Etiological factors and temporomandibular treatment outcomes: the effects of trauma and psychological dysfunction

This paper examines the effect of trauma and psychological dysfunction as etiological factors in temporomandibular disorder (TMD). It employs a thoroughly validated measurement system, the TMJ Scale, to determine the effects of traumatic temporomandibular joint injury as well as pre-treatment stress and psychological dysfunction levels upon presenting symptom levels. It also addresses these parameters for the eventual treatment outcome. During the course of the study, 754 patients were evaluated at the author's practice, which is limited to the diagnosis and Phase I treatment of temporomandibular dysfunction. Of those individuals, 693 (91.9%) were found to have clinically treatable temporomandibular disorders. At the time of this study, 201 consecutive patients (29%) have completed treatment and were deemed to have reached Maximum Medical Improvement (MMI). The validated measurement system of the TMJ Scale was readministered to this post treatment population. Data analysis revealed that trauma patients did not differ from non-trauma patients in initial symptom levels, nor in levels of symptom improvement (with the exception of a higher palpation pain level reported by the trauma patients). Stress and psychological dysfunction were predictive of higher initial symptom perception levels, but were not significantly related to treatment outcomes. These findings have important implications for practitioners in the field of temporomandibular studies. If it can be confirmed that psychological variables have no impact on treatment outcome, it would be difficult to justify the now frequently employed "dual axis" classifications and major emphasis placed on psychological treatment for temporomandibular patients.     

Clinical evaluation and psychological aspects of temporomandibular joint disorders]

Establishing the patient's clinical diagnosis depends on gathering as much information of the patient and his or her signs and symptoms as possible. This information can be gathered from history, physical and psychological examination, diagnostic analysis. It is also important to look upon pain as a disorder and to consider the relationship between pain and psychological factors. The differential diagnosis is constructed through a biopsychological model of illness rather than through a more traditional biomedical model of disease. To arrive at a consistently accurate clinical diagnosis in patients with TMJ and craniofacial pain, the technique of clinical diagnosis must be well defined, reliable and include examination of the head and the neck, cranial nerves and the stomatognathic system. The craniomandibular index provides a standardized examination of the stomatognathic system that has been tested on validity and reliability. This chapter focuses on the techniques of history taking clinical and psychological examination and diagnostic criteria for temporomandibular joint disorders and muscle pain.     

Incidence of temporomandibular joint disorders in patients seen at a hospital emergency room

A retrospective survey of a hospital emergency room population seen at an oral and maxillofacial surgery clinic during a 6-month period found 62 patients (2.7% of the total population) with temporomandibular joint disorders. The diagnoses were myofascial pain-dysfunction/temporomandibular joint dysfunction (MPD/TMJ) syndrome (70.9% of the cases) and dislocation (luxation) (22.5% of the cases). The chief complaint was well defined in relation to the diagnoses: facial pain in the MPD/TMJ syndrome cases, and displacement of the mandible in the dislocation cases.     

Symptoms of the stomatognathic system in temporomandibular and cervical spine disorders

This study was performed to assess the prevalence of signs and symptoms of temporomandibular disorders (TMD) in patients with cervical spine disorders (CSD) and to compare patients with CSD and subgroups of patients with TMD with regard to the results of orthopaedic tests of the stomatognathic system. A group of 103 consecutive patients with signs and symptoms of CSD and a group of 111 consecutive patients with TMD were examined. All subgroups of TMD patients showed a significantly smaller range of motion than the CSD patients. Patients with TMD had limited mouth opening (< 40 mm) on active and passive mouth opening more often than CSD patients. TMD patients with myogenous problems reported oral habits more often than CSD patients, although no objective differences between CSD and TMD patients were found. Subgroups of TMD patients reported joint sounds, and pain on palpation and joint play tests of the temporomandibular joint (TMJ) more frequently than CSD patients. Joint sounds on active movements, pain on palpation of the TMJ, and pain on joint play tests correctly classified 82% of the patients with TMD and 72% of the patients with CSD. In spite of the biomechanical and anatomical relationship between the neck and the stomatognathic system, the results of the study show that CSD patients have signs and symptoms of TMD comparable with those of the adult Dutch population. It was concluded that the function of the masticatory system should be evaluated in patients with neck complaints in order to rule out a possible involvement of the masticatory system.     

