Achieved competences in temporomandibular disorders/orofacial pain: a comparison between two dental schools in Europe.

AIMS: The aim was to study achieved competences in temporomandibular disorders (TMD)/orofacial pain (OP) at two universities by comparing student's knowledge and understanding, satisfaction with their education and confidence in their clinical competences of TMD/OP. METHODS: The study was conducted in collaboration between Malmö University, Sweden­which uses problem-based learning­and the University of Naples Federico II, Italy­which uses traditional educational methods. Final-semester dental students responded to a self-report questionnaire regarding their knowledge and understanding, interpretation of cases histories, clinical experience, satisfaction and confidence in clinical examination, management and treatment evaluation. RESULTS: No significant difference was found between the students regarding knowledge and understanding. Eighty-seven per cent of the Malmö students and 96% of the Naples students met the criterion on achieved competence. Malmö students had a higher per cent of correct diagnoses than Naples students in the interpretation of case histories. Overall, Malmö students reported most clinical experience and higher confidence than Naple students. CONCLUSIONS: The main findings were that students from Malmö and Naples were, similar in knowledge and understanding of TMD/OP and in satisfaction with their clinical competences. However, Malmö students perceived more confidence in clinical management of patients with TMD/OP. This may reflect that, besides the theoretical part of the programme, a sufficient level of clinical exposure to patients with TMD/OP is essential to gain competences in TMD/OP.

TMD before and after correction of dentofacial deformities by orthodontic and orthognathic treatment.

The aims of the study were to investigate the alteration of temporomandibular disorders (TMD) after correction of dentofacial deformities by orthodontic treatment in conjunction with orthognathic surgery; and to compare the frequency of TMD in patients with dentofacial deformities with an age and gender matched control group. TMD were evaluated in 121 consecutive patients (treatment group), referred for orthognathic surgery, by a questionnaire and a clinical examination. 18 months after treatment, 81% of the patients completed a follow-up examination. The control group comprised 56 age and gender matched subjects, of whom 68% presented for follow-up examination. TMD were diagnosed according to research diagnostic criteria for TMD. At baseline examination, the treatment group had a higher frequency of myofascial pain (P=.035) and arthralgia (P=.040) than the control group. At follow-up, the frequencies of myofascial pain, arthralgia and disc displacement had decreased in the treatment group (P=.050, P=.004, P=.041, respectively). The frequency of TMD was comparable in the two groups at follow-up. Patients with dentofacial deformities, corrected by orthodontic treatment in conjunction with orthognathic surgery, seem to have a positive treatment outcome in respect of TMD pain.

Dentists reflect on their problem-based education and professional satisfaction.

AIM: To determine the way in which Malmö University dental graduates perceive their problem-based dental education and evaluate their professional satisfaction. METHOD: The first five cohorts (graduating in years 1995-1999) of the problem-based curriculum were invited to participate. Of 166 graduates, 77% responded to a questionnaire comprising 20 questions on aspects of their dental education, professional situations and interest in postgraduate education. They were asked to rank their perception of their dental education and satisfaction with their professional situation on a visual analogue scale (VAS) with endpoints ranging from 'Not at all' (1) to 'Very well' (10). For other statements, the markings were made on a Likert scale from 1 (not important/not satisfied) to 5 (very important/very satisfied). There were also open-ended questions. RESULTS: Most respondents perceived their education to prepare them well for a career in dentistry (median score VAS 8), and 90% rated above six on a VAS for their professional satisfaction as dentists. Importance and satisfaction were highly correlated with principles of the curriculum: holistic view, oral health, lifelong learning, integration between theory and clinic, and clinical competence. Forty-five per cent of the graduates noted the problem-based learning approach as the most valuable asset of their education, and 19% cited training in oral surgery as a deficit. Of the respondents, 77% expressed interest in specialist training and 55% in research education. CONCLUSION: Problem-based education was perceived to prepare graduates well for their profession, and their professional satisfaction was high.

Long-term effectiveness of a prefabricated oral appliance for myofascial pain.

