TMD Treatment Outcomes: A Statistical Assessment of the Effects of Psychological Variables

This study analyzes the degree to which pretreatment psychosocial factors (psychological dysfunctions and stress)effect outcome in 269 consecutive temporomandibular disorder (TMD) patients at the completion of treatment. Employing the TMJ Scale, a validated measure of TMD symptoms, it is found that pretreatment TMD pain and overall symptom levels (excluding internal derangement symptoms) are weakly but nevertheless, significantly related to pretreatment psychological dysfunction and stress. However, the latter appeared totally unrelated to four treatment outcome measures. Additionally, the data supports the hypothesis that both initial and post-treatment intrascapular symptoms (TMJ Scale, Joint Dysfunction sub-scale) are unrelated to psychosocial factors. Data from this study call into question the value of categorizing the TMD patients by means of psychosocial “profiling” and “dual-axis” classification methods proposed by some researchers.     

Temporomandibular disorders--traumatic etiology vs. nontraumatic etiology: a clinical and methodological inquiry into symptomatology and treatment outcomes

The purpose of this research is to investigate the distinctions relating to Presenting Symptoms and Treatment Outcomes between patients suffering temporomandibular disorder (TMD) as a result of traumatic versus nontraumatic etiology. A geographically diverse cohort of 1,842 patients diagnosed with TMD was investigated with special emphasis placed on the following criteria: 1. The distribution of demographic and symptom characteristics of patients with trauma as an immediate precipitating factor versus those with other nontraumatic etiologies; 2. The relationship between nontrauma status and treatment outcomes; 3. The interrelationships between nontrauma status, psychosocial factors, and treatment outcomes. Trauma patients tended to be younger, less educated, and more likely to be male than the nontrauma patients. For this group the reported length of the TMD problem was, as expected, of shorter duration when compared to the nontrauma patient group. Length of treatment did not differ between the two groups. In comparison, trauma patients reported higher initial overall symptoms including pain and range of motion limitations. However, symptoms related to joint dysfunction did not vary appreciably. Treatment outcomes are complicated by the fact that TMD encompasses several different diagnostic entities. Trauma patients reported significantly higher percentages of improvement in palpation pain and perceived malocclusion. No significant differences were found for pain report, joint dysfunction, stress, and overall TMD symptomatology, as measured by the TMJ Scale's Global domain. Trauma patients manifested higher psychological dysfunction levels (excepting stress) and showed significantly more improvement in both psychosocial function and stress than the nontrauma group.     

Depression, pain, exposure to stressful life events, and long-term outcomes in temporomandibular disorder patients.

PURPOSE: This study investigated the role of psychological factors in temporomandibular disorders (TMD). Orofacial pain patients' pretreatment levels of depression, disability caused by pain, and exposure to stressful life events were measured, and differences on these variables between temporomandibular joint (TMJ) disease patients and patients whose pain was of muscular origin (MPD) were evaluated. The use of these variables and patient diagnostic status in predicting response to treatment in a subsample of these patients was also evaluated. PATIENTS AND METHODS: Before undergoing treatment, 258 patients were administered the Beck Depression Inventory (BDI), the Pain Disability Index (PDI), and the Social Readjustment Rating Scale (SRRS). Follow-up data on pain disability, current level of pain, depression, and satisfaction with treatment were obtained on 48 of these patients who were contacted at varying intervals after completing treatment. RESULTS: BDI scores obtained at the outset of treatment were significantly elevated and were positively correlated with SRRS and PDI scores. MPD patients had higher SRRS, BDI depression, and PDI pain disability scores than TMJ patients, and differences between the 2 groups in pain disability were greatest in areas that are often sources of interpersonal stress. Among follow-up patients, PDI scores declined after treatment, with MPD patients showing greater decreases than TMJ patients. Independent of patients' diagnostic status, their pretreatment PDI scores were predictive of their pain level at follow-up and were inversely related to their degree of satisfaction with treatment at follow-up; their pretreatment BDI scores were predictive of their depression level at follow-up. CONCLUSIONS: The findings are consistent with previous research indicating a link between emotional dysfunction and TMD and are largely supportive of the conclusion that psychological factors play a more pronounced role when pain is of muscular origin. Promising behavioral interventions are available for TMD patients in whom psychological factors appear to be playing a significant role.     

