Diagnosis and therapy of temporomandibular disorders

Temporomandibular disorders is a collective term covering a number of related disorders affecting the temporomandibular joints, masticatory muscles, and related structures. The study reviews the recent knowledge about the diagnosis and complex therapy of temporomandibular disorders on the basis of published scientific literature. The role of general dental practitioner in management of patients with temporomandibular disorders is emphasised. Since a lot of patients turn to them for a first consultation, they should be familiar with the main diagnostic aspects of these disorders. The non-invasive conservative therapeutic possibilities are described in detail and they are suggested in the initial phase of the treatment. The disorders, which usually need further consultations with other specialist, are also described.     

Severe retrognathia as a risk factor for recent onset painful TMJ disorders among adult females

OBJECTIVE: To evaluate the importance of severe retrognathia as a risk factor for the development of recent onset painful TMJ disorders among adult females. DESIGN: Case-control study. SETTING: This study was conducted in a large health maintenance organization between 1998 and 1999 [Kaiser Permanente Northwest (KPNW), Portland, OR, USA]. PARTICIPANTS: Adult females with recent onset painful TMJ disorders (n=29) and normal controls (n=104). METHODS: Cases were recruited from the TMD clinic at Kaiser Permanente Northwest (KPNW). Controls were recruited from a dental clinic at KPNW. Case status was determined using a questionnaire; mandibular sagittal position was determined by measuring a research angle on facial photographs. The mean research angle for cases was compared to the mean for controls. Multivariable exact conditional logistic regression analysis was used to examine the demographic characteristics of cases and controls, and to determine the strength of association between recent onset painful TMJ disorders and severe retrognathia. The population attributable risk percentage (PAR%) and the attributable risk percentage (AR%) were calculated to further evaluate severe retrognathia as a risk factor. RESULTS: The mean research angle among cases (67.7 degrees; 95% CI=66.0-69.4) was smaller than among controls (71.6 degrees; 95% CI=70.7-72.5, P<0.001). The odds ratio for the association between case status and the presence or absence of severe retrognathia was elevated (OR=6.3; 95% CI=1.1-47.5, P=0.039). The PAR% and AR%, associated with severe retrognathia, were 13.3 and 84.1%, respectively. CONCLUSIONS: Severe retrognathia is strongly associated with recent onset painful TMJ disorders (OR=6.3). Only a small proportion of these disorders are attributable to severe retrognathia among the total population of adult females (PAR%=13.3%). However, a large proportion of these TMJ disorders are potentially attributable to severe retrognathia among adult females with severe retrognathia (AR%=84.1%).     

An update in pediatric seizure disorders

Recent advances in knowledge of pediatric seizure disorders, including classification of seizure types and febrile convulsions, have been the topics of major symposia. In light of these recent developments, an in-depth review is presented to aid the pediatric dentist in the treatment of these children.     

Comprehensive care for children with bleeding disorders. A physician's perspective.

As a result of recent advances in the understanding of hemostatic mechanisms--and the availability of more accurate diagnostic tests, effective replacement therapy and medications--most of the common bleeding disorders in children can be diagnosed and managed. Children with bleeding disorders often present with dental problems. Their comprehensive care requires specialized preventive and acute dental treatment. With improvements in dental care protocols and surgical procedures, the risk of excessive bleeding in these children as a result of dental procedures should be minimal, particularly if they are well prepared and treated beforehand. It is important for dentists to be familiar with these specialized dental care protocols and procedures, and knowledgeable about the medical treatment provided to children with bleeding disorders. This allows dentists to coordinate the care of a hemophiliac with his or her physician in a comprehensive manner.     

Dental treatment of temporomandibular disorders and masticatory muscle pain.

The treatment of masticatory muscle and temporomandibular joint pain constitutes an important area in dentistry. Current information supports the use of reversible treatments for these disorders. Several recent references are discussed in relation to reversible treatment, the role of occlusion, and appliance therapy for internal derangement.     