The long-term effectiveness of a prefabricated oral appliance (R) was compared with a stabilisation appliance (S) in patients with myofascial pain. Sixty-five patients diagnosed with myofascial pain at two centres for Stomatognathic Physiology in Sweden and Finland were included in a randomised controlled trial using Research Diagnostic Criteria for Temporomandibular Disorders, with history questionnaires and clinical examinations performed by blinded examiners at baseline and at 6- and 12-month follow-ups. Patients were randomly assigned either to the R or the S group. Treatment outcome was measured according to IMMPACT for four chronic pain outcome domains: pain intensity, overall improvement, physical functioning and emotional functioning. Physical functioning was classified for Graded Chronic Pain severities and assessed by the Jaw Functional Limitation scale. Emotional functioning composed of scores of non-specific physical symptoms and depression. There were no differences between groups at baseline. At both follow-ups, all outcome domains showed significant within-group improvement, without significant differences between groups. At 12 months, 72% of all patients reported a 30% reduction in worst pain and 63% of the patients a 50% reduction in worst pain. Overall improvement 'better' to 'symptom-free' was observed in 81% in the R and 64% in the S group at the 12-month follow-up. Graded Chronic Pain, Functional Limitation of the Jaw, non-specific physical symptoms and depression showed statistically significant reduction at 12-month follow-up. Results support the hypothesis that the effectiveness of the prefabricated appliance is similar to that of the stabilisation appliance in the long-term when treating patients with myofascial pain.

Undergraduates' and graduates' perception of achieved competencies in temporomandibular disorders and orofacial pain in a problem-based dental curriculum in Sweden.

AIMS: Aims of this study were to assess undergraduates' and graduates' perceptions of their education by documenting their attitudes and investigating acquired competencies in temporomandibular disorders (TMD) and orofacial pain (OP). METHODS: In 2006, 141 undergraduates (in semesters 1, 6, and 10 of a 5-year dental programme) and 60 graduates of 2000 and 2001 were invited to fill in questionnaires designed for their levels. The four questionnaires contained open-ended questions, closed-ended questions, and questions requiring a scaled response on an 11-point numerical rating scale (NRS). Questions covered personal experience of pain, attitudes toward TMD/OP, clinical competencies, and satisfaction with their education. Participants rated importance of and satisfaction with clinical competencies on a 5-point scale. RESULTS: The importance of understanding TMD/OP patients was rated high (NRS 9-10) and attitudes to given statements about TMD/OP patients were positive. In general, perception of clinical competencies increased with level of education. Mean scores for importance of and satisfaction with clinical competencies of 10th semester undergraduates and graduates were above 4.0. Median graduate satisfaction with undergraduate education in TMD/OP patient management was high (NRS 9). All but one graduate had treated patients with TMD/OP. One-third of the responding graduates expressed a wish for additional training, such as in pharmacological treatment and evaluation of treatment outcome. CONCLUSION: In general, the perception of acquired clinical competencies in TMD and OP increased with level of education, and the importance of, and satisfaction with, training was highly rated. Positive attitudes toward these kinds of patients were expressed at all levels.

Short-term treatment of a resilient appliance in TMD pain patients: a randomized controlled trial.

To investigate the short-term efficacy of a resilient appliance in patients with temporomandibular disorders (TMD) suffering from pain, a randomized, controlled trial was performed in 80 recruited TMD pain patients. They were randomly allocated to one of two groups: treatment with a resilient appliance or treatment with a hard, palatal, non-occluding appliance. The primary treatment outcome measure was judged positive when patients' TMD pain at worst, according to the Visual Analog Scale (VAS), decreased by at least 30%. One additional treatment outcome was reduction of characteristic pain intensity. Number needed to treat was measured on the basis of primary treatment outcome at 10 weeks. At baseline, patient characteristics and TMD pain did not differ between the groups. There were no significant differences between groups regarding a 30% reduction in VAS-reported TMD pain at worst at 10 weeks' follow-up; 61% in the treatment group and 46% in the control group. After 6 and 10 weeks of treatment, CPI decreased in both groups. Number needed to treat was 9.1 for both the resilient and the control appliance therapy during 10 weeks. There was no statistically significant difference between the resilient appliance and the non-occluding control appliance in reducing TMD pain from a short-term perspective.

Salivary cortisol and IgA levels in patients with myofascial pain treated with occlusal appliances in the short term.

In many studies, the endocrinological response of individuals to different kinds of stresses has been tested. There seems to be widespread agreement that stress, depression, disability and dysfunctional illness behaviors are critical aspects of patients suffering from symptoms like pain, arising out of temporomandibular disorders (TMD). We aimed to explore treatment-induced changes in salivary cortisol, IgA and flow rate values in TMD patients suffering from myofascial pain. Temporomandibular disorders patients (n = 39) were randomized into two groups and treated with two different occlusal appliances. Perceived stress regarding family, work, economy, relationships, general health and stress in general was evaluated at baseline according to a verbal scale. Paraffin-stimulated saliva samples were collected before treatment and during follow-up at 6 and 10 weeks. Flow rate was measured immediately after the saliva collection while salivary cortisol and IgA were determined from samples stored at -70 degrees C. No clear association between reported stress and cortisol or IgA values could be observed at baseline. At 10 weeks follow-up, 92% of the patients felt 'better, much better, symptom-free' and no difference was found between the two appliance groups. Cortisol, IgA and flow rate values showed no systematic between appliance groups' differences. All salivary parameters showed interindividual differences but stayed intra-individually on a similar level throughout the study and no statistically significant changes could be observed when comparing before and after treatment levels. To conclude, there were no treatment-induced changes in saliva parameters despite successful appliance therapy in myofascial pain patients.

