Evaluating psychosocial functioning in dental patients

In order to make a reliable diagnosis and offer appropriate treatment, it is important that the dentist is aware of the role played by psychosocial factors in the origin and persistence of dental problems and has the ability to recognise their importance in the patient's overall presentation. This paper is an attempt to improve dentist's awareness of psychosocial issues and recognition of possible psychological problems in general dental practice. It focuses on directions for the gathering of information on patients through careful assessment prior to dental examination, covering patients biological or physical history and present symptoms, their social background, their psychological history and mental functioning, and the observation of their behaviour and mood. It is argued that interpreting these types of information will enable the dentist to be better prepared for any pitfalls that may arise in the course of treatment.     

Clinical TMD, pain-related disability and psychological status of TMD patients

This study investigated the clinical temporomandibular disorders (TMD), pain-related disability and psychological status of TMD patients using a computerized on-line TMD diagnostic system (NUS TMD v1.1). A total of 107 patients (32 male, 75 female) referred to the TMD clinics at the National Dental Centre and National University Hospital participated in this study. The mean age of the predominantly Chinese population (82.2%) was 30.8 years (range from 12 to 64 years). The history questionnaire and clinical examination were input directly into computers by patients and clinicians. A 'Summary of Findings' was then immediately generated by the program based on Axis I and II rules. The data was subsequently exported to SPSS for statistical analysis. About 20.6% of the patients had myofascial pain but only 7.5% experienced limited mandibular opening associated with myofascial pain. The majority of patients (> 80%) did not suffer from disc displacements (right and left joints). The frequency of arthralgia was also low (right joint 8.4%; left joint 7.5%) and only one patient had osteoarthosis of the TMJ. About 78.5% of the patients had low disability with almost equal distribution between low and high intensity pain, 27.1% of the patients were moderately depressed and 11.2% had severe depression. No significant difference in limitations related mandibular functioning scores was observed between normal/depressed patients and between patients with the different graded chronic pain severity classification. The three most frequent jaw disabilities were: eating hard foods (77.6%), yawning (75.7%) and chewing (64.5%). NUS TMD v1.1 is an extremely useful tool in the diagnosis/research of clinical TMD.     

Insufficient diagnostic accuracy of a single-item questionnaire to detect psychosocial distress in temporomandibular disorder patients

Objectives

Psychosocial assessment needs to be integrated into the diagnosis of chronic pain conditions; however, it is not clear how this assessment should be performed with minimal patient and health care provider burden. The aim of this study was to assess the diagnostic accuracy of a single-item questionnaire to detect psychosocial distress in temporomandibular disorder (TMD) patients.

Methods

Presence of psychosocial distress was measured in 126 TMD patients using Research Diagnostic Criteria for TMD Axis II measures (depression, somatization, dysfunctional chronic pain). A newly developed single-item questionnaire served as a test to detect psychosocial distress. The association between the presence of distress and test results was analyzed using generalized linear models (GLM). Diagnostic accuracy of the one-item test was assessed.

Results

The GLM revealed a statistically significant association between the presence of psychosocial distress and a positive test result (p?<?0.001). Psychosocially distressed patients were 70 % more likely to indicate psychosocial distress in the single-item questionnaire than patients without distress. However, diagnostic test accuracy of the single-item questionnaire was low (sensitivity 73.0 %, specificity 55.7 %). The resulting positive likelihood ratio (1.65) indicated that the single-item test is an inadequate measure for detecting psychosocial distress.

Conclusions

The single-item questionnaire was not sufficiently accurate for detecting TMD patients’ psychosocial distress and may therefore not be useful as an assessment tool for the various dimensions of psychosocial distress in TMD patients.

Clinical relevance

Health care providers should not trust in TMD patients’ responses to a single question regarding psychosocial distress. Nevertheless, this questionnaire may constitute a first step into a more profound patient–provider communication on psychological issues relevant to TMD.     

Parent reports of the psychosocial functioning of children with cleft lip and/or palate.