Measuring the Impact of a Dental Practice on TM Disorder Symptoms

This article describes a practical, quantitative method of measuring changes in temporomandibular disorder (TMD) symptoms in a dental practice. It applies the TMJ Scale? * to produce a number of clinically important measures of treatment effectiveness. Those measures include pre- and post-treatment symptom severity, percent of patients improved, level of improvement, and percent of patients converting to non-symptomatic after treatment. All of these outcome parameters were applied to a sample of the practice and to subgroups based on age, sex and problem length. The treated patients were compared to a group of diagnosed but untreated patients. The specific target symptoms of TMD are analyzed including pain, palpation pain, joint dysfunction and limited range of motion of the mandible. In addition, the overall symptom severity of the TM disorder, psychological factors and stress are studied, leading to an assessment of symptom change. The results support the concept that patients with acute problems are more treatment responsive than are patients with chronic problems. This suggests that careful screening and earlier detection of TMD may have an important impact on ultimate treatment outcome.     

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.     

Temporomandibular disorder treatment outcomes: second report of a large-scale prospective clinical study

Longitudinal studies of outcomes for temporomandibular disorder (TMD) treatment are rarely done and even when conducted often suffer methodological weaknesses. These may include the lack of valid outcome measures for symptom changes. This second report of a long-term multi-site study of 2104 treated, 250 untreated, and 44 long-term treated TMD patients is part of a continuing effort to study TMD treatment efficacy in a very large patient population. A validated symptom measurement system, the TMJ Scale, assured a valid and uniform assessment of treatment outcomes across a large number of practices. Data indicate that untreated TMD patients do not improve spontaneously over time and that patients treated with a variety of active modalities achieve clinically and statistically significant levels of improvement with no evidence of symptom relapse after treatment completion. The use of anterior repositioning appliance therapy produced better results than flat plane splint therapy.     

Prevalence and impact of post-traumatic stress disorder symptoms in patients with masticatory muscle or temporomandibular joint pain: differences and similarities

AIMS: To evaluate temporomandibular disorder (TMD) patients for differences between masticatory muscle (MM) and temporomandibular joint (TMJ) pain patients in the prevalence of posttraumatic stress disorder (PTSD) symptoms and evaluate the level of psychological dysfunction and its relationship to PTSD symptoms in these patients. METHODS: This study included 445 patients. Psychological questionnaires included the Symptom Check List-90-Revised (SCL-90-R), the Multidimensional Pain Inventory, the Pittsburgh Sleep Quality Index, and the PTSD Check List Civilian. The total sample of patients was divided into 2 major groups: the MM group (n = 242) and the TMJ group (n = 203). Each group was divided into 3 subgroups based on the presence of a stressor and severity of PTSD symptoms. RESULTS: Thirty-six patients (14.9%) in the MM group and 20 patients (9.9%) in the TMJ group presented with PTSD symptomatology (P = .112). Significant differences were found between the MM and the TMJ group in several psychometric domains, but when the presence of PTSD symptomatology was considered, significant differences were mostly maintained in the subgroups without PTSD. MM and TMJ pain patients in the "positive PTSD" subgroups scored higher on all SCL-90-R scales (P < .001) than patients in the other 2 subgroups and reached levels of distress indicative of psychological dysfunction. TMJ pain patients (58.3%; P = .008) in the positive-PTSD subgroups were more often classified as dysfunctional. Both positive-PTSD subgrounps of the MM and TMJ groups presented with more sleep disturbance (P < .005) than patients in the other 2 subgroups. CONCLUSION: A somewhat elevated prevalence rate for PTSD symptomatology was found in the MM group compared to the TMJ group. Significant levels of psychological dysfunction appeared to be linked to TMD patients with PTSD symptoms.     

