guided relaxation training (RT) on temporomandibular disorder (TMD) pain in adolescents, thereby replicating a previous randomized controlled trial, and to explore whether additional therapy administered in a crossover sequential design improves treatment outcomes. METHODS: The study involved 64 adolescents, aged 12 to 19 years, experiencing TMD pain at least once a week and diagnosed with myofascial pain in accordance with the Research Diagnostic Criteria for TMD. For phase 1 of the study, subjects were randomly assigned to OA or RT; nonresponders were offered the other treatment in phase 2. Self-reports of TMD pain and clinical assessments were performed before and after treatment in each phase and 6 months after the last treatment phase. Differences in outcomes between treatment groups across the different phases were analyzed by analysis of covariance (ANCOVA), and for differences in proportions, the chi-square test was used. RESULTS: After phase 1, a significantly higher proportion of adolescents treated with OA (62.1%) than those treated with RT (17.9%) responded to treatment, defined as a subjective report of "Completely well/Very much improved" or "Much improved." Similar differences in self- report of treatment effect occurred after phase 2. About two-thirds of all adolescents in both phases reported such an improvement level at the 6-month follow-up, including a somewhat higher proportion of phase 1 responders (79.2%) than phase 1 nonresponders (60%). CONCLUSION: The findings suggest that, for adolescents with TMD pain, use of standardized clinical treatment with OA is more effective than RT on self-evaluation of treatment improvement. For nonresponders, subsequent crossover treatment might be useful to improve subjective TMD pain.

The relationship between somatic and emotional stimuli: a comparison between adolescents with temporomandibular disorders (TMD) and a control group.

The overall purpose of this study was to determine whether adolescents with chronic temporomandibular disorder (TMD) pain are more sensitive to all types of somatic and emotional stimuli compared with a matched healthy control group. Sixty adolescents, 8 boys and 52 girls ranging from 12 to 18 years, participated in the study. Thirty of the subjects exhibited TMD, reporting pain of at least 3 months duration. The age- and gender-matched control group consisted of 30 dental recall patients who reported TMD pain less than once a week. All participants completed a 40-item questionnaire comprising 10 items each of pleasant and aversive qualities crossed with somatic and emotional forms of stimuli. The items, a selection of a broad range of familiar stimuli by a panel of experts, were rated based on intensity of experience (0-10, numerical rating scale). Well-fitting items that formed a valid construct within each of the four domains were selected using Rasch analysis. The results showed that adolescents with TMD pain reported significantly greater sensitivity (p<0.05) to aversive somatic and pleasant somatic stimuli than the controls. The differences between groups for the aversive emotional and pleasant emotional stimuli were non-significant. These findings suggest that chronic TMD pain states in adolescents are accompanied by amplification of bodily, but not purely emotional stimuli and that cognitive systems are implicated, not only an alteration of the nociceptive systems.

Treatment of temporomandibular disorders among adolescents: a comparison between occlusal appliance, relaxation training, and brief information.

In a randomized trial the effects of occlusal appliance and relaxation therapy, each combined with brief information, were compared with brief information only, in adolescents with temporomandibular disorder (TMD) pain. One-hundred-and-twenty-two adolescents (93 F and 29 M aged 12-18 years) were randomly assigned to one of the following 3 groups: brief information + occlusal appliance (BI + OA), brief information + relaxation therapy (BI + RT), or brief information (BI). Included were subjects reporting pain once a week or more often, in addition to receiving a diagnosis of TMD according to the Research Diagnostic Criteria (RDC/TMD). They were evaluated before and after treatment and at a 6-month follow-up by means of self-reports and clinical assessment. The result revealed a significantly higher reduction in frequency of pain, in pain intensity (visual analog scale [VAS]), and in a composite pain index (intensity x frequency) for patients treated with BI + OA compared with those treated with BI alone. In the BI + OA group, 60% of the patients attained a clinically significant improvement (at least 50% or more) on the pain index, a significantly higher proportion compared to that obtained in the other 2 treatment groups. Analgesic consumption was also significantly more reduced in the BI + OA group compared to the BI group. However, no significant differences were found between the treatment groups in jaw opening or in muscle and TMJ tenderness scores. Occlusal appliance was found to be superior to both relaxation therapy and brief information regarding pain reduction and can therefore be recommended when treating adolescents with TMD pain.

Temporomandibular disorders in adolescents. Epidemiological and methodological studies and a randomized controlled trial.

The aim of the present thesis was to investigate different aspects of temporomandibular disorders (TMD) and pain such as prevalence, diagnostics, and treatment among adolescents. The reliability of a questionnaire and the clinical examination and diagnoses according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) were assessed. Overall, we found it possible to assess and diagnose TMD in adolescents in a reliable way. The prevalence of TMD pain, gender differences, and the need for treatment were investigated among 864 adolescents from a Public Dental Service clinic. Seven percent of the subjects received a pain diagnosis according to the RDC/TMD, and the prevalence was higher among girls than boys. More subjects with TMD pain reported school absence and analgesic consumption compared to controls. Approximately every second subject who reported TMD pain also perceived a need for treatment. In an evaluation of psychosocial and dental factors, the following were found to play an important role in adolescents with TMD: stress, somatic complaints, and emotional problems. Three treatment methods were compared in a randomized controlled trial: brief information only, brief information and occlusal appliance, and brief information and relaxation therapy. In the brief information and occlusal appliance group, 60%--significantly more than in the other two groups--experienced a reduction of at least 50% in TMD pain. The influence of somatic and emotional stimuli was evaluated, and we found that adolescents with TMD pain were significantly more sensitive to not only aversive somatic but also pleasant somatic stimuli compared with healthy controls. The results suggest that not only nociceptive but also cognitive processes are implicated in chronic pain states in young TMD subjects. In conclusion, TMD pain is more common in girls than in boys and affects daily life. TMD pain in adolescents can best be improved by traditional treatment with occlusal appliance combined with brief information.