OBJECTIVES: (1) to determine the opinion of parents regarding the psychosocial functioning of their child with cleft lip and/or palate (CLP); (2) to identify predictors of psychosocial functioning; and (3) to determine the level of agreement between children with CLP and their parents. Participants: One hundred twenty-nine parents of children with CLP and 96 parents of children without CLP participated in this cross-sectional study. OUTCOME MEASURES: Parental opinion of the child's self-esteem, anxiety, happiness, and problems caused by facial appearance were assessed using visual analogue scales. Parents completed the Child Behavior Checklist and were interviewed. RESULTS: Children with CLP were more anxious (p < 0.05), less happy with their appearance (p < 0.001), and in general (p < 0.05) had lower self-esteem (p < 0.05) and greater behavioral problems (p < 0.001) compared with non-CLP children. Parents reported that their child with CLP was teased more often (p < 0.001) and was less satisfied with his/her speech (p < 0.01) compared with reports of parents in the control group. A number of factors affected parents' ratings of their child's psychosocial functioning (presence of CLP, appearance happiness, previous history of CLP, and visibility of scar). Children who had been teased were more anxious (p < or = 0.01), less happy with their appearance (p < 0.001) and had greater behavioral problems (p < 0.001). CONCLUSIONS: Parents of children with CLP reported various psychosocial problems among their children. Parents considered children who had been teased to have greater psychosocial problems.     

Correlation between pain and MRI findings in TMD patients

Introduction

Magnetic resonance imaging has been established as the gold standard for assessment of the temporomandibular joint. Apart from an excellent assessment of the soft tissues it has the advantage not to expose the patient to ionizing radiation. There is a lack of literature concerning the correlation between pain intensity and radiological findings of the temporomandibular joint. Moreover there is the question of whether a progressive degeneration of the cartilaginous components is accompanied by an increasing degeneration of the osseous parts of the mandibular joint and vice versa. Therefore, this study aims at analyzing correlations between pain and radiological findings. Furthermore, the link between osseous and cartilaginous degeneration is studied.

Hostility in TMD/bruxism patients and controls: a clinical comparison study and preliminary results

This study involved a group of 110 TMD/bruxing behavior patients (30 mild, 40 moderate, and 40 severe bruxers) which was compared to a group of 40 nonTMD/nonbruxer controls, with the objective to test the alternative hypothesis that, regarding hostility, there were significant differences between these groups. The mean age in the group of TMD/bruxers was 31.81 years (SD: 11.2, range 14-61) and in the control group was 30.03 (SD: 10.96, range 16-66). Patients were initially classified as presenting TMD and bruxing behavior according to previous criteria. The Cook-Medley Inventory and the Beck Depression Inventory were used to assess levels of hostility and depression, respectively, in bruxers and controls. There were no statistically significant differences in the levels of depression between the three groups of bruxers. However, the difference between the groups of bruxers and controls reached significance (unpaired t test P<0.001). Our results indicated that there was not statistically and significant difference in the levels of hostility between the three groups of bruxers and between the mild group of bruxers and control group. However, there were statistically and significant differences in the level of hostility between the moderate group of bruxers and the control group (P<0.01), and between the severe group of bruxers and the control group (P<0.05). When bruxers were classified into two groups: one presenting minimal to mild depression (N:31) and the other presenting moderate to severe depression (N:19), the group presenting moderate to severe depression demonstrated a level of hostility of about 23.36. The group presenting minimal to mild depression demonstrated a level of hostility of about 17.32, and this difference was statistically significant (unpaired t test, P<0.0004). These results suggest that in these subgroups of TMD/bruxers, increased depression corresponds to increased hostility and provides support for previous investigations indicating that there is a relationship between hostility and bruxism (but only in the groups with moderate and severe bruxism).     

