H. Clifton Simmons III, DDS, Journal of Craniomandibular Practice 30(1): 9-24, 2012

Abstract: Dr. Charles Greene's article, "Managing the Care of Patients with TMDs A New Guideline for Care", and the American Association for Dental Research (AADR) 2010 Policy Statement on Temporomandibular Disorders, published in the Journal of the American Dental Association (JADA) September 2010, are reviewed in detail.  The concept that all temporomandibular disorders (TMDs) should be lumped into one policy statement for care is inappropriate.  TMDs are a collection of disorders that are treated differently, and the concept that TMDs must only be managed within a biopsychosocial model of care is inappropriate.  TMDs are usually a musculoskeletal orthopedic disorder, as defined by the AADR.  TMD orthopedic care that is peer-reviewed and evidence-based is available and appropriate for some TMDs.  Organized dentistry, including the American Dental Association, and mainstream texts on TMDs, support the use of orthopedics in the treatment of some TMDs.  TMDs are not psychological or social disorders.  Informed consent requires that alternative care is discussed with patients.  Standard of care is a legal concept that is usually decided by a court of law and not decided by a policy statement, position paper, guidelines or parameters of care handed down by professional organizations.  The 2010 AADR Policy Statement on TMD is not the standard of care in the United States.  Whether a patient needs care for a TMD is not decided by a diagnostic test, but by whether the patient has significant pain, dysfunction and/or a negative change in quality of life from a TMD and they want care.  Some TMDs need timely invasive and irreversible care.

Note:  This Special Report contains the following statements regarding the TMJ Scale (please see the Special Report for a listing of reference citations):

“McNeill also stated that the TMJ Scale (Pain Resource Center, Inc.) is designed for use by dentists assessing TMD (ref 57), and more comprehensive psychological inventories are not necessary for routine screening" (ref 56).

“The TMJ Scale discriminates between dental patients without a clinical TMD and dental patients with a clinical TMD.  The gold standard for test development was a group of 30 TMD dentists in 19 states and Canada utilizing a clinical history and examination guided by a clinical evaluation protocol.” (ref 99) 

“The TMJ Scale is utilized to separate dental patients without clinical TMD from dental patients with a clinical TMD (refs 82, 85, 86, 90, 91, 98).  The accuracy, reliability, predictive values, integrity and effectiveness of the TMJ Scale has been rigorously scrutinized.” (refs 81-86)

“The TMJ Scale can also be used to quantitatively measure the effectiveness of treatment, and therefore outcome, by utilizing the TMJ Compare (Pain Resource Center, Inc.) to calculate differences in TMD symptom intensity before and after treatment interventions.”

“These tests, except for the TMJ Scale, usually do not discriminate between those who need chronic TMD care and those who do not.”

“Prior to undertaking TMD management, the dentist should screen with the TMJ Scale or similar test specifically for oral habits, depression, anxiety, stressful life events, lifestyle changes, secondary gain and overuse of health care (refs 56,57).  More comprehensive psychological inventories are not necessary for routine TMD screening (ref 56).  The TMJ Scale can determine which dental patients have significant TMD symptoms in the physical symptom categories Pain, TM Joint Dysfunction and TM Joint Range of Motion Limitation (ref 82).  Technological diagnostic devices, except for the TMJ Scale, test for specific TMJ and/or associated structure abnormalities, but do not determine who needs TMD care.”

"Brown and Gaudet showed in studies utilizing the TMJ Scale that TMDs are not self-limiting and that they do not resolve with time." (refs 90-92)

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

Dr. Pamela Steed, DDS, MSD

Jour of Craniomandib Practice, (16)3: 138-42, 1998

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.

Wexler Gerald B and Steed Pamela A,

Jour of Craniomandib Practice, (16)2: 72-77, 1998.

This study examines the effect of psychological dysfunction as an etiological factor in temporomandibular disorder (TMD). It employs a thoroughly validated psychometric measurement system, the TMJ Scale (Pain Resource Center, Inc., Durham, North Carolina), to determine the effects of pretreatment stress and psychological dysfunction upon presenting symptom levels. The study also addresses these parameters for the eventual treatment outcome. During the course of this study, 2,074 patients were evaluated. Seven hundred and fifty-four by Dr. Steed and 1,320 by Dr. Wexler. Both practices address essentially identical patient populations and focus special interest in craniofacial pain and the diagnosis and Phase I treatment of temporomandibular dysfunction. Of the patients in the study who were found to have clinically treatable temporomandibular disorders, 561 consecutive patients completed treatment and were deemed to have reached Maximum Medical Improvement (MMI). The TMJ Scale was re-administered to this post-treatment population. This study summarized findings pertinent to the four primary issues: 1. pre-treatment psychological factors and stress, which seem to be moderately related to presenting pain levels and overall TMD levels (excepting joint function); 2. treatment outcomes which appeared to be unrelated to the initial psychosocial symptom severity; 3. physical symptoms outcomes and psychosocial outcomes which appeared to be significantly related and; 4. intracapsular symptom improvement which appeared to be unrelated to psychological functioning changes but mildly related to stress.