Temporomandibular Disorder Treatment Outcomes: Second Report of a Large-Scale Prospective Clinical Study

Longitudinal studies of outcomes for temporomandibular disorder (TMD) treatment are rarely done and even when conducted often suffer methodological weaknesses. These may include the lack of valid outcome measures for symptom changes. This second report of a long-term multi-site study of 2104 treated, 250 untreated, and 44 long-term treated TMD patients is part of a continuing effort to study TMD treatment efficacy in a very large patient population. A validated symptom measurement system, the TMJ Scale, assured a valid and uniform assessment of treatment outcomes across a large number of practices. Data indicate that untreated TMD patients do not improve spontaneously over time and that patients treated with a variety of active modalities achieve clinically and statistically significant levels of improvement with no evidence of symptom relapse after treatment completion. The use of anterior repositioning appliance therapy produced better results than flat plane splint therapy.     

Evaluation of an anamnestic questionnaire as an instrument for investigating potential relationships between orthodontic therapy and temporomandibular disorders.

A group of 100 patients who received orthodontic treatment, between the ages of 16 to 31 years, were asked to complete the TMJ Scale (an anamnestic temporomandibular disorder [TMD] questionnaire) and undertake a simple clinical TMD examination, the Helkimo clinical dysfunction index. The purpose of this study was to compare the TMJ Scale and the Helkimo clinical dysfunction index to validate the use of the TMJ Scale as a potential method with which to examine whether there is any relationship between TMD and orthodontic therapy. Comparisons between TMJ Scale scores from the orthodontically treated group were made with previously reported TMJ Scale data. In addition, comparisons were made between various treatment and malocclusion groups identified within the orthodontically treated sample. On the basis of the TMJ Scale global scale scores for the orthodontically treated group and two normative nontemporomandibular disorder groups described by Levitt, Lundeen, and McKinney, no differences were observed. Similarly, TMJ Scale comparisons between various treatment and malocclusion subgroups showed no statistically significant differences. The results of this study support the use of the TMJ Scale as a valid instrument with which to determine whether there is any relationship between orthodontic therapy and TMD.     

Temporomandibular disorder treatment outcomes: first report of a large-scale prospective clinical study

The diagnosis and treatment of temporomandibular disorders (TMD) has been surrounded by considerable controversy. Clinical research in the field to date has been inconsistent and methodologically limited and has not firmly established the role of treatment interventions. This large scale, multisite study attempts to answer some of the questions regarding TMD diagnosis and treatment. More than 6,500 patients are currently being analyzed and 1,212 have completed TMD therapy, providing the basis for comparison with 198 untreated patients. A wide variety of treatments have been administered from 60 practice sites, whose practitioners were carefully calibrated to maximize inter-rater reliability. A validated symptom measurement system, the TMJ Scale, was employed to assure uniform assessment of treatment outcomes. Treated patients reported statistically and clinically significant symptom improvement, while untreated patients reported unchanged symptom levels. Data presented here do not support the hypothesis that TMD patients improve spontaneously without treatment.     

Evaluation of psychological factors in orthodontic patients with TMD as applied to the "TMJ Scale"

Physical and psychological evaluation have been required for TMD patients whose problems are multi dimensional. The questionnaire named the "TMJ Scale" was created to differentiate subjective TMD symptoms of patients. The purpose of this study was to clarify the reliability of the TMJ Scale for Japanese orthodontic patients with TMD and to differentiate the symptoms. Fifty orthodontic patients (average age 21y4m) with a chief complaint of TMD symptoms were compared with thirty patients (average age 21y1m) without TMD symptoms. The results were as follows: female patients in the symptom group in particular showed a higher degree of stress due to the chronic pain and abnormalities than those in the non-symptom group. Significant differences were observed in Pain Report, Joint Dysfunction and Global Scale at the 0.1% significant level, in Non-TM Disorder, Psychological Factor and Chronicity at the 1% level, and in Palpation Pain and Perceived Malocclusion at the 5% level in females. Few psychological problems were observed in male patients in the symptom group. Significant differences were observed in Range of Motion limitation at the 5% level in males. The differences in the psychological factors between male and female patients were clarified by using the TMJ Scale. These findings suggested that it was useful to differentiate the multiple symptoms, especially the psychological factors, by using the TMJ Scale for orthodontic patients with TMD.     