Validity of three screening questions (3Q/TMD) in relation to the DC/TMD

Temporomandibular disorders (TMD) are common but seem to be largely undetected within general dental care. To improve dentists’ awareness of these symptoms, three screening questions (3Q/TMD) have been introduced. Our aim was to validate 3Q/TMD in relation to the diagnostic criteria for TMD (DC/TMD), while taking into account the severity level of the symptoms. The study population consisted of 7831 individuals 20–69 years old, who had their routine dental check‐up at the Public Dental Health Service in Västerbotten, Sweden. All patients answered a health declaration, including the 3Q/TMD regarding frequent temporomandibular pain, pain on movement and catching/locking of the jaw. All 3Q‐positives (at least one affirmative) were invited for examination in randomised order. For each 3Q‐positive, a matched 3Q‐negative was invited. In total, 152 3Q‐positives and 148 3Q‐negatives participated. At examination, participants answered 3Q/TMD a second time, before they were examined and diagnosed according to DC/TMD. To determine symptom's severity, the Graded Chronic Pain Scale and Jaw Functional Limitation Scale‐20 (JFLS‐20) were used. In total, 74% of 3Q‐positives and 16% of 3Q‐negatives met the criteria for DC/TMD pain or dysfunction (disc displacements with reduction and degenerative joint disorder were excluded). Fifty‐five per cent of 3Q‐positives had a TMD diagnosis and CPI score ≥3 or a JFLS‐20 score ≥5, compared to 4% of 3Q‐negatives. The results show that the 3Q/TMD is an applicable, cost‐effective and valid tool for screening a general adult population to recognise patients in need of further TMD examination and management.     

Variability of centric relation position in TMD patients

Reproducibility of the centric relation position for patients with temporomandibular disorders (TMD) is not documented in the current literature. It was the objective of this study to assess clinical variability of the centric relation position for TMD patients with a muscle-determined technique by means of an anterior deprogramming device, the leaf gauge. A sample of 60 patients with signs of TMD was selected, 8 men (Mean age 28,6, SD 5,2) and 52 women (Mean age 30,5, SD 10,1). All patients were examined with the Research Diagnostic Criteria, including pain on movement and/or function, mouth opening, joint sounds and palpation of masticatory muscles. All 60 patients were allocated to one of the following diagnostic subgroups: myofascial pain, disk displacement with reduction, disk displacement without reduction, osteoarthritis, trauma. Twelve control subjects were taken from a previous study. Three sequential centric relation records were taken; the first one was used to mount a set of casts to an articulator. Criteria of precision were formulated beforehand: 2 out of 3 centric relation records had to be identical in a split-cast procedure. Variables XL and XR represented mandibular displacement in the sagittal plane, variables YL and YR in the transversal plane, and ZL and ZR in the vertical plane, on the left and right condylar level respectively. Variables XMIN, YMIN and ZMIN represented the minimal sagittal, transversal and vertical displacement left or right respectively. Likewise, variables XMAX, YMAX and ZMAX represented the maximal sagittal, transversal and vertical displacement left or right. XDIFF, YDIFF and ZDIFF represented the difference between the minimal and maximal values of X, Y and Z. The diagnostic subgroup trauma was excluded, because there was only one patient. The null-hypothesis of no between-group differences in within-subject and total variability was tested with an analysis of variance (ANOVA). The level of significance was set at 0.05. To minimize type I errors caused by multiple testing Scheffe's test was used to maintain an overall significance of 0.05. No significant difference between patients and control subjects could be found for variables XL, XR, YL, YR, ZR and ZL. Variables XMIN, YMIN, ZMIN, XMAX, YMAX, ZMAX, XDIFF, YDIFF and ZDIFF showed no significant differences. Scheffe's testing for the variables XL, XR, YL, YR, ZL and ZR, as well as the variables XMIN, YMIN, ZMIN, XMAX, YMAX, ZMAX, XDIFF YDIFF and ZDIFF showed no significant differences. The results of this study suggest no variability in centric relation position between TMD-patients and control subjects by means of the leaf gauge.     

