Treatment of temporomandibular disorders - knowledge, attitudes and clinical experience among general practising dentists in Sweden

Knowledge and Attitudes regarding Temporomandibular Disorders among Postgraduate Dental Students and Practicing Dentists in Western China: A Questionnaire-Based Observational Investigation

Background

It is necessary for dental students and dentists to apply their temporomandibular disorders (TMDs)-related knowledge to clinical practice. The current study aimed to evaluate the knowledge and awareness of postgraduate dental students and practicing dentists regarding etiology, diagnosis, and treatment of TMD in western China and thus provide suggestions on TMD curricula design to get postgraduate students and dentists better prepared for TMD diagnosis and treatment.

Methods

This observational and descriptive cross-sectional study was conducted among postgraduate students and practicing dentists in western China. Twenty-five reorganized knowledge questions in four domains were selected from the published literature and were evaluated with answer options from "strongly agree" to "strongly disagree," and "I don't know." "Consensus" is defined as more than 50% of respondents in a group agree or disagree with a statement. Chi-square tests were performed for comparisons between the two groups.

Results

A total of 132 postgraduate dental students and 123 dentists completed the questionnaire. Around 75% of postgraduate students and 85% of dentists claimed that they have never participated in systematic training in TMD. Nine statements in etiology, diagnosis, treatment, and prognosis of TMD had different consensus between the two groups. And the dentist group tended to agree more with 12 statements in the questionnaire.

Conclusions

The majority of Chinese dentists and dental students have not taken any TMD courses and possess limited knowledge of TMD. Curriculum reform for predoctoral education, postgraduate education, and continuing education is needed to augment knowledge and skills for TMD diagnosis and treatment.

Persistent somatic symptom related stigmatisation by healthcare professionals: A systematic review of questionnaire measurement instruments

OBJECTIVE

Patients with persistent somatic symptoms (PSS) experience stigmatising attitudes and behaviours by healthcare professionals. While previous research has focussed on individual manifestations of PSS related stigma, less is known about sound ways to measure stigmatisation by healthcare professionals towards patients with PSS. This review aims to assess the quality of questionnaire measurement instruments and make recommendations about their use.

METHODS

A systematic review using six databases (PubMed, Embase, CINAHL, PsycINFO, Open Grey and EThOS). The search strategy combined three search strings related to healthcare professionals, PSS and stigma. Additional publications were identified by searching bibliographies. Three authors independently extracted the data. Data analysis and synthesis followed COSMIN methodology for reviews of outcome measurement instruments.

RESULTS

We identified 90 publications that met the inclusion criteria using 62 questionnaire measurement instruments. Stereotypes were explored in 92% of instruments, prejudices in 52% of instruments, and discrimination in 19% of instruments. The development process of the instruments was not rated higher than doubtful. Construct validity, structural validity, internal consistency and reliability were the most commonly investigated measurement properties. Evidence around content validity was inconsistent or indeterminate.

CONCLUSION

No instrument provided acceptable evidence on all measurement properties. Many instruments were developed for use within a single publication, with little evidence of their development or establishment of content validity. This is problematic because stigma instruments should reflect the challenges that healthcare professionals face when working with patients with PSS. They should also reflect the experiences that patients with PSS have widely reported during clinical encounters.

Temporomandibular disorders: knowledge, competency, and attitudes of predoctoral dental students

OBJECTIVE

To evaluate knowledge, competency, and attitudes related to temporomandibular disorders (TMD) among predoctoral dental students, and to investigate the curricular organization of contents related to TMD and occlusion.

METHODS

Predoctoral dental students (n = 147) answered a questionnaire with topics related to TMD. Another questionnaire evaluated the organization of TMD and occlusion courses.

RESULTS

Contents related to TMD and occlusion were taught in the same course in all dental schools. The students' responses showed low agreement with the current gold standards pertaining to TMD. Most students declared that they did not feel confident to treat patients with TMD (62.6%), were not satisfied with the content pertaining to TMD (55.8%), and considered a lack of clinical practice to be the primary limitation in their training (59.2%).

