TMJ Scale™ Scientific Publications

™Select the links below to see abstracts of publications by:

Levitt, SR Mckinney, MW Pocock, PR Chibnall, JT Brown, DT
Willis, WA Simmons, HC Steed, PA Aghabeigi, B Yamaguchi, D
Sollecito, TP

1. Lundeen TF, Levitt SR, McKinney MW. Discriminative Ability of the TMJ Scale: Age and Gender Differences. Jour of Prosth Dent, 56(1):84-92, 1986. PubMed

2. Levitt SR, Lundeen TF, McKinney MW. The TMJ Scale Manual. Pain Resource Center Inc., Durham, NC, 1987.

3. Levitt SR, Lundeen TF. The TMJ Scale: Quantitative Measurements of Symptoms and Treatment Result. TMJ Update, 5(5):77-80, 1987. PubMed

4. Lundeen TF, Levitt SR, McKinney MW. Clinical Applications of the TMJ Scale. Jour Craniomandib Practice, 6(4):339-345, 1988. PubMed

5. Lundeen TF, Levitt SR, McKinney MW. Evaluation of Temporomandibular Joint Disorders by Clinician Ratings. Jour Prosth Dent, 59(2):202-211, 1988. PubMed

6. Levitt SR, Lundeen TF, McKinney MW. Initial Studies of a New Assessment Method for Temporomandibular Joint Disorders. Jour Prosth Dent, 59 (4):490-495, 1988. PubMed

7. Levitt SR, McKinney MW, Lundeen TF. The TMJ Scale: Cross-Validation and Reliability Studies. Jour of Craniomandib Practice, 6(1):17-25, 1988. PubMed

8. Lundeen TF, Scruggs R, McKinney MW, Daniel S, Levitt SR. TMD Symptomatology Among Denture Patients. Jour Craniomandib Disord Fac Oral Pain, 4(1):40-45, 1990. PubMed The relationship between denture wearing and symptoms of temporomandibular disorder (TMD) was assessed with a psychometric test specifically developed to measure TMD symptoms. The subjects were 278 denture patients and 36 elderly patients with a diagnosed TMD. Denture wearers were found to have a higher prevalence of TMD symptoms than the normal population, but the average level of symptoms was of low intensity and not clinically significant. Denture wearers reported fewer TMD symptoms and less stress and psychological distress than TMD patients. Responses to test items assessing perceived malocclusion apparently were not affected by denture wearing.

9. McKinney MW, Lundeen TF, Turner S, Levitt SR. Chronic TM Disorder and Non-TM Disorder Pain: A Comparison of Behavioral and Psychological Characteristics. Jour Craniomandib Practice, 8(1):40-46, 1990. PubMed The purpose of this paper is to determine whether patients with chronic temporomandibular disorder (TMD) pain manifest behavioral, experimental, and psychological characteristics similar to patients with other chronic pain illnesses. The Chronic Pain Battery (CPB), a multidimensional assessment tool for chronic pain patients, was used to compare several important variables between 78 TM disorder (TMD) patients and 98 non-TMD chronic pain patients. The study found that chronic TMD patients had lower "usual" pain intensity and suffering levels, fewer vegetative symptoms associated with depression, higher pain tolerance, less impairment of activity, more hope about treatment outcome, lower health care system utilization, but higher reported stress levels than non-TMD chronic pain patients. The two groups manifested no significant differences in use of narcotics, sedatives, and sleeping pills; levels of depression, anxiety, somatization, hostility, or psychoticism; illness behavior reinforcement in their social surroundings; or ratings of problems with work, family, self-esteem, or suicidal impulses. These findings suggest that chronic TMD pain patients (with a symptom duration of over six months) are behaviorally and psychologically similar to non-TMD chronic pain patients, but that they differ in their perceptions of their disorder, rendering them less handicapped by their problems. Psychological, social, and behavioral treatment methods useful for treating chronic pain syndrome may thus also be applied along with dental therapy for optimal treatment of TMD associated with chronic pain.