Clinical diagnoses and MRI findings in patients with TMD pain

The aim of this study was to compare the findings on magnetic resonance imaging (MRI) in temporomandibular disorders (TMD) pain patients with clinical diagnoses of myofascial pain or arthralgia/osteoarthritis in combination with myofascial pain according to the Research Diagnostic Criteria for TMD. The temporomandibular joints of 60 consecutive patients, 19 with myofascial pain and 41 patients with arthralgia/osteoarthritis in combination with myofascial pain were examined clinically and with MRI. Overall the most common MRI findings were different kinds of disc displacements and structural bone changes, which were found in both pain groups. However, disc displacements were found significantly (P=0.002) more often in the group arthralgia/osteoarthritis in combination with myofascial pain. One hundred and four joints were found to have no clinical diagnosis of disc displacements, but 64 of these joints had findings of disc displacements on MRI. Joint fluid was found in both pain groups. Patients having a combination of disc displacement and joint fluid were significantly (P=0.047) more common in the pain group arthralgia/osteoarthritis in combination with myofascial pain. In conclusion, the MRI findings of different kinds of disc displacement and structural bone changes were common in TMD patients. The clinical diagnoses for subdivision into myogenous only or combined arthrogenous and myogenous pain groups were not confirmed by MRI.     

Masticatory function in subacute TMD patients before and after treatment

Summary  Masticatory function can be impaired in temporomandibular disorders (TMDs) patients. We investigated whether treatment of subacute non-specific TMD patients may influence oral function and clinical outcome measures. Fifteen patients with subacute TMD participated in the study. We quantified masticatory performance, maximum voluntary bite force, muscle activity and chewing cycle duration before and after treatment. Masticatory performance and bite force of patients were compared with the results obtained for an age- and gender-matched group of subjects without TMD complaints. Furthermore, we determined possible changes in anamnestic and clinical scores from questionnaires (mandibular function impairment questionnaire; MFIQ), pain scores and clinical outcome measures. Maximum bite force significantly increased, although the values after treatment were still significantly lower than those of the subjects without TMD complaints. The corresponding electromyography values did not show significant change after treatment. The masticatory performance of the patients remained unaltered; patients chewed significantly less efficient than controls. The average duration of chewing cycles significantly decreased after treatment. We observed a significant improvement in MFIQ scores. During the clenching and chewing tasks, the visual analogue scale scores were significantly higher than before these tasks. We may conclude that subacute temporomandibular joint disorders negatively influence chewing behaviour. Bite force, chewing cycle duration and also perceived mandibular function significantly improved after treatment, although the masticatory performance remained unaltered.     

145例颞下颌关节紊乱病患者的磁共振影像分析

目的 研究145例颞下颌关节紊乱病（TMD）患者的磁共振（MRI）影像学表现,为临床治疗提供依据。方法 利用MRI对145例TMD患者的290侧关节完成开闭口斜矢状位、闭口斜冠状位T1/T2加权成像,观察盘突关系,髁突骨质改变,关节腔积液,关节盘形态改变等情况,并进行分类统计。结果 MRI检查结果显示：37.2%患者双侧TMD病变,71%患者伴有不可复关节盘前移位,10.3%患者伴有可复性关节盘前移位,6.9%患者伴有髁突骨质改变,4.8%患者伴关节腔积液,52.4%患者伴关节盘明显变形。结论 TMD患者中以关节盘不可复性前移位最为常见,提示正常盘突关系的重要性。MRI可以为临床医师提供可靠的影像学诊断依据。     