DISCUSSION

Students' knowledge of basic concepts related to TMD was limited, highlighting the need for readjustment of the dental curriculum to increase clinical experience.

The role of social media for patients with temporomandibular disorders: A content analysis of Reddit

BACKGROUND

Social media is frequently used to discuss health topics among users. Reddit is a popular social media platform particularly suit for discussion about chronic illness because of its anonymity that allow users to express uninhibited feelings. Temporomandibular disorders (TMD) represent a chronic painful disorder which has been rarely studied in terms of social media discussion.

OBJECTIVES

By exploring how Reddit is used to discuss about TMD, we aim to raise awareness to clinicians involved in TMD management about the online discussion on this topic.

METHODS

A quantitative content analysis was performed on a pool of most relevant threads and comments about the topic "TMJ" on Reddit. Following a codebook, two independent coders assessed multiple clinically relevant variables. A third subject resolved eventual discrepancies.

RESULTS

Reddit is mostly used by subjects with TMD asking for advice to other users about symptoms and treatment modalities. The most discussed causes of TMD were bruxism and dental occlusion, and the most discussed treatments were oral appliance therapy and complementary and alternative treatments. The most favourable opinions about treatment modalities were for self-care and behavioural therapy while the least favourable opinions were for surgery and irreversible dental treatments.

CONCLUSIONS

Reddit represents an excellent data-mining platform to retrieve valuable information about health-related discussion by the community. Our findings suggest an overall alignment of such discussion with evidence-based science about TMD; however, to further increase this trend, we encourage healthcare provider to take an active role in the digital spread of scientifically valid information.

Impact of the DC/TMD instructional video on the practical skills of undergraduate students-A single-blinded, randomized controlled trial

INTRODUCTION

Competencies in the clinical examination of patients with temporomandibular disorders (TMD) can be achieved by self-instruction. This study aimed to identify the impact of the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) instructional video on the practical examination skills of undergraduate students.

MATERIALS AND METHODS

One week prior to completing an objective structured clinical examination (OSCE) addressing the examination of patients with TMD, undergraduate students in their third year received either the DC/TMD manual (control group) or additionally watched the instructional video once (intervention group). After passing the OSCE, a feedback questionnaire was completed by the students.

RESULT

Fifty undergraduates were recruited to take part in the OSCE prior to their first clinical course. The sum scores achieved in the stations were higher in the intervention group, but missed significance. Participants of the intervention group more often agreed that completing the OSCE stations was easy, which was significant for one station (P = .023). 95.8% of the participating students supported the implementation of the video in dental education.

DISCUSSION

Due to the conception of the study, the video was only presented once to ensure that the control group had no access to the medium at all. However, it might be interesting to investigate whether repeated watching of the video enhances its effect.

CONCLUSIONS

Clinical competencies in the examination of TMD patients can be achieved by self-instruction with the DC/TMD manual and instructional video. Watching the video for educational purposes was highly recommended by undergraduate students.

Patients referred to a German TMD-specialized consultation hour-a retrospective on patients without a diagnosis according to RDC/TMD decision trees

OBJECTIVES

The objective was to describe the physical and psychosocial features of patients attending a specialized consultation hour for temporomandibular disorders (TMD). This investigation focused on those patients who did not receive a diagnosis according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD).

MATERIALS AND METHODS

From 2004 to 2017, patients seeking care during a TMD-specialized consultation hour were consecutively recruited. Each patient completed a TMD-related questionnaire, psychosocial questionnaires (Graded Chronic Pain Scale, Hospital Anxiety and Depression Scale, Beschwerden-Liste), and the Oral Health Impact Profile-49. The clinical examination was performed according to the RDC/TMD.

RESULTS

The mean age of the 1020 patients was 43.3 years (75.3% female). According to the RDC/TMD decision trees, 351 patients were categorized without a TMD diagnosis (NoTMDdx). The most frequent reasons for seeking care were orofacial pain/TMJ pain or headaches revealing an OR of 1.89 (for TMDdx group). A relevant proportion of patients was categorized as positive for anxiety (NoTMDdx/TMDdx 30.8/41.2%; p = 0.072), depression (20.8/23.9%; p = 0.433), non-specific physical symptoms (31.4/44.1%; p < 0.001), or dysfunctional chronic pain (11.5/18.2%; p < 0.001). In both patient groups, the oral health-related quality of life was impaired (42.9/52.7 points; p < 0.001), and the frequency of therapy measures prior to the consultation hour was high.

