Diagnostic criteria for temporomandibular disorders (DC/TMD) in children and adolescents: an international Delphi study-Part 2-Development of Axis II

Therapeutic exercises, manual therapy, and health education program for adolescents with temporomandibular disorders: face-to-face and online multimodal rehabilitation protocol for a randomized controlled clinical trial

BACKGROUND

Multimodal rehabilitation has shown good results in adults with temporomandibular disorder (TMD), but there is still doubt regarding the protocol's ideal format (face-to-face or online), and its effectiveness among adolescents. The purpose of this study is to describe a randomized clinical trial protocol of face-to-face and online multimodal rehabilitation, in adolescents with TMD, and to determine its effects on pain, peripheral oxygenation of the masseter muscle, and mandibular range of motion, kinesiophobia and parafunction.

METHODS

A randomized, controlled clinical trial, blinded to statistical analyses, will be carried out, involving 26 adolescents, diagnosed with TMD. After randomization, the participants will be allocated into two groups: (1) telerehabilitation and (2) face-to-face treatment groups. Each group will undergo an initial assessment, followed by three treatment sessions, reassessment, and follow-up. Appointments and reassessments will be face-to-face, with instruments validated and adapted for adolescent age groups. The intervention protocol also aims at practicality, ease of execution, and strategies for the patient to easily self-manage and perform independently, adapted for face-to-face or online formats. The Diagnostic Criteria for Temporomandibular Disorders, physical and psychosocial aspects, algometry, near-infrared spectroscopy, and the Tampa scale for kinesiophobia will be used to assess the outcomes.

DISCUSSION

It is expected that this study will contribute to online and face-to-face assessments and demonstrate the differences in the practice of rehabilitation of adolescents with TMD. Data will be published after the study is completed, and if the benefits are proven, care modalities may be implemented.

TRIAL REGISTRATION

REBEC-RBR-5scd5tm, UTN code: U1111-1288-4495 . Registered on 19 May 2023.

Long-Term Prognosis and Influencing Factors of Chinese Adolescents With Temporomandibular Disorder After Physical Therapy

BACKGROUND

Physical therapy is the preferred conservative treatment for patients with temporomandibular disorder (TMD). However, few studies have investigated the application of physical therapy in adolescents, especially follow-up studies on the long-term prognosis of these patients. This study investigated the short-term effects and long-term prognosis of physical therapy in adolescent patients with TMD and the factors influencing long-term symptoms.

METHODS

Information regarding baseline data, specific treatment methods, treatment times and evaluation results was collected retrospectively for adolescent patients with TMD who received physical therapy. Patients were followed up via telephone and online questionnaires, and the influence of age, sex, disease course, mouth opening, pain intensity, oral parafunctional habits and treatment methods on long-term symptoms was analysed.

RESULTS

Pain intensity, maximum mouth opening and the joint noise score improved significantly in 270/286 patients who received individualised comprehensive physical therapy. TMD-related symptoms improved with no noticeable impact on daily life in 187/199 patients who were followed up for an extended period (average, 30.71 ± 10.86 months) and were divided into asymptomatic or symptomatic groups according to the persistence of symptoms. Logistic regression analysis revealed that uncorrected oral parafunctional habits and fewer treatments were related to long-term symptoms.

CONCLUSION

The long-term prognosis of adolescent patients with TMD after physical therapy was satisfactory. However, 52.8% of the patients experienced persistent TMD-related symptoms for an extended period, possibly due to insufficient treatment times and parafunctional habits.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT05781607.

Association between stress and catecholamines with painful TMD in children

BACKGROUND

Studying biomarkers in children with temporomandibular disorders (TMD) such as epinephrine, norepinephrine, and dopamine may reveal factors like screen time or sleep loss that affect these biomarkers and predict TMD-related pain, offering new research opportunities.

AIM

To determine the association between stress and catecholamines with myofascial pain and headache related to TMD in children.