Recommendations by the EACD for examination, diagnosis, and management of patients with temporomandibular disorders and orofacial pain by the general dental practitioner.

The Council of the European Academy of Craniomandibular Disorders charged the Educational Committee with the task of establishing Guidelines and Recommendations for the examination, diagnosis, and management of patients with temporomandibular disorders and orofacial pain by the general dental practitioner. It was not their purpose to present a thorough and critical review of the vast amount of literature available but to summarize the at-present generally accepted clinical approach. These recommendations are based as much as possible on scientific evidence and on sound clinical judgment in cases where only partial evidence or contradictory data were found.

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.

Treatment outcome of short- and long-term appliance therapy in patients with TMD of myogenous origin and tension-type headache.

The aim was to compare the short- and long-term effect of a stabilization appliance with a control appliance in myofascial pain patients suffering from episodic or chronic tension-type headache. Sixty patients (mean age 29 +/- 12 years) with temporomandibular disorders (TMD) of myogenous origin and headache were studied in this prospective controlled study. Seventy-seven per cent of the patients reported episodic and 23% chronic tension-type headache at the start of the study. The 60 patients were randomly assigned to a treatment group (stabilization appliance) or to a control group (control appliance). The patients were interviewed regarding symptoms of headache and myofascial pain and clinically examined for masticatory muscle tenderness. At the 10-week and the 6- and 12-month evaluations of appliance therapy, the treatment outcome of tension-type headache was studied. At the 10-week evaluation, 17 patients dropped-out from the control group by requesting another appliance and receiving a stabilization appliance. Another patient in the control group dropped out later during the trial. In an intent-to-treat analysis, significant differences in improvement of headache between treatment and control groups were found at the follow-ups. A 30% reduction of muscles tender to palpation correlated significantly to improvement of headache at all follow-ups. The stabilization appliance seems to have a positive effect on tension-type headache, both in a short- and in a long-term perspective in patients with TMD with pain of myogenous origin.

Temporomandibular disorders, occlusion and orthodontic treatment.

OBJECTIVES: To prospectively and longitudinally study symptoms and signs of temporomandibular disorders (TMD) and occlusal changes in girls with Class II malocclusion receiving orthodontic fixed appliance treatment in comparison with untreated Class II malocclusions and with normal occlusion subjects. DESIGN: Prospective observational cohort. SUBJECTS: Sixty-five girls with Class II malocclusion who received orthodontic treatment, 58 girls with no treatment, and 60 girls with normal occlusion. METHOD: The girls were examined for symptoms and signs of TMD and re-examined 2 years later. Additional records were taken in the orthodontic group during active treatment and 1 year after treatment RESULTS: All three groups included subjects with more or less pronounced TMD, which showed individual fluctuation during the ongoing study. In the orthodontic group, the prevalence of muscular signs of TMD was significantly less common post-treatment. Temporomandibular joint clicking increased in all three groups over the 2 years, but was less common in the normal group. The normal group also had a lower overall prevalence of TMD than the orthodontic and the Class II group at both registrations. Functional occlusal interferences decreased in the orthodontic group, but remained the same in the other groups over the 2 years. CONCLUSIONS: (i) Orthodontic treatment either with or without extractions did not increase the prevalence or worsen pre-treatment symptoms and signs of TMD. (ii) Individually, TMD fluctuated substantially over time with no predictable pattern. However, on a group basis, the type of occlusion may play a role as a contributing factor for the development of TMD. (iii) The large fluctuation of TMD over time leads us to suggest a conservative treatment approach when stomatognathic treatment in children and adolescents is considered.

Long-lasting orofacial pain--a study of 109 consecutive patients referred to a pain group.