10. Levitt SR. The Predictive Value of the TMJ Scale in Detecting Psychological Problems and Non-TM Disorders in Patients with Temporomandibular Disorders. Jour Craniomandib Practice, 8(3):225-233, 1990. PubMed Identification of psychological problems and non-TM disorders in patients with temporomandibular disorders (TMD) is an essential but often difficult task. The TMJ Scale is a self-report symptom inventory that can detect these problems. The predictive value model for assessing the accuracy of diagnostic tests is reviewed. This model is then used to study the Psychological Factors, Stress, and Non-TM Disorder scales of the TMJ Scale to determine whether they add accuracy to the diagnostic process compared with dentists' predictions. The results suggest that these scales provide an improvement in diagnostic accuracy in ruling out and in confirming these problems in the individual patient throughout the range of base rates found in clinical practice. The application of the principles of predictive values to test interpretation helps the dentist determine what level of confidence may be placed in the diagnostic test results and associated clinical decisions.

11. Levitt SR. Predictive Value of the TMJ Scale in Detecting Clinically Significant Symptoms of Tempormandibular Disorders. Jour Craniomandib Disord Facial Oral Pain, 4(3):177-185, 1990. PubMed It is important for the dentist to differentiate between subclinical and clinically significant symptoms of TMD. The TMJ Scale tests for clinical significance of pain report, palpation pain, perceived malocclusion, joint dysfunction, and range of motion limitation. To evaluate the accuracy of test results in a patient, the predictive values for each scale must be known. The positive and negative predictive values are calculated and found to produce an increase in diagnostic accuracy of the TMJ Scale compared to pre-test predictions throughout most of the base rate range found in clinical practice. The use of predictive values to interpret test results correctly and to confirm or rule out clinically significant symptoms is described.

12. Spiegel EP, Levitt SR. Measuring Symptom Severity and Treatment Outcome of Tempormandibular Disorders with the TMJ Scale: Case Report. Jour Craniomandib Practice, 8(4):353-358, 1990. PubMed

13. Spiegel EP, Levitt SR. Measuring Symptom Severity with the TMJ Scale. Jour Clinical Orthodont, 25(1):21-26, 1991. PubMed

14. Levitt SR, Spiegel EP, Claypoole WH. The TMJ Scale and Undetected Brain Tumors in Patients with Temporomandibular Disorders. Jour Craniomandib Practice, 9(2):152-158, 1991. PubMed The symptoms of non-temporomandibular disorders, including mass lesions of the central nervous system, may mimic or be masked by symptoms of temporomandibular disorders, and thus not be detected. The dentist must remain alert to this possibility and maintain a high level of suspicion. Three cases illustrate how the TMJ Scale was used in patients having internal derangements of the temporomandibular joints to screen for and detect non-temporomandibular disorders, which, on further evaluation or referral, led to the diagnosis of brain tumors that had not been detected previously.

15. Levitt SR. Predictive Value: A Model for Dentists to Evaluate the Accuracy of Diagnostic Tests for Temporomandibular Disorders as Applied to the TMJ Scale. Jour of Prosthetic Dent, 66(3):385-390, 1991. PubMed The predictive value model for assessing the accuracy of diagnostic test results in the individual patient with a temporomandibular disorder is described. The use of predictive values to help the clinician ascertain the degree of confidence to be placed in diagnostic test results is illustrated. The predictive value model is used to study the accuracy of the TMJ Scale as a diagnostic tool. For all base rates between 0% and 100%, the predictive values of the TMJ Scale result in a gain in accuracy in confirming or excluding a diagnosis of a temporomandibular disorder. The TMJ Scale provides the dentist with improved accuracy of diagnostic decisions regarding the presence of temporomandibular disorders throughout the entire range of base rates found in clinical practice. Application of the predictive value model helps the dentist avoid serious diagnostic errors that could place both the patient and dentist at unnecessary risk.