DESIGN

Sixty-six 9- to 11-year-old children assisting at the clinics of Pediatric Dentistry of Universidad CES participated in the study. Myofascial pain and headache attributed to TMD were determined according to the Diagnostic Criteria for TMD (DC/TMD) Axis I. Stress was evaluated with the Perceived Stress Scale-Children (PSS-C), and a 24-h urine sample was analyzed using liquid chromatography to assay catecholamines. Single and multiple regression analyses were performed.

RESULTS

Children with a mean age of 10.3 years participated in the study. The mean score of stress was 29 ± 4. Perceived stress, dopamine, epinephrine, and norepinephrine were statistically significant predictors of myofascial pain and headache attributed to TMD in the single- and multiple variable logistic regression analyses.

CONCLUSION

Stressful states and its biological biomarkers increase the probability of developing myofascial pain and headache attributed to TMD in children.

Prevalence of psychosocial findings and their correlation with TMD symptoms in an adult population sample

BACKGROUND AND AIM

Some studies suggested an association between Temporomandibular Disorders (TMD) and psychosocial status, but most of them are focused on samples of patients looking for treatment or present limits of sample representativeness. The aim of the present study was to evaluate the psychosocial status in a large sample of adult population, further than to assess its association to TMD symptoms, oral behaviours, and self-reported facial trauma.

RESULTS

the study sample included 4299 subjects older than 18 years randomly recruited from general population in public spaces during their daily life (1700 Males, 2599 Females mean ± SD age = 40.4 ± 18.1). Psychosocial status and pain-related disability were assessed by means of Patient Health Questionnaire 4 (PHQ-4) and Graded Chronic Pain Scale (GCPS). TMD symptoms were assessed by RDC/TMD and validated screening tools for TMD pain. Oral Behaviours Checklist was used to investigate on oral behaviours. Logistic regression model was used to evaluate the association of the psychosocial status, TMD symptoms, trauma, and oral behaviours. The association was tested using both univariate and multivariate models. The PHQ4 evaluation showed a severe impairment in 4.6% of our sample, moderate in 18.8% and mild in 32.5%. We found a Characteristic Pain Intensity (CPI) level and Interference Score greater that 30 respectively in 36.2% and 22.2% of the study sample. The GCPS status revealed a high disability with severe limitation in 2.5% of the sample, high disability with moderate limitation in 7.0%, low disability high pain intensity in 7.4% and low disability low pain intensity in 37.8%. Anxiety and depression's levels were significantly associated with gender, TMD pain, coexistence of TMD Pain and sound, and oral behaviours. GCPS status was significantly associated with age, TMD Pain, coexistence of TMD pain and sound, trauma, and oral behaviours.

CONCLUSIONS

In the general population, psychosocial impairment is associated to TMD pain, female gender, and report of oral behaviours. Hence, in adults with TMD accompanied by pain, psychosocial status should also be evaluated.

Accuracy of temporomandibular disorders diagnosis evaluated through the diagnostic criteria for temporomandibular disorder (DC/TDM) Axis II compared to the Axis I evaluations: a systematic review and meta-analysis

BACKGROUND

The temporomandibular joint (TMJ) is a complex joint that facilitates mandibular movements during speech, chewing, and swallowing activities. The Axis I evaluation of the DC/TMD focuses on assessing physical diagnoses related to TMDs. It includes an assessment of pain and functional limitations, such as jaw opening range, joint sounds, and joint tenderness. The Axis II evaluation of the DC/TMD provides information on the patient's psychological status and quality of life. This Systematic Review with Meta-Analysis aimed to evaluate the accuracy of Temporomandibular Disorders diagnosis considered through the Diagnostic Criteria for Temporomandibular Disorder (DC/TDM) axis II compared to the Axis I evaluations.

METHODS

A search was made in PubMed, Web of Science and Lilacs for articles published from the inception until 20 January 2023. We applied the Population, Exposure, Comparator, and Outcomes (PECO) model [1] to assess document eligibility. Only studies that evaluated patients by DC/TMD Axis I and Axis II were considered. Review Manager version 5.2.8 (Cochrane Collaboration) was used for the pooled analysis. We measured the odds ratio (OR) between the two groups (Axis I and Axis II).