The aim was to register and evaluate the orofacial pain condition, with special focus on the equalities/inequalities between the sexes, in consecutive patients referred to the pain group at the Centre for Oral Health Sciences in Malmö, Sweden. The 109 patients, 85 (78%) women and 24 (22%) men, were referred to the pain group during the years 1988 to 1993 and were clinically examined using a standardised procedure. Pain duration of one year or more was experienced by 83% of the patients. The pain onset was related to dental care or toothache by 56% of the patients. Temporomandibular disorders were the most common diagnoses (52%) and were more common among women than among men (p < 0.05). Multiple pain locations were frequently reported, range 1-47 locations, and the women had significantly (p < 0.05) more pain locations than the men. Equalities between the sexes were more frequent than inequalities among patients referred for long-lasting orofacial pain. It can be discussed whether the sex difference in the prevalence of pain of musculoskeletal origin emerges from biological differences or can be explained by different psychosocial circumstances.

Signs of temporomandibular disorders in girls receiving orthodontic treatment. A prospective and longitudinal comparison with untreated Class II malocclusions and normal occlusion subjects.

The aim of this investigation was to prospectively and longitudinally study signs of temporomandibular disorders (TMD) and occlusal changes in girls with Class II malocclusion receiving orthodontic treatment and to compare them with subjects with untreated Class II malocclusions and with normal occlusion subjects. Three groups of age-matched adolescent girls were examined for clinical signs of TMD and re-examined 2 years later. Sixty-five Class II subjects received orthodontic fixed straight-wire appliance treatment (Orthodontic group), 58 subjects were orthodontically untreated (Class II group), and 60 subjects had a normal occlusion (Normal group). In the Orthodontic group, the prevalence of muscular signs of TMD was significantly less common post-treatment. The Class II and the Normal groups showed minor changes during the 2-year period. Temporomandibular joint clicking increased in all three groups over the 2 years, but was less common in the Normal group. The Normal group also had a lower overall prevalence of signs of TMD than the Orthodontic and the Class II groups at both registrations. Functional occlusal interferences decreased in the Orthodontic group, but remained the same in the other groups over the 2 years. In conclusion, orthodontic treatment did not increase the risk for or worsen pretreatment signs of TMD. On the contrary, subjects with Class II malocclusions and signs of TMD of muscular origin seemed to benefit functionally from orthodontic treatment in a 2-year perspective. The Normal group had a lower prevalence of signs of TMD than the Orthodontic and the untreated Class II groups.

Temporomandibular disorders and the need for stomatognathic treatment in orthodontically treated and untreated girls.

The aim of this investigation was to study symptoms of temporomandibular disorders (TMD) and headaches longitudinally in girls with Class II malocclusions receiving orthodontic treatment in comparison with subjects with untreated Class II malocclusions and girls with normal occlusion, and to evaluate the need and demand for stomatognathic treatment. The frequency and location of subjective symptoms of TMD and headaches were registered by means of an interview and a questionnaire in three groups of age-matched adolescent girls. Sixty-five Class II subjects received orthodontic fixed straight-wire appliance treatment (Orthodontic group), 58 with Class I malocclusion were orthodontically untreated (Class II group) and 60 had a normal occlusion (Normal group). Individual fluctuations of reported symptoms of TMD were found in all three groups over the 2-year period of the study. Subjects with untreated Class II malocclusions rated their overall symptoms of TMD as more severe than the Orthodontic and the Normal groups. In the Orthodontic group, the prevalence of symptoms of TMD decreased over the 2 years. The overall prevalence of symptoms of TMD was, however, lower in the Normal group than in the other two groups. The need for stomatognathic treatment in the whole sample was estimated to be 13 per cent, while the actual demand was 3 per cent. The large fluctuation of symptoms of TMD over time leads us to suggest a conservative treatment approach when stomatognathic treatment in children and adolescents is considered. The results show that orthodontic treatment did not increase the risk of TMD.

The influence of stabilisation appliance therapy and other factors on the treatment outcome in patients with temporomandibular disorders of arthrogeneous origin.

The aim of this study was to investigate if the difference in treatment outcome between patients provided with a stabilisation appliance and a control appliance was due to the treatment and/or other factors in patients with temporomandibular disorders (TMD) of arthrogeneous origin. Sixty patients were assigned to two equally sized groups: a treatment group, treated with a stabilisation appliance, and a control group given a control appliance. Thirteen possible background variables for the treatment outcome were correlated to changes in severity of temporomandibular joint (TMJ) pain on a verbal scale in the two patient groups. The logistic regression analyses revealed that, after correcting for the background variables, stabilisation appliance treatment was a strong explanatory factor for a positive treatment outcome, with a significance of P = 0.0013 compared to patients belonging to the control group. Background variables of significant importance for the treatment outcome were male sex (positive) (P = 0.0268), and severe or very severe TMJ pain (negative) (P = 0.0034). These findings indicate that not only the treatment with a stabilisation appliance but also sex and the intensity of the TMJ pain before treatment might influence the treatment outcome in patients with TMD of arthrogeneous origin.