16.  Owen III, AH, Record Keeping Adjuncts for TMD Therapy. Jour Craniomandib Practice, 9(1):39-48, 1991.

17. Murphy GJ, McKinney MW, Gross WG. Temporomandibular-Related Pressure Thresholds: A Model for Establishing Baselines. Jour Craniomandib Practice, 10(2):118-123, 1992. PubMed The use of pressure threshold measurement to quantify tender spots and trigger points in muscles is well established. Its application to the field of temporomandibular disorders, however, has been more recent and less widely published. Pressure threshold measurement may be useful to define values for dysfunctional muscles or structures so that changes in muscle condition through a course of treatment can be quantified. Normal values for many muscles in the body have been established, but studies of this type in the masticatory system are limited and have often used a fixed, pre-determined pressure cutoff, rather than measuring thresholds across a number of patients. This pilot study seeks to determine whether normal values exist for the anterior temporalis muscles, the masseter muscles, and the lateral capsules of the temporomandibular joints. Intrarater and interrater reliability in measuring thresholds was also studied with the aim of contributing toward a methodological model for further study.

18. Pocock PR, Mamandras AH, Bellamy N. Evaluation of an Anamnestic Questionnaire as an Instrument for Investigating Potential Relationships between Orthodontic Therapy and Temporomandibular Disorders. Am Jour Orthod Dentofac Orthop, 102(3):239-243, 1992. PubMed 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.

19. Levitt SR, McKinney MW, Willis WA. Measuring the Impact of a Dental Practice on TM Disorder Symptoms. Jour of Craniomandib Practice, 11(3):211-216, 1993. PubMed 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.

20. Levitt SR, McKinney MW. Validating the TMJ Scale in a National Sample of 10,000 Patients: Demographic and Epidemiologic Characteristics. Jour of Orofacial Pain, 8(1):25-25, 1994. PubMed 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.

21. Chibnall JT, Duckro PN, Greenberg MS. Evidence for Construct Validity of the TMJ Scale in a Sample of Chronic Post-Traumatic Headache Patients. Jour of Craniomandib Practice, 12(3):184-189, 1994. PubMed The construct validity of the TMJ Scale was examined in a sample of chronic post-traumatic headache patients. Clinical indicators of temporomandibular (TM) dysfunction and measures of psychosocial distress were compared with relevant scales of the TMJ Scale. The clinical indicators were first subjected to principal components analysis. The resulting factor scores correlated significantly with selected physical domain scales of the TMJ Scale. The factor scores also significantly predicted the TMJ Global Scale in a regression analysis. Selected psychosocial domain scales of the TMJ Scale correlated strongly with measures of depression and anger and a clinical diagnosis of post-traumatic stress disorder. The results support the validity of the TMJ Scale and demonstrates its utility with post-traumatic headache patients.

22. Levitt SR, McKinney MW. The Appropriate Use of Predictive Values in Clinical Decision Making and Evaluating Diagnostic Tests for TMD. Jour of Orofacial Pain, 8(3):298-308, 1994. PubMed Temporomandibular disorder literature contains serious misunderstandings and misapplications of statistical concepts, including predictive values, in evaluating diagnostic modalities and in clinical decision making. The use of general population prevalence data for temporomandibular disorders to evaluate positive predictive values of diagnostic modalities is shown to be invalid. The positive predictive value of a diagnostic tool should not be used to evaluate the efficacy of the tool or to confirm the presence of temporomandibular disorders when the pretest likelihood of temporomandibular disorder is low (eg, 10%). In such a situation, the TMJ Scale's negative predictive value of 98% supports the dentist's clinical impression of the absence of temporomandibular disorders. When the pretest likelihood of TMD is high (eg, 90%), the TMJ Scale's positive predictive value of 97% supports the dentist's clinical impression of the presence of temporomandibular disorders. The predictive values of the subscales of the TMJ Scale that measure joint dysfunction and stress may be used to further refine the diagnostic impression. When the dentist is unsure of the presence of TMD and makes a pretest estimate of 50%, the TMJ Scale's positive predictive value of 81% and negative predictive value of 83% substantially improve the accuracy of clinical decisions.