Absolute indications for salivary gland scintigraphy with 99mTc-pertechnetate

In recent years salivary gland scintigraphy has gained widespread acceptance as a useful means for evaluating salivary gland disorders. An absolute indication for this procedure exists when the ductal orifice of one or several major salivary glands cannot be found or cannot be cannulated. Clinical conditions in which this problem occurs include technical failure to probe and cannulate the duct, developmental anomalies, obstructive disorders, traumatic lesions and fistulae and the need of postsurgical information after glandular excision or after ligation or repositioning of a major excretory duct. The clinical value of scintigraphy in these conditions is demonstrated by means of case presentations.     

Severe retrognathia as a risk factor for recent onset painful TMJ disorders among adult females

Abstract

Objective: To evaluate the importance of severe retrognathia as a risk factor for the development of recent onset painful TMJ disorders among adult females.

Design: Case-control study.

Setting: This study was conducted in a large health maintenance organization between 1998 and 1999 [Kaiser Permanente Northwest (KPNW), Portland, OR, USA].

Participants: Adult females with recent onset painful TMJ disorders (n=29) and normal controls (n=104).

Methods: Cases were recruited from the TMD clinic at Kaiser Permanente Northwest (KPNW). Controls were recruited from a dental clinic at KPNW. Case status was determined using a questionnaire; mandibular sagittal position was determined by measuring a research angle on facial photographs. The mean research angle for cases was compared to the mean for controls. Multivariable exact conditional logistic regression analysis was used to examine the demographic characteristics of cases and controls, and to determine the strength of association between recent onset painful TMJ disorders and severe retrognathia. The population attributable risk percentage (PAR%) and the attributable risk percentage (AR%) were calculated to further evaluate severe retrognathia as a risk factor.

Results: The mean research angle among cases (67.7°; 95% CI=66.0–69.4) was smaller than among controls (71.6°; 95% CI=70.7–72.5, P<0.001). The odds ratio for the association between case status and the presence or absence of severe retrognathia was elevated (OR=6.3; 95% CI=1.1–47.5, P=0.039). The PAR% and AR%, associated with severe retrognathia, were 13.3 and 84.1%, respectively.

Conclusions: Severe retrognathia is strongly associated with recent onset painful TMJ disorders (OR=6.3). Only a small proportion of these disorders are attributable to severe retrognathia among the total population of adult females (PAR%=13.3%). However, a large proportion of these TMJ disorders are potentially attributable to severe retrognathia among adult females with severe retrognathia (AR%=84.1%).     

Screening for psychosocial risk factors in patients with chronic orofacial pain: recent advances

BACKGROUND: The authors compiled information about recent advances in screening for psychosocial risk factors considered to be yellow flags for potentially poor outcomes among patients with chronic orofacial pain (most commonly temporomandibular disorders). TYPES OF STUDIES REVIEWED: The authors conducted MEDLINE searches for the period 1995 through 2002 using the terms "temporomandibular disorders," "assessment" and "psychological," as well as "primary care," "screening" and "psychological disorders." They also searched personal files for relevant articles. RESULTS: Psychosocial dysfunction is prevalent among patients with chronic orofacial pain. Yellow flags include high levels of disability; psychological disorders; and prolonged or excessive use of opiates, benzodiazepines, alcohol or other drugs. The authors identified several reliable, valid and brief patient self-administered questionnaires that can be used to screen for these yellow flags. Some of these are the Research Diagnostic Criteria/ Temporomandibular Disorders Axis II, Alcohol Use Disorders Identification Test and Patient Health Questionnaire. CLINICAL IMPLICATIONS: Dentists can improve the quality of care for patients with chronic orofacial pain by screening for psychosocial risk factors and by referring patients with risk factors for psychological or psychiatric assessment and treatment.     

