Luca Guarda-Nardini

Research diagnostic criteria for temporomandibular disorders: a systematic review of axis I epidemiologic findings.

OBJECTIVES The aim of this study was to summarize and systematically review the literature on the prevalence of different research diagnostic criteria for temporomandibular disorders (RDC/TMD) version 1.0 axis I diagnoses in patient and in the general populations. STUDY DESIGN For each of the relevant papers, the following data/information were recorded for meta-analysis and discussion: sample size and demographic features (mean age, female-to-male ratio); prevalence of the assigned diagnoses; prevalence of the diagnoses assigned to the left and right joints, if available; prevalence of the diagnoses assigned to the 2 genders, if available; prevalence of the different combinations of multiple diagnoses, if available; and prevalence of TMD (only for community studies). RESULTS Twenty-one (n = 21) papers were included in the review (15 dealing with TMD patient populations and 6 with community samples). The studies on TMD patients accounted for a total of 3,463 subjects (mean age 30.2-39.4 years, female-to-male ratio 3.3), with overall prevalences of 45.3% for group I muscle disorder diagnoses, 41.1% for group II disc displacements, and 30.1% for group III joint disorders. Studies on general populations accounted for a total of 2,491 subjects, with an overall 9.7% prevalence for group I, 11.4% for group IIa, and 2.6% for group IIIa diagnoses. CONCLUSIONS Prevalence reports were highly variable across studies. Myofascial pain with or without mouth opening limitation was the commonest diagnosis in TMD patient populations, and disc displacement with reduction was the commonest diagnosis in community samples.

Epidemiology of bruxism in adults: a systematic review of the literature

AIMS To investigate the association among temporomandibular disorders (TMD), sleep bruxism, and primary headaches, assessing the risk of occurrence of primary headaches in patients with or without painful TMD and sleep bruxism. METHODS The sample consisted of 301 individuals (253 women and 48 men) with ages varying from 18 to 76 years old (average age of 37.5 years). The Research Diagnostic Criteria for Temporomandibular Disorders were used to classify TMD. Sleep bruxism was diagnosed by clinical criteria proposed by the American Academy of Sleep Medicine, and primary headaches were diagnosed according to the International Classification of Headache Disorders-II. Data were analyzed by chi-square and odds ratio tests with a 95% confidence interval, and the significance level adopted was .05. RESULTS An association was found among painful TMD, migraine, and tension-type headache (P < .01). The magnitude of association was higher for chronic migraine (odds ratio = 95.9; 95% confidence intervals = 12.51-734.64), followed by episodic migraine (7.0; 3.45-14.22) and episodic tension-type headache (3.7; 1.59-8.75). With regard to sleep bruxism, the association was significant only for chronic migraine (3.8; 1.83-7.84). When the sample was stratified by the presence of sleep bruxism and painful TMD, only the presence of sleep bruxism did not increase the risk for any type of headache. The presence of painful TMD without sleep bruxism significantly increased the risk in particular for chronic migraine (30.1; 3.58-252.81), followed by episodic migraine (3.7; 1.46-9.16). The association between painful TMD and sleep bruxism significantly increased the risk for chronic migraine (87.1; 10.79-702.18), followed by episodic migraine (6.7; 2.79-15.98) and episodic tension-type headache (3.8; 1.38-10.69). CONCLUSION The association of sleep bruxism and painful TMD greatly increased the risk for episodic migraine, episodic tension-type headache, and especially for chronic migraine.

Efficacy of Botulinum Toxin in Treating Myofascial Pain in Bruxers: A Controlled Placebo Pilot Study

Abstract The present investigation is a preliminary double-blind, controlled placebo, randomized clinical trial with a six month follow-up period. The study aimed to assess the efficacy of type A botulinum toxin (Botox, Allergan, Inc. Irvine, CA) to treat myofascial pain symptoms and to reduce muscle hyperactivity in bruxers. Twenty patients (ten males, ten females; age range 25-45) with a clinical diagnosis of bruxism and myofascial pain of the masticatory muscles were enrolled in a double-blind, controlled placebo, randomized clinical trial, with a treatment group (ten subjects treated with botulinum toxin injections- BTX-A) and a control group (ten subjects treated with saline placebo injections). A number of objective and subjective clinical parameters (pain at rest and during chewing; mastication efficiency; maximum nonassisted and assisted mouth opening, protrusive and laterotrusive movements; functional limitation during usual jaw movements; subjective efficacy of the treatment; tolerance of the treatment) were assessed at baseline time and at one week, one month, and six months follow-up appointments. Descriptive analysis showed that improvements in both objective (range of mandibular movements) and subjective (pain at rest; pain during chewing) clinical outcome variables were higher in the Botox treated group than in the placebo treated subjects. Patients treated with BTX-A had a higher subjective improvement in their perception of treatment efficacy than the placebo subjects. Differences were not significant in some cases due to the small sample size. Results from the present study supported the efficacy of BTX-A to reduce myofascial pain symptoms in bruxers, and provided pilot data which need to be confirmed by further research using larger samples.