UNIFOLIATA regulates leaf and flower morphogenesis in pea

Signs and symptoms of craniomandibular dysfunction (CMD) and social medical history were reported in 29 subjects, aged 23-68 years, with longstanding (5 years or more) bruxing behaviour. The subjects were selected from answers to an advertisement in the local newspaper. The subjects presented many symptoms of a general character including somatic and psycho-social problems, sleep disorders (72%), and pain (86%). More than half of the subjects (55%) had symptoms every day. Frequent aches in the neck, back, throat or shoulders were reported by 69% and frequent headache by 48% of the subjects. The most common symptoms of CMD were pain in the face or jaws (48%), stiffness in the jaws in the morning (44%), temporomandibular joint (TMJ) sounds (34%) and fatigue in the jaws during chewing (38%) and the most common clinical signs were more than three muscles tender on palpation (76%), TMJ-sounds (55%) and tenderness of TMJ on lateral palpation (66%). There was a statistically significant correlation between frequent tooth clenching and headache, pain in the neck, back, throat or shoulders, sleep disorders and high scores of the clinical dysfunction index (Di). The frequent clenchers had higher score values than the 'non-clenchers' for pain in the face and the jaws; headache; pain in the neck, back, throat or shoulders and the clinical dysfunction index (Di). These findings indicate a causal relationship between frequent tooth clenching and signs and symptoms of CMD, including headache and pain in the neck, back, throat or shoulders and high pathogenicity for frequent clenching. However, the material in this study is small and some precaution must be taken prior to generalized conclusions. More studies are required, especially sleep laboratory investigations, which could perhaps give answers to some of the numerous questions in this unexplored field of odontology.     

Reliability and validity of imaging diagnosis of temporomandibular joint disorder

The purpose of this article is to review reliability and validity of imaging diagnosis of temporomandibular joint disorders. Plain-film and tomography are basic imaging techniques for assessment of the temporomandibular joint. These can be used for evaluation of osseous disease and as a baseline for follow-up. In patients with symptoms from the joint, plain-film and tomography are rarely definitive, and evaluation of the soft tissues is frequently necessary. Arthrography, computed tomography, and magnetic resonance imaging have all been used for evaluation of the soft-tissue components of the joints. Accuracy studies of these techniques have demonstrated the highest diagnostic accuracy for magnetic resonance imaging. Arthrography is relatively insensitive for detection of medial and lateral displacements. Magnetic resonance imaging accurately depicts both hard and soft tissues, and this technique is emerging as the prime diagnostic imaging technique in patients presenting with clinical signs and symptoms of a disorder of the temporomandibular joint. The most frequent findings when patients with clinical symptoms of temporomandibular joint disorders are "imaged" are different forms of disc displacement and degenerative joint disease. Studies have demonstrated a high prevalence of different forms of disc displacement in patients, although these abnormalities are also seen in some asymptomatic volunteers. Future research should further refine imaging techniques to come closer to an understanding of the association between morphologic alterations and patient symptoms.     

Stress-induced alterations of somatodendritic 5-HT1A autoreceptor sensitivity in the rat dorsal raphe nucleus--in vitro electrophysiological evidence

The role of trauma in the etiology of temporomandibular disorders (TMD) is controversial. The objectives of this study were to compare presenting signs, symptoms, and diagnoses in patients who had motor vehicle accident trauma-related TMD to patients who had nontrauma-related TMD. Files of 50 trauma and 50 matched nontrauma TMD patients were reviewed. Information concerning presenting pain, temporomandibular joint (TMJ) and related symptoms, examination findings, and diagnoses was recorded. Posttraumatic TMD patients reported higher facial (P = .006) and headache (P = .0001) pain ratings, neck symptom frequency (P < .01), ear-related symptoms (P = .02), sleep disturbance (P < .001), and occupational and avocational disability frequencies (P < .0001). They had greater masticatory muscle (P < .001), neck muscle (P < .001), and TMJ tenderness (P = .01) scores and myofascial pain (P = .006) and arthralgia/capsulitis (P = .008) diagnoses. The nontrauma group had more subjective (P = .02) and objective (P = .05) TMJ crepitus and higher self-reports of parafunctional jaw habits (P = .05). Trauma may be an important etiologic factor for some TMD patients.     