Imaging of shoulder disorders

The radiological evaluation of shoulder disorders has evolved to incorporate virtually all imaging modalities. This article discusses the varying roles of these modalities and includes key points for understanding the indications, diagnostic value, and limitations of each. Plain radiography, ultrasound, computed tomography, and magnetic resonance imaging (including magnetic resonance arthrography) are discussed, as well as recent innovations in these fields. The optimum imaging method for the diagnosis of specific shoulder pathologies, such as fracture, rotator cuff tendon disease and arthropathy, is discussed, while incorporating useful advice on diagnostic accuracy and availability from the radiologist's perspective. The purpose is to give an overview and a general approach to the imaging diagnosis of shoulder disorders to inform current and future orthopaedic practice.     

Dentofacial orthopedics and craniomandibular dysfunction

There has been a recent recrudescence of cranio-mandibular disorders (CMD), predominantly affecting women. Even children can be affected by CMD, often under diagnoses by their families and by medical professionals. Therefore, a multidisciplinary approach is important when evaluating the variety of diagnostic and etiological problems. The search for postural etiology, whether lingual or dental, is always necessary to better act on the etiology of these disorders. The involvement of orthodontics, in the prevention of CMD, has three impacts: functional, aesthetic and psychological, allowing for a better balance of the cranio-mandibular system. This makes the treatment of cranio-facial orthopedics, a successful choice in the recovery of CMD.     

The role of prosthodontists in habilitation and rehabilitation in rare disorders: the ectodermal dysplasia experience

PURPOSE: The aim of this article is to highlight the strong worldwide trend of enhancing the opportunities for individuals with rare disorders to get adequate information and treatment. Hypohidrotic ectodermal dysplasia is used as an example. MATERIALS AND METHODS: The development in recent years of databases for rare disorders, the establishment of resource centers in dentistry, and the strong movement of user influence by the formation of patient organizations and exchange of information through the Internet are described. Reference is made to the recent Scandinavian consensus conference on ectodermal dysplasia. RESULTS: Motives for the centralization of treatment planning to resource centers for persons with rare disorders, the compilation of treatment outcomes in databases, and the advocation of a multidisciplinary team approach in dentistry are presented. CONCLUSION: The prosthodontic profession has a key position in the habilitation and rehabilitation of many different diagnoses of rare disorders.     

The dental role in smoking cessation advice for patients with mental and behavioural disorders--time for improvement?

The past few years have seen an increasing emphasis upon the role of the dental team in smoking cessation. The recent advances in knowledge of the level and role of tobacco use in patients with mental and behavioural disorders, the biological factors involved and the influences of tobacco on psychiatric medication metabolism and side effects has not been reflected in dental postgraduate education. Perhaps it is time for an evidence based improvement in care standards by referring these patients for specialist cessation advice?     

Classical and variant Creutzfeldt-Jakob diseases and their potential impact on the practice of clinical dentistry in Australia

Following recent published evidence regarding the experimental transmission of prion diseases via blood transfusion, dental practitioners have expressed their concern about the potential impact of these transmissible spongiform encephalopathies on dental care provision. This review provides updated information on Creutzfeldt-Jakob disease and related disorders and highlights their potential significance for the practice of clinical dentistry. The current guidelines in Australia relating to infection control and clinical dental procedures are discussed together with recommended guidelines and considerations from the United Kingdom and the World Health Organization (WHO).     

New developments in craniofacial surgery research.

The recent explosion in our understanding of developmental biology and genetics has enhanced our understanding of craniofacial biology. While it is not possible to summarize all new developments in craniofacial research, this article will review three areas: fetal models and surgery for craniofacial disorders, the biology of distraction osteogenesis, and the molecular mechanisms of cranial suture fusion. Numerous models of craniofacial disorders have been described, including small, short gestation and large, long gestation. The benefits and shortcomings of each are discussed. In addition, we discuss recent studies investigating the molecular mechanisms of mandibular distraction osteogenesis. Finally, we present a review of recent advances in the understanding of mechanisms of craniosynostosis, with particular emphasis on the biology of programmed cranial suture fusion in rodents.     