RESULTS

Fifty-one articles were selected because of the search. Four papers were excluded before the screening: 2 pieces were not in English, and two were reviewed. The remaining 47 articles were selected for the title and abstract screening to evaluate whether they met the PECO criteria. Among these, four papers were established; the overall effect showed that there was no difference in TMD diagnosis between Axis I and Axis II (RR 1.17; 95% CI: 0.80- 1.71; Z:0.82; P = .41), suggesting that there is no difference between Axis I and Axis II.

CONCLUSION

In conclusion, DC/TMD is an effective tool for the diagnosis of TMD. It improves the accuracy of TMD diagnosis, allows for the classification of subtypes, and assesses psychosocial factors that may impact the development or maintenance of TMD symptoms.

Increase in stress contributes to impaired jaw function in juvenile idiopathic arthritis: a two-year prospective study

BACKGROUND

Stress in patients with Juvenile Idiopathic Arthritis (JIA) has been found to be associated with orofacial pain, psychological distress, jaw dysfunction and loss of daily activities in a cross-sectional study. The aim of this study was to investigate the relations between stress and change of stress over time versus changes in orofacial pain, psychosocial factors and jaw function over a two-year period in patients with JIA.

METHODS

This is a two-year prospective follow-up study involving 40 JIA patients. At baseline (2015) the median age was 12 years and at two-year follow up (2018) 14 years. The JIA patients were examined clinically and with questionnaires at baseline and follow-up with the diagnostic criteria for temporomandibular disorders (DC/TMD) and completed the same set of DC/TMD questionnaires regarding orofacial pain symptoms and psychosocial factors.

RESULTS

Change in stress was associated with change in catastrophizing, psychological distress as well as limitation in general function and jaw function.

CONCLUSIONS

This study emphasizes the importance of maintaining a low stress level in patients with JIA since an increase in stress level over a two-year period seems to impair jaw function as well as psychological distress and catastrophizing.

Influence of malocclusion on sleep bruxism and orofacial pain: data from a study in school children

OBJECTIVES

This cross-sectional school-based study explored the influence of malocclusion on temporomandibular disorders (TMD) pain complaints, and whether this association would be mediated by sleep bruxism in a representative sample of 7- to 8-year-old children.

METHODS

Path analysis estimated direct, indirect, and total effects of occlusal features on sleep bruxism and TMD pain in 7- to 8-year-old children. Occlusal features were assessed with Dental Aesthetic Index (DAI), orofacial pain complaints using the TMD pain screener, possible sleep bruxism based on self-reports, and probable sleep bruxism based on self-reports combined with clinical findings. Structural equation modeling analyzed data with confounding factors.

RESULTS

From 580 participants, possible sleep bruxism was observed in 136 children (31.5%), probable sleep bruxism in 30 children (6.7%), and TMD pain complaints in 78 children (13.8%). Malocclusion had no direct effect on either possible sleep bruxism [standardized coefficient (SC) 0.000; p = 0.992], or TMD pain complaints (SC - 0.01; p = 0.740). When probable sleep bruxism was set as the mediator of interest, malocclusion did not directly affect probable sleep bruxism (SC 0.01; p = 0.766), nor TMD pain complaints (SC - 0.02; p = 0.515). A direct effect of probable sleep bruxism on TMD pain complaints was observed with an SC of 0.60 (p < 0.001). However, in neither case, malocclusion indirectly affected TMD pain complaints via bruxism.

CONCLUSION

Malocclusion in 7- to 8-year-old children did not directly influence possible or probable sleep bruxism or TMD pain complaints. Instead, probable sleep bruxism was strongly associated with TMD pain complaints.