Pathology of temporomandibular joint internal derangement and osteoarthrosis

Temporomandibular joint (TMJ) osteoarthrosis and disk displacement seem to be strongly related, but they may also represent mutually independent temporomandibular disorders. This paper presents relevant aspects of normal physiology and degeneration of synovial joints, aspects of normal temporomandibular articular disk physiology and of displacement of the disk, the relationship between TMJ osteoarthrosis and disk displacement, and a general classification of temporomandibular disorders.     

Differential regulation of microglial activation by propentofylline via cAMP signaling

This study investigated sex differences in orofacial pain symptoms in a sample of elderly adults. Furthermore, differences across sex were tested on symptom continuity, overall duration, pain severity, activity reduction, and health care utilization, related to each specific symptom. Telephone interviews were conducted with a stratified random sample of community dwelling older (65+) north Floridians. A total of 5860 households were contacted and screened, with 75.3% participating to the point where their eligibility for the study could be determined. Of the remaining households, 1636 completed the interview. Of the total sample, 17.4% reported experiencing at least one of the four target orofacial pain symptoms (jaw joint pain, face pain, oral sores, burning mouth) during the past year, suggesting that orofacial pain symptoms are common in older adults. Our findings for prevalence of each specific symptom (jaw joint pain, 7.7%; face pain, 6.9%; oral sores, 6.4%; toothache, 12.0%; burning mouth, 1.7%) are similar to those estimated by the 1989 National Health Interview Survey, for the US adult population. Consistent with other epidemiological and clinical studies, we found that females were more likely to report jaw joint pain and face pain than males. In contrast to clinical studies, no differences were found on subjective ratings of pain severity, for any symptom. Differences across sex were most likely to be reported for jaw joint pain related variables, suggesting undetermined sex-uniqueness for these symptoms. In contrast to previous studies, older females tended to report lower levels of health care utilization than older males. This is the first study to our knowledge that reports orofacial symptom-specific sex differences among the elderly.     

Electronic thermography for the assessment of acute temporomandibular joint pain

Electronic thermography (ET) has the potential to be a nonionizing, noninvasive, low-cost diagnostic alternative for evaluating temporomandibular joint (TMJ) disorders. This study was designed to evaluate the use of ET as a diagnostic aid in the assessment of patients with acute TMJ pain. Computer measurements made using facial thermography were able to distinguish normal patient populations from symptomatic patients with acute TMJ pain. Additional studies are needed before thermographic diagnosis of TMJ disorders will be clinically accepted.     

The health of our children continues to improve--but... (a litany of change--Part III)

Interarch occlusal relationships are defined by temporomandibular joint (TMJ) position. Determination of the most physiologic joint position is a logical prerequisite for occlusal analysis. Existing classification systems for occlusion do not consider TMJ position or condition when relating the mandibular arch to the maxillary arch or the range of adaptive changes that can affect the position of the condyles or influence long-term occlusal stability. If the relationship between occlusion and TMJ position is as important as many clinicians believe, condylar position must be defined precisely as an essential control in any clinical study that purports to evaluate the relationship between occlusion and any masticatory system disorder to include temporomandibular disorders. This article presents a new classification system that defines the relationship between maximal intercuspation and the position and condition of the TMJs. The classification uses guidelines that are specific enough to be consistent and verifiably reproducible. A recently introduced term, "adapted centric posture," is used in this classification to distinguish deformed TMJs that have remodeled or adapted to a conformation that can comfortably accept maximal loading. This classification is necessary because deformed but adapted joints may within certain conditions function with the same degree of comfort as intact, properly aligned condyle disk assemblies in centric relation.     