Molecular biology of temporomandibular joint disorders: Proposed mechanisms of disease

The biologic processes of temporomandibular joint adaptation and disease are poorly understood. However, recent technologic advances have provided methods that allow sophisticated studies of the molecular mechanisms that are relevant to the pathophysiology of degenerative temporomandibular joint diseases. This review examines current models of the molecular events that may underlie both adaptive and pathologic responses of the articular tissues of the temporomandibular joint to mechanical stress. It is hoped that an increased understanding of these complex biologic processes will lead to improved diagnostic and therapeutic approaches directed to the management of temporomandibular disorders.     

颞下颌关节紊乱病疼痛的分子机制

颞下颌关节紊乱病是一种多因素疾病,在临床上以疼痛为主要症状。关于颞下颌关节紊乱病的疼痛机制迄今仍未完全明了,因而其治疗也没有取得突破性进展。近年来,颞下颌关节紊乱病疼痛的分子机制已成为国内外研究的热点,本文就此作一综述。     

Broad support evident for the emerging specialty of orofacial pain

The emerging field of Orofacial Pain is being considered by the American Dental Association for full status as a new dental specialty. Many recent advances in the neuroscience of orofacial pain have lead to treatments by orofacial pain dentists that provide significant relief for patients with chronic orofacial pain disorders. However, access to this care has been limited leaving many patients to continue to suffer. Subsequently, recent efforts to improve this by developing the field into a specialty have shown broad support among dentists and increased awareness of the benefits this field can provide for dentists and their patients. A recent survey of 805 individuals in the general population who reported having a persistent pain disorder revealed that more than four out of 10 people have yet to find adequate relief, saying their pain is out of control-despite having the pain for more than 5 years and switching doctors at least once. "This survey suggests that there are millions of people living with severe uncontrolled pain," says Russell Portenoy, MD, President of the American Pain Society. "This is a great tragedy. Although not everyone can be helped, it is very likely that most of these patients could benefit if provided with state-of-the-art therapies and improved access to pain specialists when needed." (1). Development of the field of Orofacial Pain into a dental specialty has been motivated primarily by this issue; patients with complex chronic orofacial pain disorders have not been historically treated well by any discipline of health care. Recent studies of chronic orofacial pain patients have found that these patients have a high number of previous clinicians and have endured many years with pain prior to seeing an orofacial pain dentist (2) (Fig. 1). Complex pain patients and the clinicians who see them are often confused about whom they should consult for relief of the painful disorder. Treatment for these patients within the existing structure of dental or medical specialties has been inadequate and millions of patients are left suffering. Insurers are also confused with regard to reimbursement and make decisions to exclude treatment for orofacial pain disorders under both dental and medical policies. However, Dentistry has taken a leading role in health care to address this national problem by developing the field of Orofacial Pain into a dental specialty. A study of dentists and dental specialists have shown that there is a recognized need and broad support for further development of this field into a new dental specialty(3).     

Temporomandibular disorders. 1. Clinical evaluation

The treatment of temporomandibular disorders continues to provide dental practitioners with a difficult challenge that has yet to overcome numerous major obstacles. In this, the first of a series of three articles, an overview of the current understanding of the diagnosis of temporomandibular disorders will be presented. The subsequent two articles will present an overview of the management strategies that have appeared in the literature in recent years.     

Systemic dissemination as a result of oral infection in individuals 50 years of age and older

The oral pathosis caused by systemic disorders in middle-aged and elderly adults has been the focus of many publications in recent years. The intraoral soft and hard tissue changes associated with systemic disorders, medications, chemotherapy, and radiation treatment have been well-investigated and-documented. Far less attention has been paid to the role of oral Infection as the etiology of systemic disorders. A literature review (1980–1994) is provided here focusing on well-documented cases in which systemic disorders were caused by oral foci of infections. This paper attempts to raise the level of awareness of practitioners in considering possible systemic complications caused by oral infection. It also emphasizes the need for further longitudinal studies in this field involving healthy and medically compromised elderly individuals.