Prevalence of temporomandibular disorder pain,jaw noises and oral behaviours in an adult Italian population sample

To evaluate the prevalence of temporomandibular disorder pain (TMD‐pain), temporomandibular joint (TMJ) noises, oral behaviours in an Italian adult population sample, their possible association with gender, oral behaviours, self‐reported facial trauma and orthodontic treatment. Subjects older than 18 years were recruited from general population in public spaces during their daily life. A specific questionnaire was developed to collect data on TMD‐pain, TMJ noises, oral behaviours, orthodontic treatment and facial trauma. A total of 4299 subjects were included in the study. The most common symptom in the sample was TMJ clicking (30.7%), followed by TMD‐pain (16.3%) and TMJ crepitus (10.3%). Oral behaviours were reported in 29% of the sample; 43.6% of the sample reported a previous or ongoing orthodontic treatment. TMD‐pain and TMJ clicking were significantly associated to gender, oral behaviours and a positive history of previous facial trauma. Crepitus was significantly associated to oral behaviours, facial trauma and higher age. Ongoing orthodontic treatment was significantly associated to TMD‐pain and TMJ sounds. In a general Italian adult population sample, TMD‐pain is associated to female gender and is less prevalent than TMJ clicking. TMDs are associated to trauma and oral behaviours.     

Outcomes of physical therapy in patients with temporomandibular disorder: a retrospective review

Temporomandibular disorder (TMD) encompasses a spectrum of disorders that are associated with pain in the temporomandibular joint (TMJ) and surrounding musculature. Current research shows that conservative physical therapy is beneficial in the management of the disorder. This study further explores if physical therapy is an effective approach to treating patients with TMJ disorders. Our objectives were to determine the effect of conservative physical therapy interventions on pain, maximal mouth opening, and TMJ disability index for patients with TMD. Medical records from 2013-2018 were retrospectively reviewed to identify patients and obtain demographic, baseline, and short-term outcomes of maximal mouth opening (MMO), pain, and temporomandibular disability index (TDI). A total of 100 patients were included. Significant changes were noted in MMO, pain rating, and TDI from initial evaluation to discharge from physical therapy. Sex, age, and weight did not affect the outcomes. There was also no correlation between the number of visits attended and change in MMO. Patients treated conservatively did show improvements in short term outcomes (MMO, pain rating, and TDI). These changes were statistically significant, indicating that conservative therapy may be a beneficial treatment option for patients with TMJ dysfunction. Future studies assessing the long-term outcomes of TMJ patients treated conservatively would determine if this treatment is beneficial in the long-term. In addition, researching the effectiveness of specific interventions for TMJ patients, and if certain TMJ disorders are more responsive to conservative care than others would be valuable in providing information on the effectiveness of conservative treatment in this patient population.     

Outcome Measurement for Treated and Untreated TMD Patients Using the TMJ Scale

Changes in symptom profiles of two groups of treated and untreated temporomandibular disorders (TMD) patients were measured using the TMJ Scale^TM.' Forty-nine consecutive TMD patients were included in the study. Of these, 29 patients were treated using splint therapy, physical therapy, counseling, and non-steroidal anti-inflammatory (NSAID) medications. Patients completed the TMJ Scale questionnaire prior to treatment and at completion of the TMD therapy. Sixty-five patients were not treated in any manner, having completed the questionnaire during an initial diagnostic study and having declined treatment. They were contacted by mail at least four months later and asked to complete the second questionnaire if they had not received any treatment. Twenty untreated patients returned the completed questionnaire. The initial scale scores for the two groups were similar. Comparison of the two tests of both groups revealed the treated group improved significantly, while the untreated group remained unchanged, except for a statistically non-significant increase of scale scores (increased symptom severity) for joint dysfunction and range of motion limitation. Younger patients responded more favorably to therapy than older patients. The findings do not support the conclusions of the few previous studies that found TMD are often self-limiting and rarely progress to chronic intracapsular derangement. The findings strongly support the hypothesis that symptom improvement was related to treatment and not solely to the passage of time.     