23. Brown DT, Gaudet EL, Jr.. Outcome Measurement for Treated and Untreated TMD Patients Using the TMJ Scale. Jour of Craniomandib Practice, 12(4):216-221, 1994. PubMed Changes in symptom profiles of two groups of treated and untreated temporomandibular disorders (TMD) patients were measured using the TMJ Scale. 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.

24. Willis WA. The Effectiveness of an Extreme Canine-Protected Splint with Limited Lateral Movement in the Treatment of Temporomandibular Dysfunction. Am Jour Orthodont Dentofac Orthop, 107(3):229-234, 1995. PubMed This study suggests that a splint design incorporating extreme canine guidance with limited lateral movement may be effective in the treatment of temporomandibular dysfunction (TMD) symptoms. Fifty consecutively treated TMD patients were evaluated with the TMJ Scale before and after treatment. A group of 11 similar patients identified as having TMD, but who declined treatment, were used as a control group.

25. Wexler GB, McKinney MW. Assessing Treatment Outcomes in Two TMD Diagnostic Categories Employing a Validated Psychometric Test. Jour of Craniomandib Practice, 13(4):256-263, 1995. PubMed This study measures the effects of treatment interventions on two classes of temporomandibular disorder (TMD) patients in a dental practice in Ottawa, Canada. Other studies of TMD treatment outcome have employed subjective, largely qualitative and nonquantitative measures of symptom levels to make this type of assessment, rendering such research largely incapable of being replicated. The current study employs the TMJ Scale, a validated and psychometrically-developed symptom inventory, to measure symptom levels before and after treatment. The study first determined the sensitivity (92.1%) and specificity (88.1%) of the TMJ Scale for 219 patients in the practice population. One hundred and eleven consecutive TMD patients completed TMJ Scales prior to treatment, and then were retested after the completion of treatment. Results indicate that patients with symptoms of internal joint derangement reported more symptomatic improvement than those with predominantly muscular symptomology, despite the fact that the latter manifested lower symptom levels initially. Patients with internal derangement symptoms initially presented with lower levels of psychological symptoms than patients with muscular symptoms. Substantial improvements in both groups were noted, employing TMJ Scale percentile rank changes as outcome measures. This study can serve as a model for future research toward establishing baselines for expected TMD symptom improvement.

26. Simmons HC, Gibbs SJ. Recapture of Temporomandibular Joint Disks Using Anterior Repositioning Appliances: An MRI Study. Jour of Craniomandib Practice, 13(4):228-237, 1995. PubMed

27. Steed PA. Clinical Application of Psychometric Analysis for Temporomandibular Dysfunction. The Functional Orthodontist, 13:32-39, Fall 1996. PubMed The proper diagnostic modalities needed for detecting a temporomandibular dysfunction should include testing procedures from three distinct arenas of data. Those encompass anatomic diagnostic imaging, physiologic testing and psychometric analysis. This article addresses the clinical pretreatment uses and benefits, as well as the post treatment application of a specific psychometric analysis, the TMJ Scale. Additionally, medical-legal issues and case studies are provided.

28. Murphy GJ. Physical Medicine Modalities and Trigger Point Injections in the Management of Temporomandibular Disorders and Assessing Treatment Outcome. Jour of Oral Surgery, Oral Medicine, Oral Radiology and Endodontics, 83:118-122, 1997. PubMed Temporomandibular disorders (TMDs) are principally musculoskeletal, orthopedic, and neurologic in nature. The use of trigger point injections and physical medicine modalities has become commonplace in the management of TMDs. These modalities have a long and successful history in the management of similar disorders in other areas of the body, and it is only natural that they would be included in the management of TMD as well.