Wexler GB, McKinney MW, Temporomandibular Treatment Outcomes within Five Diagnostic Categories, Jour of Craniomandib Practice, (17)1: 30-37, 1999

Abstract

This study of temporomandibular disorder (TMD) treatment outcomes examines 274 consecutive patients in five diagnostic categories and a 25 patient comparison group to determine relative levels of symptom improvement. Employing a psychometric outcome measure, the TMJ Scale, it was found that patients receiving active TMD treatments manifest statistically significant symptom improvements. Untreated patients reported minor and statistically insignificant symptom variations. Patients with intracapsular TM joint dysfunctions exhibited higher levels of improvement in pain and other TMD symptoms than patients presenting with primarily muscle symptoms. This research supports the hypothesis that TMDs are not self-limiting and require active treatment interventions. It is suggested that some studies cited to show that TMDs are self-limiting have major methodological limitations, relying upon unvalidated and subjective assessments of symptom levels. This research also outlines a procedure for TMD practitioners to measure treatment efficacy and the relative effectiveness of differing treatment modalities in a valid, consistent and unbiased manner.

Levitt SR, McKinney MW, Jour of Orofacial Pain, 8(1):25-25, 1994.

The accuracy and reliability of the TMJ Scale were originally determined in cross-validation studies on large, research-based patient samples. It had been assumed that the demographic characteristics and test responses of these research-based samples would be representative of the clinical population in which the TMJ Scale would ultimately find use. The present study on more than 10,000 patients that were evaluated for temporomandibular disorders in clinical practice demonstrates that the test scores, demographic variables, and the patterns of symptom severity that characterize the original TMJ Scale research sample accurately represent the general temporomandibular disorder patient population in which the TMJ Scale is now being used. The results suggest a high degree of confidence in the clinical efficacy of this assessment tool. The overall symptom severity of temporomandibular disorders was found to be normally distributed in the patient population. Women with temporomandibular disorders report a higher level of severity of all physical and psychological symptoms than men. This may explain the high female-to-male ratio in patients seeking treatment. However, a higher percentage of male temporomandibular disorder patients has clinically significant psychological and stress-related problems than do women. The severity and prevalence of symptoms associated with joint dysfunction and range of motion limitation are lower in older age groups, and the overall symptom severity of temporomandibular disorders is not higher in older age groups. However, the severity and prevalence of symptoms associated with joint dysfunction are greater in groups in which temporomandibular disorders have existed for longer durations, although pain levels do not follow this trend. There is also an association between time duration of the temporomandibular disorder and the severity of psychological problems and chronicity. Patients with chronic problems are symptomatically more impaired than those with acute problems.

Jour of Craniomandib Practice, (19)3: 188-194, 2001

Abstract

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.

Brown DT, Gaudet EL, Jr, Temporomandibular Treatment Outcomes: Second Report of a Large-Scale Prospective Clinical Study, Jour of Craniomandib Practice, (20)4: 244-253, 2002. 

Abstract:

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.

Abstract

Qasim WF, The Effectiveness of Occlusal Splint Therapy in Treatment of Iraqi Temporomandibular Disorder (TMD) Patients, J Med J, (40) 4:1-6, 2006.

The effectiveness of an occlusal splint as a conservative non-invasive treatment modality of
temporomandibular joint disorders evaluated clinically with the design of full coverage, flat, maxillary
occlusal splint. Twenty-eight temporomandibular disorder treated patients were evaluated with the
Temporomandibular Joint scale (TMJ Scale) before and after treatment. A group of twenty-six similar
patients identified as having temporomandibular disorders, but they did not obtained treatment, were
used as a control group. It was found that this splint design had a significant effect on improvement of
physical signs related to temporomandibular disorder, but it had no significant effect on the elimination
of temporomandibular joint clicking at the end of final evaluation period. Accordingly, its indication was
limited for myogenic facial pain and not for repositioning purposes.

Nasr MK, Bataglion C, Nunes L de J, Bataglion SAN, Paiva AF, "Application of the TMJ Scale and Electromyography in Masseter and Anterior Temporal Muscles in Subjects with Temporomandibular Joint Dysfunction With and Without Orthodontic Treatment and Operative Dentistry Restorative Treatment: Comparative Study", Jornal Brasileiro de Oclusao, ATM e Dor Orofacial, 2(5): 34-43, 2002.

This research had as its objective to verify in subjects at university all presenting temporomandibular joint dysfunctions and with operative restorative dentistry, divided in two groups, with and without orthodontic treatment, the electromyographic activity of the masseter and anterior temporal muscles in different mandibular positions, and the validity of the anamnestic questionnaire TMJ Scale. The results showed that, at the rest position and in maximum habitual intercuspation, the group of the subjects with orthodontic treatment showed less electromyographic activity in relation to the group that had not received orthodontic treatment, however the activities were shown more balanced. In the right and left movement, in both groups, there was a greater activity in the ipsilateral temporal muscles, in relation to the contralateral muscle.  The TMJ Scale showed that this questionnaire appeared to be reliable and that it can be applied to the practice of dentistry, either in private or in epidemiologic studies.