CLINICAL SIGNIFICANCE

The impact of occlusal features on TMD pain complaints and bruxism has been a long-standing controversy in dentistry. However, the scientific literature linking this association may be inconsistent, mainly due to biased sample selection methods with inadequate consideration of confounders. Further research should try to identify additional risk factors for TMD pain in addition to probable sleep bruxism in children.

Biological and psychological factors affecting the sensory and jaw motor responses to orthodontic tooth movement

Orthodontic tooth movement (OTM) is associated with an inflammatory response, tooth pain (i.e. orthodontic pain) and changes in dental occlusion. Clinical realms and research evidence suggest that the sensory and jaw motor responses to OTM vary significantly among individuals. While some adjust well to orthodontic procedures, others may not and can experience significant pain or not adjust to occlusal changes. This is of concern, as clinicians cannot anticipate an individual's sensorimotor response to OTM. Converging evidence shows that some psychological states and traits significantly affect the sensorimotor response to OTM and may considerably affect an individual's adaptation to orthodontic or other dental procedures. We performed a topical review to synthesize the available knowledge about the behavioural mechanisms regulating the sensorimotor response to OTM, with the intent of informing orthodontic practitioners and researchers about specific psychological states and traits that should be considered while planning orthodontic treatment. We report on studies focusing on the role of anxiety, pain catastrophising, and somatosensory amplification (i.e. bodily hypervigilance), on sensory and jaw motor responses. Psychological states and traits can significantly affect sensory and jaw motor responses and a patient's adaptation to orthodontic procedures, although large interindividual variability exists. Clinicians can use validated instruments (checklists or questionnaires) to collect information about patients' psychological traits, which can assist in identifying those individuals who may not adjust well to orthodontic procedures. The information included in this manuscript also assists researchers investigating the effect of orthodontic procedures and or/appliances on orthodontic pain.

Atomoxetine and escitalopram migrate the derangement of the temporomandibular joint morphologic and histologic changes in rats exposed to stress-induced depression

PURPOSE

The purpose of this in vivo study was to determine the effects of stress-induced depression and antidepressants on depressive-like behavior, microstructure, and histomorphology of the temporomandibular joint (TMJ) using rats.

METHODS

Experimentally induced depression in rats was created before being treated with two antidepressants; escitalopram (selective-serotonin-reuptake inhibitors) and atomoxetine (norepinephrine-reuptake inhibitors). Micro-computed tomography (Micro-CT) was performed to measure the change in bone volume and bone porosity of the condyle. Further histological evaluation of the condylar cartilage was performed.

RESULTS

Micro-CT scanning revealed a decrease in bone volume in the depression group. The bone porosity percentage significantly increased in both the escitalopram and atomoxetine groups compared with the control group and the depression group. Histopathological analysis showed increased thickness of cartilage layers in the depression group. In the atomoxetine group, there was a significant increase in the pre-hypertrophic and hypertrophic layer thickness and cell count, but a significant decrease in proteoglycans.

CONCLUSION

The present study findings indicated the change in TMJ characteristics, especially on the superficial part of the condylar head in the depression group. Concerning the applicability of the different antidepressants, depression with the treatment of atomoxetine has the most disadvantages due to bone porosity and cartilaginous condyle changes.

Prevalence of Temporomandibular Disorders Based on a Shortened Symptom Questionnaire of the Diagnostic Criteria for Temporomandibular Disorders and Its Screening Reliability for Children and Adolescents Aged 7-14 Years