Clinical and psychological characteristics of TMD patients with trauma history

Oral Diseases (2010) 16 , 188–192 Objective: The purpose of this study was to investigate clinical and psychological characteristics of temporomandibular disorders (TMD) patients with trauma history. Materials and methods: The clinical and psychological characteristics of 34 TMD patients with trauma history were compared with those of 340 TMD patients without trauma history. Craniomandibular index (CMI) was used for clinical characteristics of TMD patients. Symptom severity index (SSI) was used to assess the multiple dimensions of pain. Symptom checklist‐90‐revision (SCL‐90‐R) was used for psychological evaluation. Results: Temporomandibular disorders patients with trauma history displayed significantly higher CMI and palpation index. TMD patients with trauma history also exhibited higher values in duration, sensory intensity, affective intensity, tolerability, scope of symptom, and total SSI score. In addition, these patients showed significantly higher values in symptom dimensions of somatization, depression, anxiety, phobic anxiety, and paranoid ideation. Among the symptom dimensions of SCL‐90‐R, somatization showed the most significant correlations with CMI and SSI. Conclusions: Temporomandibular disorders patients with trauma history displayed more severe subjective, objective, and psychological dysfunction than those without trauma history. Pain of myogenous origin, history of physical trauma, and psychosocial dysfunction were all closely related.     

The longevity of temporomandibular disorder improvements after active treatment modalities

Of concern to practitioners and patients alike are the long-term results following temporomandibular disorder/craniofacial pain (TMD/CP) treatments. This paper examines 270 patients who underwent active TMD/CP treatment and had follow-up an average of 41 months after the termination of treatment when the patients had reached maximum medical improvement (MMI). Data show that, notwithstanding a mild degree of recrudescence, overall levels remain significantly lower than initial baseline symptoms, indicating a long-term benefit from active treatment. It could not be determined whether the recrudescent symptom levels were related to the conditions for which patients initially sought treatment or to new pathological states. Possible considerations for relapse may be the function of aging, musculoskeletal structural adaptation, resorting to parafunctional habits, and/or a change in psychosocial status. No significant differences were found between males and females regarding symptom levels and outcomes. Clinical experience suggests that TMD/CP symptoms do not resolve spontaneously and generally require active treatment. Unfortunately, most studies to date have largely measured symptom changes immediately (or very shortly) after the completion of treatment. This article, however, finds that the benefits of appropriate active TMD treatments remain long after treatment completion.     

Mood spectrum in patients with different painful temporomandibular disorders

The purpose of this study was to investigate for difference in the prevalence of mood disorders between patients with different painful temporomandibular disorders (TMD). After a sample size necessary for the study was calculated, 60 patients with a painful TMD were selected and divided into the following groups: myofascial pain (n=20), temporomandibular joint (TMJ) pain (n=18), combined myofascial and TMJ pain (n=22). Two distinct comparison groups were selected: subjects with a nonpainful TMD (n=25) and TMD-free subjects (n=29). All participants filled out a self-report validated instrument (MOODS-SR) to evaluate psychopathological symptoms related to mood disturbances. A one-way analysis of variance (ANOVA) with Bonferroni's post hoc test for multiple comparisons was performed to investigate for significant differences among the groups. The three groups of patients with painful TMD scored significantly higher than comparison groups in all MOODS-SR domains investigating depression, but no difference was shown between subjects with myofascial pain and those with TMJ pain. No significant differences among the groups emerged for the presence of manic symptoms, indicating that depressive disorders associated with TMD are not an expression of a more complex manic depressive illness. The study concluded that the presence of depressive symptoms in TMD patients seems to be related to the presence of a painful condition and seems to be unrelated to the location of pain. Furthermore, depressive disturbances in painful TMD patients affect the whole spectrum of depressive psychopathology.     