Dental occlusion, body posture and temporomandibular disorders: where we are now and where we are heading for

The aim of this investigation was to perform a review of the literature dealing with the issue of relationships between dental occlusion, body posture and temporomandibular disorders (TMD). A search of the available literature was performed to determine what the current evidence is regarding: (i) The physiology of the dental occlusion-body posture relationship, (ii) The relationship of these two topics with TMD and (iii) The validity of the available clinical and instrumental devices (surface electromyography, kinesiography and postural platforms) to measure the dental occlusion-body posture-TMD relationship. The available posturographic techniques and devices have not consistently found any association between body posture and dental occlusion. This outcome is most likely due to the many compensation mechanisms occurring within the neuromuscular system regulating body balance. Furthermore, the literature shows that TMD are not often related to specific occlusal conditions, and they also do not have any detectable relationships with head and body posture. The use of clinical and instrumental approaches for assessing body posture is not supported by the wide majority of the literature, mainly because of wide variations in the measurable variables of posture. In conclusion, there is no evidence for the existence of a predictable relationship between occlusal and postural features, and it is clear that the presence of TMD pain is not related with the existence of measurable occluso-postural abnormalities. Therefore, the use instruments and techniques aiming to measure purported occlusal, electromyographic, kinesiographic or posturographic abnormalities cannot be justified in the evidence-based TMD practice.

Age peaks of different RDC/TMD diagnoses in a patient population

AIMS To evaluate the prevalence of different Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) diagnoses in a population of patients seeking for TMD treatment at a tertiary clinic in Northern Italy; to evaluate the pattern of age distribution of RDC/TMD diagnoses and to compare data with those from similar studies in the literature. MATERIALS AND METHODS Two-hundred-forty-three (N=243) consecutive patients seeking TMD treatment at the TMD Clinic, Department of Maxillofacial Surgery, University of Padova, Italy, during the period from July 1st to December 31st, 2008, underwent a RDC/TMD axis I assessment by the use of a systematically translated Italian version of the RDC/TMD guidelines. RESULTS One-hundred-ninety-nine (N=199) patients (female:male ratio 5:1, mean age 39.7+/-17.1 years, range 18-80) satisfied the RDC/TMD consortium inclusion criteria. Group I disorders (muscle disorders) were diagnosed in 49.7% of patients, group II disorders (disc displacements) in 57.3%, and group III disorders (arthralgia, osteoarthritis, and osteoarthrosis) in 81.4%. The majority of patients (64.3%) received RDC/TMD diagnoses of more than one group. On the basis of the age distribution of RDC/TMD diagnoses, two main distinct groups of TMD patients could be identified: a first group of patients showing disc displacement in the absence of degenerative disorders (any group II diagnoses alone or combined with group I diagnoses of muscle disorders and/or group IIIa diagnosis of arthralgia), and a second group of patients with signs and symptoms of inflammatory-degenerative joint disorders (group IIIb diagnosis of osteoarthritis and/or group IIIc diagnosis of osteoarthrosis). The former comprised 107 patients (20 males, 18.7%; 87 females, 81.3%) with a mean age of 32.7+/-14.5 years, while the latter comprised 46 patients (4 males, 8.7%; 42 females, 91.3%) with a mean age of 54.2+/-15.1 years, thus accounting for about 80% of the study population and being characterized by a significantly different age peak. CONCLUSIONS Along with descriptive relative frequencies of the RDC/TMD diagnoses, which have been compared with other similar studies in the literature, the main findings of the present investigation were that at least two distinct age peaks are identifiable within this population of patients seeking for TMD treatment. These data might be useful to gather data on the specific epidemiologic features of each single RDC/TMD diagnoses. These findings have to be confirmed by means of multicenter studies involving many calibrated investigators.

Psychosocial impairment in temporomandibular disorders patients. RDC/TMD axis II findings from a multicentre study