29. Duckro PN, Chibnall JT, Greenberg MS, Schultz KT. Prevalence of Temporomandibular Dysfunction in Chronic Post-Traumatic Headache Patients. Headache Quarterly, 7:228-233, 1997.

30. Steed PA. Etiological Factors and Temporomandibular Treatment Outcomes: the Effects of Trauma and Psychological Dysfunction. The Functional Orthodontist, 14:17-22, Fall 1997. PubMed This paper examines the effect of trauma and psychological dysfunction as etiological factors in temporomandibular disorder (TMD). It employs a thoroughly validated measurement system, the TMJ Scale, to determine the effects of traumatic temporomandibular joint injury as well as pre-treatment stress and psychological dysfunction levels upon presenting symptom levels. It also addresses these parameters for the eventual treatment outcome. During the course of the study, 754 patients were evaluated at the author's practice, which is limited to the diagnosis and Phase I treatment of temporomandibular dysfunction. Of those individuals, 693 (91.9%) were found to have clinically treatable temporomandibular disorders. At the time of this study, 201 consecutive patients (29%) have completed treatment and were deemed to have reached Maximum Medical Improvement (MMI). The validated measurement system of the TMJ Scale was readministered to this post treatment population. Data analysis revealed that trauma patients did not differ from non-trauma patients in initial symptom levels, nor in levels of symptom improvement (with the exception of a higher palpation pain level reported by the trauma patients). Stress and psychological dysfunction were predictive of higher initial symptom perception levels, but were not significantly related to treatment outcomes. These findings have important implications for practitioners in the field of temporomandibular studies. If it can be confirmed that psychological variables have no impact on treatment outcome, it would be difficult to justify the now frequently employed "dual axis" classifications and major emphasis placed on psychological treatment for temporomandibular patients.

31. Steed PA, Clinical Application of Psychometric Analysis for Temporomandibular Dysfunction, in Anthology of Craniomandibular Orthopedics, Vol IV, Richard E. Coy (ed), International College of Craniomandibular Orthopedics, Seattle, 1997. PubMed

32. Wexler GB, Steed PA, Psychological Factors and Temporomandibular Treatment Outcomes, Jour of Craniomandib Practice, (16)2: 72-77, 1998. PubMed 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.

33. Steed PA, "TMD Treatment Outcomes: A Statistical Assessment of the Effects of Psychological Variables. Jour of Craniomandib Practice, (16)3: 138-42, 1998. PubMed 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.

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

35. Gaudet EL, Jr., Brown DT, Temporomandibular Treatment Outcomes: First Report of a Large-Scale Prospective Clinical Study, Jour of Craniomandib Practice, (18)1: 9-22, 2000. PubMed 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.

36. Steed PA, Wexler, GB, Temporomandibular Disorders-Traumatic Etiology vs. Nontraumatic Etiology: A Clinical and Methodological Inquiry into Symptomatology and Treatment Outcomes, Jour of Craniomandib Practice, (19)3: 188-194, 2001. PubMed 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.