Long-term follow-up study on drop-out TMD patients with self-administered questionnaires

Although patient attrition might be a serious threat to the validity of treatment-outcome studies on temporomandibular disorders (TMD), studies on TMD patient attrition are scarce. Of the 1405 consecutive TMD patients examined in a recent 10-year period, 367 (26.1%) drop-out patients or patients identified with a control group were sampled. A mailed questionnaire failed to reach 41 patients, and 203 (62.3%) were returned. The questionnaire elicited information on reasons for dropping out, changes in symptoms, treatment received in other clinics after dropping out, present treatment needs, and current signs and symptoms. Dropouts were divided into two groups: (1) those who failed to show up for their first scheduled appointment after the clinical examination; (2) those who failed to complete treatment. A group of patients who were judged by the examiner not to need treatment were included as a control group. The main reasons for dropping out were environmental obstacles, perceived improvement of the disease, and dissatisfaction with services. Only 21.7% considered themselves to be in need of treatment, and only 10.3% had visited other clinics after dropping out. Only 8.9% complained of the continued aggravation of symptoms, whereas 57.6% reported improvement. In addition, pain, dysfunction, and daily activity limitation tended to improve with time, although temporomandibular joint noise tended to persist. These results suggest that TMD signs and symptoms tend to decrease in patients after dropping out, and that the natural fluctuation of TMD signs and symptoms should be taken into consideration when treating TMD.     

The hypomobile temporomandibular joint

The hypomobile (restricted) temporomandibular joint (TMJ) is usually caused by a restricted joint capsule or by an anteriorly displaced disk. Here, painful unilateral hypomobility (19 mm jaw opening), with normal disk position, caused by voluntary immobilization after a dental procedure, was the presenting symptom. Management included inflammation control, TMJ manipulation (mobilization), and lateral pterygoid muscle relaxation. Inflammation and pain were alleviated by nonsteroidal anti-inflammatory drugs (NSAIDs) and local TMJ ice massage. TMJ mobilization was performed at every visit, to tear joint capsule adhesions and to realign collagen fibers. Exercise consisted mainly of resistive opening (the patient resists an upward force applied to the chin), with the jaw maintained at full opening. This produced lateral pterygoid muscle relaxation at full length, aiding in the restoration of a pain-free 44 mm opening.     

Temporomandibular disorders: what the neurologist needs to know

Temporomandibular disorders are a complex group of conditions which are common causes of orofacial pain and are frequently associated with headaches. Because a wide variety of diseases can ultimately cause symptoms that result in dysfunction of the masticatory system, it is important for the clinician to establish an accurate diagnosis and rule out any serious neurologic pathology. Serious extra-articular conditions often can simulate the nonspecific symptoms of a temporomandibular joint disorder. A careful history and clinical examination of the head, neck, and cranial nerves are important in establishing a differential diagnosis. Diagnostic imaging and consultation with specialists in several disciplines are often necessary to establish an accurate diagnosis and develop an appropriate therapeutic regimen.     

Social class, psychological disorder, and the nature of the psychopathologic indicator.

Evaluated the nature and degree of differences between 3 measures of clinical status often used as primary indicators of psychological disorder: (a) a general severity score, combining information on both numbers of symptoms and intensity of distress; (b) a symptom distress score, reflecting only intensity of distress; and (c) a pure enumerative indicator, reflecting only numbers of symptoms. The indicators were contrasted within the context of patient social class, since previous work has shown it to be an important influence in determining symptom patterns. A strong inverse relationship has been repeatedly demonstrated between social class and psychological disorder. Data from previous studies of 1,104 anxious neurotic outpatients were used, and measurement was done in terms of the 5 primary symptom dimensions and the total pathology score of the Hopkins Symptom Checklist. Results confirm the traditional inverse relationship between social class and psychological disorder but demonstrate that it was conditional in nature. Only when disorder was defined in terms of an indicator based to some degree on numbers of symptoms, and only on the symptom dimensions of somatization and anxiety, did the traditional pattern clearly emerge. (26 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The clinical diagnosis of heart failure in older patients

OBJECTIVE: To review the differences in presentation and clinical manifestation of heart failure in older and younger patients and to determine if these differences influence the ability to diagnose the disorder clinically. Based on this information, an approach to diagnosing heart failure in older patients is provided. DATA SOURCE: Scientific reports regarding heart failure in both the general population and the geriatric population were identified from repeated searches of MEDLINE data base and citations from appropriate articles. DATA EXTRACTION AND SYNTHESIS: Relevant data were obtained from articles, with special importance placed on studies designed to examine older patients exclusively or as a subgroup in a larger study. Review of data pertaining to clinical characteristics and presentation of heart failure was performed, with emphasis on comparing the characteristics between age groups. Specific cardiac diseases that cause ventricular impairment in older patients were assessed, and the importance of systolic versus diastolic dysfunction in this age group was analyzed. CONCLUSION: Clinical diagnosis of heart failure in older patients may be difficult because of the absence of typical symptoms and physical findings. When present, the symptoms and signs may be mistakenly diagnosed as caused by concomitant disorders or aging changes. In other older patients, the symptoms and signs will be obscured by the presence of aging changes or the presence of other diseases. As a result of these difficulties, the initial diagnosis of heart failure in older patients is made later in the course of the cardiac disease process; older patients will be more unstable, and secondary preventive therapies may be of less benefit than in younger patients with the disorder. Though clinically difficult, the differentiation between systolic and diastolic ventricular dysfunction is mandatory in all older patients with heart failure.     