CONCLUSIONS

Patients seeking care from TMD specialists were usually referred with TMD-associated symptoms. Of those, a relevant proportion did not receive a diagnosis according to RDC/TMD decision trees.

CLINICAL RELEVANCE

Psychosocial screening and the avoidance of overtreatment are recommended for patients with TMD-related symptoms.

Evaluation of Knowledge among Dentists on Symptoms and Treatments of Temporomandibular Disorders in Italy

To determine the knowledge of general dentists and dental specialists on temporomandibular disorders (TMD) in Italy, a web-based questionnaire including 20 multiple- choice questions was sent to all general dental practitioners and specialists in Italy. Mean score of diagnosis and treatment knowledge of all participants was 23.8 ± 7.3 out of 40 achievable scores. There was a significant difference between the knowledge of dentists and the variables of sex, age, and years of experience (p < 0.05). However, overall, it is not possible to state a significant difference between the final score of dentists with different specializations (p = 0.89). The results of this study showed an acceptable knowledge of participants regarding TMD.

Newly graduated dentists' knowledge of temporomandibular disorders compared to specialists in Saudi Arabia

Background

General dentists are often the first healthcare professionals to see patients with orofacial pain (OFP). OFP conditions associated with the temporomandibular joint are often confused with dentoalveolar disorders, which leads to mismanagement. The objective of this study was to evaluate the level of knowledge of temporomandibular disorders (TMD) among newly graduated dentists compared to OFP specialists in Saudi Arabia.

Methods

This was a descriptive cross-sectional study utilizing an anonymous validated questionnaire assessing professional knowledge regarding TMDs in newly qualified dentists and OFP specialists. The questionnaire interrogated four domains including chronic pain/pain behavior, etiology, diagnosis/classification, and treatment/prognosis. OFP specialists were used as the reference group.

Results

A total of 393 dentists participated, a response rate of 67.6% in newly graduated dentists and 77.3% in OFP specialists. The degree of agreement between newly graduated general dentists and OFP specialists was highest for the “chronic pain and pain behavior” domain. The consensus among specialists was highest for the “treatment and prognosis” domain and the least for the “chronic pain and pain behavior” domain.

Conclusion

Newly graduated general dentists have limited knowledge of TMD in almost all domains compared to specialists. Given that a lack of knowledge of TMD can lead to clinical mismanagement, dental school curricula must address this important knowledge gap.

Self-Perceived Dentists' Knowledge of Temporomandibular Disorders in Krakow: A Pilot Study

Introduction

The most common nondental orofacial pain conditions are temporomandibular disorders (TMDs). TMD basic examination and clinical management are included in a curriculum of each dentistry programme taught in Poland, but it is not clear how the dentists cope with diagnosis and possible treatment in their routine dental practices. The objective of the present study was to assess a level of self-perceived knowledge of TMD amongst dentists in Poland. Materials and methods. The participants, of whom all studied and graduated from a Polish university, were randomly selected from dental offices in Krakow (Poland). The selected dentists were administered an anonymous questionnaire, which contained questions measuring self-assessment of knowledge of TMD diagnosis and therapy and assessing knowledge of ethology and TMD symptoms.

Results

Only 6.5% of the participants identified their TMD knowledge as very good, 32.3% assessed it as good, 39.3% thought it was sufficient, 20.4% as insufficient, and 1.49% considered it as poor. 9.4% of all participants have attempted to diagnose and treat TMD patients very often, 26.4% declared performing it often, 45.8% rarely, and 18.4% had never made such an attempt. There was a significant relationship between the dentists' knowledge and their attempts at diagnosing and treating TMD patients (p < 0.05).