37. Aghabeigi B, Hiranaka D, Keith D, Kelly J, Crean St. J, Effect of Orthognathic Surgery on the Temporomandibular Joint in Patients with Anterior Open Bite, Int J Adult Orthod Orthognath Surg, (16): 153-160, 2001. PubMed This study examined the prevalence of temporomandibular joint (TMJ) signs and symptoms in patients with anterior open bite. The influence of orthognathic surgery on the TMJ in these patients and the interaction of occlusal and psychologic variables on the presence and/or persistence of pain was studied. A retrospective survey of 83 patients with an anterior open bite who underwent orthognathic surgery was carried out. Records were examined for the prevalence of abnormal TMJ signs and symptoms, including pain. A survey was mailed to these patients that consisted of: (1) the TMJ Scale, (2) the Symptom Checklist 90 (SCL90), (3) the Spielberger State-Trait Anxiety Inventory (STAI), and (4) a visual analog scale on which patients indicated their degree of satisfaction with the procedure. Thirty-seven (42%) patients responded to the survey, and 13 (15%) also attended a clinical and radiographic examination. Multiple regression analysis was used for statistical analysis of the factors contributing to the presence and/or persistence of pain. In the preoperative group, the prevalence of pain was 32%, dysfunction 40%, and limitation of opening 7%. Age and gender were significantly associated with the presence of pain. The overall prevalence of abnormal TMJ signs and symptoms was not significantly different after orthognathic surgery. An abnormal psychologic profile was the most significant factor associated with the presence and/or persistence of pain. It is concluded that that the prevalence of temporomandibular disorders in anterior open bite patients increases with age, is significantly higher in females, and is not influenced by other occlusal variables. Furthermore, orthognathic surgery does not significantly influence temporomandibular disorders in patients with anterior open bite. Female patients, particularly those with an abnormal psychologic profile, are at a higher risk of persistent postoperative TMJ pain.

38.  Winocur E, Gavish T, Finkelshtein M, Halachmi M and Gazit, E, Oral habits among adolescent girls and their association with symptoms of temporomandibular disorders, Jour Oral Rehabilitation 28: 624-629, 2001.

39.  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. PubMed 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.

40. Yamaguchi D, et al, Evaluation of Psychological Factors in Orthodontic Patients with TMD as Applied to the "TMJ Scale", The Bulletin of Tokyo Dental College, (43)2: 83-87, 2002. PubMed 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.  

41. 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.

42. Sollecito TP, Clayton LG, DeRossi SS, Laster L, Greenberg MS, The Clayton Intraaural Device for Temporomandibular Disorders, Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics,(97)4: 455, 2004.

43.  Steed PA, The Longevity of Temporomandibular Disorder Improvements after Active Treatment Modalities, Jour Craniomandibular Pract 22(2):110-114, 2004.

44.  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.

45.  Talley, RL,  Use of MINTIVA TMJTM Topical Cream for Treatment of Temporomandibular Joint and Muscle Pain in Symptomatic Patients, TMDiary 23(2): 23-34. 2010.  Eight Six consecutive patients with the primary complaint of temporomandibular joint (TMJ) pain were studied to assess their responses to interceptive provisional treatment between the time of their initial examination and the onset of their planned definitive treatment.  Ten patients (12%) received no provisional treatment; eighteen patients (23%) received a pain-release splint; and fifty-two patients (65%) received a new topical pain-relieving cream, Mintiva TMJTM.  All patients were tested with the TMJ ScaleTM , a 97-question inventory that is a qualitative and quantitative analysis of patient symptoms.  Published studies have shown the validity, reliability, sensitivity and specificity of the TMJ Scale.  None of the patients who were not given the provisional treatment prior to initiating definitive treatment demonstrated symptom change between appointments other than symptoms being slightly worse.  72% of patients who received the pain-relieving splint derived a benefit.  90% of patients receiving the topical pain-relieving cream noted clincial improvement almost equally distributed between mild, moderate and significant.  Conclusion:  the  ease and clinical efficacy of the topical cream for a provisional and/or supplemental treatment during definitive care shows great efficacy and improved clincial outcomes.

46.  Simmons, HC, A Critical Review of Dr. Charles S. Greene's Article titled "Managing the Care of Patients with Temporomandibular Disorders: A New Guideline for Care" and A Revision of the American Association of Dental Research's 1996 Policy Statement on Temporomandibular Disorders, Approved by the AADR Council in March 2010, Published in the Journal of the American Dental Association September 2010, Jour of Craniomandib Pract, 30(1): 9-24, 2012. 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 article 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)