Biofeedback and relaxation therapy for chronic temporomandibular joint pain: Predicting successful outcomes.

57 patients with chronic temporomandibular joint (TMJ) pain were randomly assigned to receive either relaxation or biofeedback therapy. 27 Ss (mean age 35.6 yrs) listened to tape-recorded relaxation once a week at the therapist's office for 3 sessions and were encouraged to practice daily. 30 Ss (mean age 43 yrs) participated in biofeedback sessions and were instructed to practice relaxation for 20 min/day between sessions. Results show no significant differences in outcomes. However, successful Ss in the 2 conditions differed from each other. Successful relaxation Ss tended to be younger, had TMJ pain for a shorter period of time, and reported problems with other psychophysiologic disorders. Successful biofeedback Ss were older, married, had TMJ pain for a longer period of time, and had not received prior equilibration treatment. Equilibration and presence of other disorders were related to both short- and long-term outcomes, suggesting they may be useful as predictors of outcome. It is also suggested that knowledge of pretherapy factors may allow for optimal assignment to therapy conditions. (30 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Resistance to antiretroviral drugs]

A sample of 30 subjects, 15 with and 15 without subjective temporomandibular joint (TMJ) complaints (noises, sounds), underwent a clinical examination, a sonography and an axiography, to detect TMJ clicking. The clinical examination found 22 noisy joints in a total of 60 TMJs considered. Axiography found 19 noisy joints and sonography 32. While 90% of the examined joints showed agreement between axiography and clinical examination (with a little higher sensitivity demonstrated by clinical examination with respect to axiography), 20% of the joints were positive for clicking in sonography only. Sonography showed a high sensitivity in detection of joint noises which suggests its utility as a screening test for early detection of craniomandibular disorders.     

MMPI-2 profiles of motivated fakers given specific symptom information: A comparison to matched patients.

Two groups of normal adults were given specific symptom information on posttraumatic stress disorder (PTSD) and paranoid schizophrenia, respectively, and instructed to simulate these disorders on the MMPI-2. Monetary prizes were offered for successful faking. To determine whether symptom information helped Ss produce responses that closely resembled patients' profiles, scores from fakers were compared with scores from patients with these disorders, using a 2?×?2 (Disorder?×?Response Style) ANOVA. Results showed significant differences for response style, with fakers in both groups producing lower scores on K and higher scores on F, Fb, F–K, Ds, as well as on all 10 clinical scales, than patients. The findings suggest that having specific information about the symptoms of psychological disorder does not enable fakers to avoid detection and/or produce profiles equivalent to those produced by patients with the disorder. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Masseter muscle hyperactivity and myofascial pain dysfunction syndrome: a relationship under stress

Myofascial pain dysfunction syndrome (MPD) of the temporomandibular joint (TMJ) is a psychophysiological disorder that develops because of hyperactive muscles of mastication. Ten women meeting criteria for MPD and 12 symptom-free women participated in the study. The rationale for this study was to observe cardiovascular and masseter muscle changes during four contiguous experimental periods: baseline/adaptation, reaction time, recovery, and relaxation. MPD patients showed less masseter muscle activity and higher heart rates at baseline than controls. Controls had significantly higher masseter EMG activity during reaction time. Both groups showed significant elevation in masseter muscle activity and heart rate over the 14-min reaction period. MPD patients' recovery from stress was equivalent to controls' for both heart rate and masseter muscle activity. MPD patients exhibited significantly slower reaction times than controls. The results suggest that masseter muscle hyperactivity may not account for the development and maintenance of MPD.