Conclusion

The level of TMD knowledge amongst the Polish dentists is still insufficient. Raising its level would considerably help the dentists to refer their patients to right specialists for a diagnosis and TMD treatment and/or interdisciplinary management of TMD patients.

The implementation of a decision-tree did not increase decision-making in patients with temporomandibular disorders in the public dental health service

OBJECTIVE

Many patients with temporomandibular disorders (TMD) seem to go undetected within primary dental health care. Primarily we evaluated if the implemented intervention increased the clinical decision-making for TMD patients; secondarily we evaluated if other factors could be identified that predicted performed or recommended TMD treatment.

MATERIAL AND METHODS

This case-control study was carried out within the Public Dental Health service in Västerbotten County, Sweden. An intervention based on a decision-tree with three screening questions for TMD (3Q/TMD) was implemented during 2015 in four clinics and compared with the remaining county. A total of 400 individuals were selected-200 3Q-positives and 200 3Q-negatives. The 3Q/TMD consists of Q1-frequent jaw pain, Q2-frequent pain on function, and Q3-frequent catching and/or locking of jaw. The 3Q/TMD answers were analyzed in relation to TMD treatment and any TMD related decision that was collected from the digital dental records.

RESULTS

The intervention did not increase the frequencies of traceable clinical decisions among patients with TMD.

CONCLUSIONS

Despite the implemented intervention aimed, the indicated undertreatment of patients with TMD remains. Future studies are still needed to gain a deeper understanding of the clinical decision-making process for TMD patients in general practice dentistry.

Prevalence and treatment strategies regarding temporomandibular disorders in children and adolescents-A systematic review

AIMS

Temporomandibular disorders (TMD) in children/adolescents are very common. Yet, there is a lack of consensus regarding which clinical interventions are appropriate. The aim of this systematic review was to gather and assess the quality of the available literature on the prevalence and evidence-based treatment strategies in children and adolescents suffering from TMD.

METHODS

A systematic literature review was conducted including articles from 1992 to 2016. A total of 2293 articles were found. Eight were included, six regarding prevalence and two regarding treatment. Simple or multiple conjunctions of different search words: "temporomandibular disorder", "temporomandibular joint disorder", "prevalence", "children" "adolescents", "occlusal appliance", "jaw exercise" and "relaxation" were used on the databases PubMed and Web of Science. Inclusion criteria were (a) scientific articles or randomised controlled clinical trials evaluating prevalence, choice of therapy and treatment outcome for children and/or adolescents with TMD published in Swedish or English and (b) a TMD diagnosis according to the Research Diagnostic Criteria for TMD or Diagnostic Criteria for TMD.

RESULTS

Prevalence (ages 10-19 years) varied between 7.3 and 30.4%, and the most common diagnoses were myofascial pain and anterior disc displacement with reduction. Only two articles were found regarding treatment in adolescents (ages 12-18 years). The stabilising occlusal appliance had superior treatment outcome compared to relaxation therapy or brief information.

CONCLUSION

The general absence of standardised studies concerning children/adolescents with TMD pain states the evident need for further systematic prevalence and treatment evaluations. Considering this, it is not possible to achieve any evidence-based treatment strategies or guidelines for children and adolescents with TMD.

Diagnostic accuracy of three screening questions (3Q/TMD) in relation to the DC/TMD in a specialized orofacial pain clinic

OBJECTIVE

To determine the diagnostic accuracy of three screening questions (3Q/TMD) in relation to the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD), in a specialized clinic.

MATERIAL AND METHODS

Consecutive patients, >18 years, referred with a possible TMD complaint to the Orofacial Pain and Dysfunction clinic, Academic Centre for Dentistry Amsterdam, the Netherlands, were included in the study. All patients (n = 449; mean age 44 years; 72% females), answered the 3Q/TMD and the DC/TMD questionnaire before a DC/TMD examination. The 3Q/TMD constitutes of two questions on weekly pain from the jaw, face and temple region (Q1), and on function (Q2), and one function-related question on weekly catching and/or locking of the jaw (Q3). Q1 and Q2 were evaluated in relation to a DC/TMD pain diagnosis and Q3 in relation to a subgroup of DC/TMD intra-articular diagnosis, referred to as the reference standard.