Symptoms and signs of temporomandibular disorders before, during and after orthodontic treatment.

The relationship between orthodontic treatment and symptoms and signs of temporomandibular disorders (TMD) was studied prospectively and longitudinally in 65 adolescent girls with Class II malocclusion. The subjects received orthodontic fixed appliance treatment with the straight-wire technique combined with or without extractions and were examined for symptoms and signs of TMD before, during, after, and finally one year post-treatment. Both symptoms and signs of TMD showed considerable fluctuations over the three-year period within the individuals. The general tendency was a decreased prevalence of symptoms of TMD over the three years. The prevalence of pain on mandibular movement and tenderness to palpation of the masticatory muscles was significantly less common during and after orthodontic treatment than before. Clinically registered TMJ clicking increased slightly over the three year period. One orthodontic treatment effect when normalizing Class II malocclusions with fixed appliances was a decreased prevalence of functional occlusal interferences. We concluded that the orthodontic treatment either with or without tooth extractions did not increase the risk for TMD or worsen pre-treatment signs of TMD. Subjects with Class II malocclusion and pre-treatment signs of TMD of muscular origin seemed rather to benefit functionally from orthodontic treatment in a three-year perspective.

An evaluation of digital subtraction radiography for assessment of changes in position of the mandibular condyle.

OBJECTIVE: To compare conventional visual evaluation with digital subtraction for assessing changes in condylar position on TMJ radiographs. METHODS: Horizontally corrected oblique lateral transcranial radiographs of the TMJ were taken bilaterally with and without a stabilisation or a control appliance on the same occasion in 20 patients. All of the radiographs were assessed both conventionally and following digital subtraction by seven observers. Three observers assessed both sets of radiographs twice to calculate observer agreement. RESULTS: There were no statistically significant differences in observer performance or diagnostic outcome between the two techniques. Intra-observer agreement varied between 85 and 90% for the conventional visual evaluation and between 62 and 85% for digital subtraction. Although interobserver agreement was greater with the conventional evaluation the difference was not significant. CONCLUSION: Conventional visual evaluation is recommended for the assessment changes in condylar position from TMJ radiographs.

Treatment outcome in patients with craniomandibular disorders of muscular origin: a 7-year follow-up.

The outcome of different treatment modalities after 7 years was investigated in a selected group of 50 patients with craniomandibular disorders of muscular origin. To minimize the possible effects of selection on the clinical material, the selected treatment group was compared to a consecutive group of patients in terms of age, gender, intensity/duration of pain, and socioeconomic profile. Both groups were comparable in most respects, but the selected group had a longer duration and a higher intensity of pain at baseline. There were more men in the consecutive group than in the selected group. A combined treatment approach resulted in a better outcome than single treatments. Sixty-five percent of all patients in the selected group reported improvement at the 7-year follow-up. All of the 19 patients who received counseling combined with different occlusal treatments improved. Forty-three percent of the patients treated otherwise showed improvement. Patients who were aware of stress responded better to treatment.

Occlusal appliance therapy in a short-term perspective in patients with temporomandibular disorders correlated to condyle position.

PURPOSE: The purposes of this study were to compare changes in the condyle-fossa relationship in patients with temporomandibular disorders of arthrogenous origin treated with either a stabilization or a control appliance in a double-blind controlled study, and to compare the changes in the condyle-fossa relationship with the short-term treatment effect in the two treatment groups. The radiographic appearance of the temporomandibular joint was also studied. MATERIALS AND METHODS: Fifty-eight patients with temporomandibular disorders of arthrogenous origin were assigned to two equally sized groups: a treatment group given a stabilization appliance; and a control group, given a control appliance. The study covered 10 weeks. The treatment outcome regarding changes in severity of temporomandibular joint pain on a verbal scale was compared to changes in the condyle-fossa relationship in horizontally corrected oblique lateral transcranial radiographs taken with and without the appliance. Condyle-fossa relationship and structural bone changes were observed before treatment in corrected lateral tomograms. RESULTS: The group treated with a stabilization appliance showed a changed condylar position significantly more often (P = 0.004) than the control group. Of the patients reporting a successful treatment outcome, significantly more (P = 0.006) showed a changed condyle position in the group treated with a stabilization appliance than in the group treated with a control appliance. CONCLUSION: In patients with temporomandibular disorders of arthrogenous origin, the short-term occlusal appliance therapy resulting in a changed condylar position gave relief of symptoms more often than if the condylar position was unchanged.