Anterior repositioning appliance therapy for TMJ disorders: specific symptoms relieved and relationship to disk status on MRI

Forty-eight (48) consecutive patients seeking treatment in a referral based practice for complex chronic painful temporomandibular joint (TMJ) disease were enrolled in a prospective study to assess specific symptom relief from anterior repositioning appliance (ARA) therapy and the relationship between specific symptom relief and the status of the TMJ disk. Each patient was assessed on 86 symptoms based upon whether each symptom was present before treatment and absent, better, unchanged or worse after Maximum Medical Improvement (MMI). The most common symptom was occipital cephalalgia (94%). The least common symptom was pain and burning of tongue (8%). A profile of a temporomandibular disorder (TMD) patient was developed. The typical TMD patient has cephalalgia, mainly in the occipital, temporal and frontal region, pain upon chewing food, pain upon opening and closing the mouth, TMJ pain, pain in the back of the neck and difficulty chewing food. Before treatment, patients with bilateral displaced disks had more symptoms than those with unilateral displaced disks and the opposite side normal. After MMI, the maximum benefit (percent of pretreatment symptoms relieved) was found in patients with normal or recaptured disks. The minimum occurred in patients whose disks did not recapture with therapy. ARA therapy improved or eliminated symptoms in all patients in the study.     

The treatment of temporomandibular disorders with stabilizing splints in general dental practice: one-year follow-up

BACKGROUND: The authors evaluated temporomandibular disorder (TMD) outcomes in general dental practice one year after treatment with stabilizing splints (SS) or nonoccluding control splints (CS). METHODS: Seventy-two randomly allocated subjects completed initial treatment. The outcomes measures were a pain visual analog scale (VAS), muscle tenderness, temporomandibular joint (TMJ) tenderness, interincisal opening, TMJ clicks and headaches. After initial treatment, 81 percent of the subjects were found to have been treated satisfactorily. The dentists referred the remaining subjects to a dental hospital. At one year, the authors recalled 52 of the original subjects for evaluation. RESULTS: Improvements after initial treatment were maintained at one year for all outcomes, except for TMJ clicking, which returned to pretreatment levels. Eighty-one percent of the subjects rated their treatment as either good or excellent in reducing jaw pain. The authors found that subjects were aware of more of their TMJ clicks than dentists observed at the one-year clinical examination, but most subjects thought their clicking or the associated pain had been reduced. Fifty-five percent subjects had used their splints in the previous six months, but only 31 percent of these had done so daily. There were no significant differences between splint groups. CONCLUSION: At one year, a good response to TMD treatment in general practice had been maintained, but many subjects still had clicking TMJs. CLINICAL IMPLICATIONS: Trained dentists can manage TMD satisfactorily, with only a small proportion of patients needing specialist attention.     

Anamnestic index severity and signs and symptoms of TMD

The aim of this study was to determine the frequency and to characterize the symptoms and clinical signs of temporomandibular disorders (TMD) related to each severity category of Fonseca's anamnestic index in a sample of Brazilian young adults (mean age 21.61+/-1.91 years, 87% females and 13% males), by the application of an anamnestic index proposed by Fonseca (1992) and by clinical examination considering mandibular range of motion and tenderness to palpation of stomatognathic system structures. A significant number of participants were classified with mild TMD (43.2%) and moderate TMD (34.8%). Pain frequency during mastication, temporomandibular joint (TMJ) pain, and TMJ sounds were shown to be good predictors of TMD severity. Neck pain, headache, difficulty during mouth opening and lateral deviation, and tenderness to palpation of masticatory sites and during protrusion accompanied the TMD severity but failed to demonstrate differences between moderate and severe groups, showing a poor ability to determine TMD severity progression. This study suggests that not only the frequency of signs and symptoms of TMD should be determined, but also symptom severity and its relationship to the presence of clinical signs in order to discriminate patients with real treatment needs in nonpatient samples.