RESULTS

In total, 44% of patients received a pain-related DC/TMD diagnosis and 33% an intra-articular reference DC/TMD diagnosis. Sensitivity for the two pain screening questions was high (0.83-0.94), whereas specificity was low (0.41-0.55). For the function-related question, sensitivity was low (0.48), whereas specificity was high (0.96).

CONCLUSIONS

In a specialized pain clinic, the two pain questions (Q1, Q2) are positive in most patients with pain-related TMD. Therefore, in case of a positive response, further diagnostic procedures for TMD pain are warranted. For the functional screening question (Q3), a positive response is indicative for an intra-articular DC/TMD diagnosis, while in case of a negative outcome, an intra-articular TMD might still be present.

Diagnostic criteria for temporomandibular disorders: Diagnostic accuracy for general dentistry procedure without mandatory commands regarding myalgia, arthralgia and headache attributed to temporomandibular disorder

The clinical examination in diagnostic criteria for temporomandibular disorders (DC/TMD) is a strict procedure and comprises mandatory commands. However, learning and using these mandatory commands in general practice have proven to be difficult and their use of DC/TMD is minimal. To investigate whether reliability on a diagnostic level for DC/TMD diagnoses differs between examiners using the mandatory commands or not. Six examiners were divided into two groups: one using the mandatory commands in DC/TMD for the clinical examination and one who did not use the mandatory commands. A reliability assessment was performed twice, one occasion for each group of examiners. The assessment was performed according to the guidelines from the International Network for Orofacial Pain and Related Disorders Methodology. Each group of examiners thereby examined 16 subjects (11 TMD patients and 5 healthy individuals) each, and the diagnostic agreement (reliability) as compared to diagnoses derived by a reference standard examiner was calculated with Cohen' s kappa coefficient. The DC/TMD diagnoses myalgia, arthralgia and headache attributed to TMD were included in the reliability assessment. There was no significant difference regarding diagnostic agreement reliability between the examiners using or not using the mandatory DC/TMD commands. This study indicates that not using the mandatory commands in DC/TMD in general practice does not impair the diagnostic reliability regarding the diagnoses myalgia, arthralgia and headache attributed to TMD compared to including the commands.

Short clinical examination for temporomandibular symptoms in general practice

OBJECTIVE

The aims of the study are to assess the reliability of the short clinical examination, and to compare the information gained with a well-known and validated examination, the diagnostic criteria for temporomandibular disorders (DC/TMD).

MATERIALS AND METHODS

The study comprises 52 consecutive, newly referred patients at their first visit and examination to an Orofacial Pain and TMD Clinic, 15 years and older, mean age 44 years. The patients first answered three screening questions for reported symptoms. The clinical examination was performed using both the short examination and the DC/TMD and the result was compared. Another group of 40 newly referred patients, with similar inclusion criteria, was examined twice according to the short clinical examination by two examiners, and the inter-examiner variation was studied. The protocol of the short clinical examination is described.

RESULT

The overall agreement between the two methods was fairly good to excellent, as was the degree of agreement between repeated examinations and two examiners using the short clinical examination method. The sensitivity and specificity of the short examination for diagnoses were acceptable to high (with DC/TMD as the golden standard).

CONCLUSIONS

The short clinical examination has acceptable reliability and, together with three screening questions, provides enough information about the jaw function to decide whether there is a dysfunction.