DC/TMD推荐心理量表在颞下颌关节紊乱病诊疗中的应用

目的: 采用新版DC/TMD推荐的心理量表,评估颞下颌关节紊乱病（temporomandibular disorders, TMD）患者焦虑、抑郁及躯体症状等心理状况,探讨新版量表作为TMD心理轴诊断依据的临床意义。方法: 选择100例TMD初诊患者作为实验组,100例无TMD症状的普通门诊患者作为对照组。收集2组患者的一般信息,包括年龄、性别、受教育程度、个人收入等。采用广泛性焦虑症量表（GAD-7）、抑郁症状量表（PHQ-9）和健康问卷量表15（PHQ-15）对患者心理因素进行评估。采用SPSS 20.0软件包对数据进行统计学分析。结果: <30岁组和30~50岁组TMD发病率显著高于50岁以上年龄组（P<0.05）。实验组高学历者比例显著高于对照组（P<0.05）,而收入水平不是罹患TMD的危险因素（P=0.642）。实验组焦虑发生率与平均得分显著高于对照组（P<0.05）,而两组间抑郁和躯体症状得分无统计学差异（P>0.05）。疼痛性TMD患者的焦虑和抑郁程度显著高于关节疾病患者（P<0.05）,而两组间躯体症状无显著差异（P>0.05）。结论: 性别（女）、年龄（<50岁）和高学历（本科及以上）是罹患TMD的高危因素,而与收入水平无关。TMD患者的焦虑发生率和评分均高于普通口腔门诊患者,但抑郁和躯体症状与普通患者的发生率无显著差异。     

关节盘无移位的症状性颞下颌关节的核磁共振研究

目的：本研究的目的是应用核磁共振成像（MRI）诊断颞下颌关节紊乱病（TMD），讨论在关节盘位置正常的TMD关节中的核磁共振影像发现，并探讨这些影像发现与临床症状间的关系。方法：本研究对2000－2002年期间在芬兰欧鲁大学牙学院颌面外科就诊的78名TMD患中，经MRI发现为关节盘位置正常的68侧关节作了影像及临床症状的对比分析。结果：在此68侧关节MRI中，发现了髁突运动异常：过度运动（61.8%）及运动受限（2.9%）；发现了怀疑为翼外肌上头和／或下头的肥大、萎缩及挛缩等病理改变（58.9%）。在关节盘形态方面，未发现明显的关节盘畸形，但发现了关节盘整体变厚的病理影像表现（22.1%），还到涉及关节囊上腔、下腔和／或双板区的炎性渗出（35.3%）。髁突过度运动及翼外肌病理改变与症状组有显性关系。结论：本研究的结果提示，髁突过度运动及可能发生的翼外肌病理改变，在引起关节盘位置正常的颞下颌关节的临床TMD症状中，扮有十分重要的角色。     

Diagnostic sub-types, psychological distress and psychosocial dysfunction in southern Chinese people with temporomandibular disorders

Summary  The study aimed to assess the distribution of temporomandibular disorders (TMD) sub-types, psychological distress and psychosocial dysfunction in southern Chinese people seeking treatment for TMD using Research Diagnostic Criteria for TMD (RDC/TMD) and investigate potential cross-cultural differences in sub-type prevalence and psychosocial impact. Eighty-seven consecutive patients (77 females; 10 males) with a mean age of 39·3 years (s.d. 12·8) newly referred to the specialist TMD clinic at the Prince Philip Dental Hospital, Hong Kong over a 20-month period took part in the study. RDC/TMD history questionnaire and clinical assessment data were used to derive Axis I and II findings. Group I muscle disorders were the most common and found in 57·5% of patients. Group II (disc displacement) disorders were found in 42·5% and 47·1% of the right and left temporomandibular joints (TMJ) respectively. Group III disorders (arthralgia/arthrosis/arthritis) were revealed in 19·5% and 23·0% of right and left TMJ's respectively. In the Axis II assessment, 42·5% of patients had moderate/severe depression scores, 59·7% had moderate/severe somatization scores and based on graded chronic pain scores 15·0% had psychosocial dysfunction (grade III and IV). While acknowledging the small sample size, the distribution of RDC/TMD Axis I and II diagnoses was fairly similar in Chinese TMD patients compared with Western and other Asian patient groups. However, in Chinese patients, myofascial pain with limited jaw opening and TMJ disc displacement with reduction were more common and a significant number experienced psychological distress and psychosocial dysfunction. The findings have implications for the management of TMD in Chinese people.