OBJECTIVES The relationship between the rate of chronic pain-related disability and depression and somatization levels as well as the influence of pain duration on Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) axis II findings were assessed in a three centre investigation. METHODS The study sample (N=1149; F:M 4.1:1, m.a. 38.6 years) consisted of patients seeking for TMD treatment and undergoing RDC/TMD axis II psychosocial assessment to be rated in chronic pain-related disability (Graded Chronic Pain Scale, GCPS), depression (Symptoms Checklist-90[SCL-90] scale for depression, DEP) and somatization levels (SCL-90 scale for non-specific physical symptoms, SOM). The null hypotheses to be tested were that (1) no correlation existed between GCPS categories and DEP and SOM scores, and (2) no differences emerged between patients with pain from more or less than 6 months as for the prevalence of the different degrees of pain-related impairment, depression, and somatization. RESULTS In the overall sample, the prevalence of high pain-related disability (GCPS grades III or IV), severe depression and somatization was 16.9%, 21.4%, and 28.5%, respectively. A correlation was shown between GCPS and both DEP and SOM categories (Spearmans correlation test, p<0.001). A significant association between pain lasting from more than 6 months and high GCPS scores was shown (chi(2), p<0.001), while no association was found between DEP and SOM scores and pain duration in the overall sample (chi(2), p=0.742 and p=0.364, respectively). CONCLUSIONS Pain-related disability was found to be strongly related with depression and somatization levels as well as associated with pain duration. Depression and somatization scores were not associated with pain duration.

Temporomandibular joint osteoarthritis: an open label trial of 76 patients treated with arthrocentesis plus hyaluronic acid injections

This study is an open-label trial on a sample of 76 consecutive patients with temporomandibular joint (TMJ) osteoarthritis treated with a cycle of five weekly arthrocenteses plus hyaluronic acid injections. Patients had a diagnosis of osteoarthritis according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD Axis I Group IIIb). They underwent a cycle of five arthrocenteses with injections (1 per week) of 1ml hyaluronic acid and four follow-up assessments after the end of the treatment (at 1 week, 1 month, 3 months, 6 months). At each appointment, several subjective and objective outcome variables were assessed to test the efficacy of the treatment protocol. Marked improvements were reported for all variables during the treatment phase. The improvements were maintained over the 6-month follow-up period. The p-value of the multivariate permutation test for the efficacy of the treatment over time (with Tippetts combination) was 0.001, and significant changes at the end of the follow-up period were detected for almost all the outcome variables. Data from this study lend further support to the usefulness of serial hyaluronic acid injections performed after arthrocentesis for the treatment of TMJ osteoarthritis and for the maintenance of improvements over a 6-month follow-up period.

Temporomandibular disorders assessment: medicolegal considerations in the evidence-based era.

Summary  Temporomandibular disorders (TMD) are a frequent finding in cases of facial trauma or dental malpractice, and legal claims for TMD damage have been increased over the years. Temporomandibular disorders assessment in the medical legal setting is complicated by the peculiarities of these disorders, whose symptoms are heterogeneous, fluctuant, and recognise a multifactorial origin. A systematic Medline search in the National Library of Medicines PubMed database pointed out that, despite the medical legal aspects of the dental profession are gaining a growing attention, there is a paucity of literature dealing with patients with TMD assessment. For these reasons, evidence-based knowledge in the field of TMD diagnosis and treatment was summarised in this article with the aim of providing useful suggestions for a medical legal approach to TMD.

Arthrocentesis with or without additional drugs in temporomandibular joint inflammatory-degenerative disease: comparison of six treatment protocols*.

The aim of the present pilot investigation was to compare the effectiveness of six treatment protocols providing temporomandibular joint (TMJ) arthrocentesis with or without additional drugs to manage symptoms in patients with inflammatory-degenerative TMJ disease. A consecutive series of 72 patients with TMJ osteoarthritis (axis group IIIb) with pain lasting from more than 6 months were randomly assigned to one of the groups receiving the following treatment protocols: single-session two-needle arthrocentesis (A), single-session two-needle arthrocentesis plus corticosteroid (B), single-session two-needle arthrocentesis plus low molecular weight hyaluronic acid (HA) (C), single-session two-needle arthrocentesis plus high molecular weight HA (D), 5 weekly two-needle arthrocenteses plus low molecular weight HA (E) and 5 weekly single-needle arthrocenteses plus low molecular weight HA (F). At the 3-month follow-up, improvement with respect to mean baseline values was recorded in all the five treatment groups completing the protocol. No significant differences emerged between groups in any outcome variable. The protocol providing five sessions of two-needle arthrocenteses plus low molecular weight HA allowed achieving the highest improvement in almost all the outcome variables. Findings suggested that no statistically significant differences existed between the treatment groups. The clinical significance of these findings needs to be tested with future studies on larger samples with longer follow-up periods.

Arthrocentesis of the temporomandibular joint: a proposal for a single-needle technique

Arthrocentesis is a method of flushing out the temporomandibular joint (TMJ) that is currently performed by providing a double access to the joint space. Several studies have shown that arthrocentesis of the upper compartment of the TMJ may be a highly effective method to restore normal maximal mouth opening and functioning. Nonetheless, the classical 2-needle technique has some limits, such as the low tolerability and difficulty in performing it in the presence of intra-articular adherences. The adoption of a single-needle for both fluid injection and aspiration might have some advantages with respect to the traditional 2-needle approach in terms of time of execution, tolerability, and retention of medication. These potential advantages have to be assessed with future randomized and controlled clinical trials.