Dentist's distress in the management of chronic pain control: The example of TMD pain in a dental practice-based research network

We aimed to obtain greater understanding of dentists' distress when they diagnose and treat patients with temporomandibular disorders (TMD), and to explore ways in which TMD can be better treated.We conducted a cross-sectional study based on a questionnaire survey of dentists (n = 148). Dentists were queried using an open-ended questionnaire about distress they experienced when treating patients with TMD. Survey responses were analyzed using mixed methods. Associations between specific dentist and patient characteristics and types of distress were analyzed by one way analysis of variance and residual analysis.One hundred thirteen clinicians responded to the questionnaire, giving a 76% response rate. Thematic analysis identified 6 major themes: difficulty in predicting therapeutic effect and prognosis; difficulty in diagnosis; difficulty in the decision about whether to do occlusal adjustment; difficulty in specifying a cause; difficulty in communicating with patients and mental factors; and health insurance system barriers. Clinicians who reported difficulty in deciding whether to do occlusal adjustment saw significantly more patients who experienced shoulder stiffness and headache (P = .008 and P = .022, respectively). Dentists' knowledge of TMD guidelines was associated with a lower percentage of difficulty in predicting therapeutic effect and prognosis (residual analysis; P = .010).These findings provide important insights into clinician's perception of difficulties with patients experiencing TMD-related pain. Knowledge of the existence of TMD clinical practice guidelines may lower dentist distress, particularly with regard to prognosis. Further studies are needed to decrease dentist's distress and to overcome the evidence-practice gap in TMD treatment.

Knowledge and competence in temporomandibular disorders among Swedish general dental practitioners and dental hygienists

OBJECTIVE

The aim of this study was to investigate knowledge and competence in temporomandibular disorders (TMD) among dentists and dental hygienists working in the public dental service (PDS) in Sweden.

MATERIALS AND METHODS

The study population comprised all general dentists (n = 110) and dental hygienists (n = 80) working in the PDS in two Swedish counties: Kronoberg (K) and Blekinge (B). The participants filled out a questionnaire comprised of 15 questions.

RESULTS

The results of these questions are presented. The overall response rate for the general dentists was 87%, while the rate for the dental hygienists was 71%. Statistically significant differences between the general dentists in the two counties were found regarding the following: education in the field of TMD over the last 5 years (K: 37%, B: 73%), evaluation of occlusion when examining patients with suspected TMD ('always': K: 61%, B: 82%), and a desire for consultation of the OFP (orofacial pain)/TMD specialist by telephone (K: 71%, B: 44%). Regarding the dental hygienists, there was a statistically significant difference concerning the use of the treatment modality 'reassurance' (K: 41%, B: 7%).

CONCLUSIONS

The majority of the dental care providers in both counties - irrespective of professional category - had a positive attitude towards patients with TMD. Knowledge and competence in the field are sparse and require postgraduate education. There is a great need of an OFP/TMD specialist for more complicated patients and a need to implement updated knowledge and competence in the PDS in these two counties.

Knowledge About Chronic Orofacial Pain Among General Dentists of Kermanshah, Iran

Background and Objective:

Diagnosis and treatment of chronic orofacial pain are one of the most challenging issues in dentistry. The purpose of this study was to assess the knowledge of general dentists regarding orofacial pain in Kermanshah, Iran.

Methods:

This cross-sectional study was conducted in 2016 including general dentists of Kermanshah city. A researcher-designed questionnaire was administered to collect demographic data as well as measuring knowledge of the dentists in four sections including etiology, clinical presentations, physical examination, and treatment of chronic orofacial pain. The questionnaire had acceptable validity (content validity > 0.9) and reliability (intraclass correlation coefficient= 0.857 for test re-test; Cronbach’s alpha= 0.72 for internal consistency). The data were analyzed by the SPSS software (ver. 18.0) using Spearman’s correlation coefficient (P < 0.05).

Results:

There were 121 male (72.9%) and 45 female (27.1%) dentists with mean (SD) age of 40.55 (8.03) years and mean (SD) practice history of 13.28 (8.43) years. Mean (SD) knowledge score was 10.54 (2.36) (maximum possible score= 15). 48.2% of dentists had good knowledge in overall. 48.2% about etiology, 45.2% about clinical presentations, 36.1% about physical examination, and 7.8% about treatment had good knowledge. Knowledge had direct and significant relationship with age (r = 0.179; P = 0.022) and practice history (r = 0.18; P = 0.021).

Conclusion:

The results showed that the studied dentists did not have enough knowledge about chronic orofacial pain especially in the treatment field. Therefore, it is recommended to implement educational programs to improve their knowledge.