The prevalence and adequacy of diagnostic approaches for temporomandibular disorders (TMD) in children and adolescents are still matters of debate. This study aimed to determine the prevalence of TMD and oral habits in children and adolescents aged 7-14 years and evaluate the consistency between self-reported TMD symptoms and clinical findings using a shortened Axis I of Diagnostic Criteria for TMD (DC/TMD). Children (aged 7-10) and adolescents (aged 11-14) of both sexes were invited to participate in this study (n = 1468). Descriptive statistics for all observed variables and Mann-Whitney U-Tests for the clinical examination were performed. A total of 239 subjects participated in the study (response rate 16.3%). The self-reported prevalence of TMD was found to be 18.8%. The most frequently reported oral habit was nail biting (37.7%), followed by clenching (32.2%) and grinding (25.5%). Self-reported headache increased with age, while clenching and grinding decreased. Based on the answers to the DC/TMD Symptom Questionnaire, subgroups of asymptomatic and symptomatic participants (n = 59; 24.7%) were established and randomly selected for the clinical examination (f = 30). The shortened Symptom Questionnaire showed a sensitivity of 0.556 and a specificity of 0.719 for pain during the clinical examination. Although the Symptom Questionnaire exhibited high specificity (0.933), its sensitivity (0.286) for temporomandibular joint sounds was low. Disc displacement with reduction (10.2%) and myalgia (6.8%) were the most common diagnoses. In conclusion, the self-reported prevalence of TMD in children and adolescents in this study was comparable to that reported in the literature for adults. However, the accuracy of the shortened Symptom Questionnaire as a screening tool for TMD-related pain and jaw sounds in children and adolescents was found to be low.

Idiopathic Non-Dental Facial Pain Syndromes in Italian Children: A Clinical Case Series

BACKGROUND

The orofacial pain syndromes (OFPs) are a heterogeneous group of syndromes characterized by painful attacks involving the orofacial structures. They may be summarily subdivided into two great categories: (1) orofacial pain mainly attributed to dental disorders such as dentoalveolar and myofascial orofacial pain or temporomandibular joint (TM) pain; (2) orofacial pain mainly attributed to non-dental pain as neuralgias, facial localization of primary headaches or idiopathic orofacial pain. The second group is uncommon, often described by single case reports, can often show overlapping symptoms with the first group, and represents a clinical challenge, carrying the risk of undervaluation and possibly invasive odontoiatric treatment. We aimed to describe a clinical pediatric series of non-dental orofacial pain and better to underline some topographic and clinical features associated with them. We retrospectively collected the data of children admitted to our headache centers (Bari, Palermo, Torino) from 2017 to 2021. Our inclusion criterion was the presence of non-dental orofacial pain following the topographic criteria of 3° International Classification of Headache Disorders (ICHD-3), and exclusion criteria included the pain syndromes attributed to the dental disorders and pain syndromes due to the secondary etiologies Results. Our sample comprised 43 subjects (23/20 M/F, in the range of ages 5-17). We classified them int: 23 primary headaches involving the facial territory during attacks, 2 facial trigeminal autonomic cephalalgias, 1 facial primary stabbing headache, 1 facial linear headache, 6 trochlear migraines, 1 orbital migraine 3 red ear syndrome and 6 atypical facial pain. All patients described debilitating pain for intensity (moderate/severe), 31 children had episodic attacks, and 12 had continuous pain. Almost all received drugs for acute treatment (less than 50% were satisfied), and some received non-pharmacological treatment associated with drug therapy Conclusion. Although rare OFP can occur in pediatric age, it can be debilitating if unrecognized and untreated, affecting the psychophysical well-being of young patients. We highlight the specific characteristics of the disorder for a more correct and earlier identification during the diagnostic process, already difficult in pediatric age, and to define the approach and possible treatment to prevent negative outcomes in adulthood.

Prevalence of temporomandibular disorders in children and adolescents evaluated with Diagnostic Criteria for Temporomandibular Disorders: A systematic review with meta-analysis

BACKGROUND

The prevalence of temporomandibular disorders (TMDs) in children and adolescents is not well-known. This is partly because TMD is not often diagnosed in children and partly because there is no agreed-upon definition of TMD. There is a growing body of evidence to suggest that there are gender differences in the prevalence and presentation of TMD in adult. The aim was to assess the prevalence of TMDs in subjects aged 8-19 evaluated with Diagnostic Criteria for TMDs (DC/TMD) and to assess gender differences.

METHODS

PubMed, Web of Science and Lilacs were systematically searched until 30 November 2022, to identify studies presenting children and adolescents patients affected by TMDs.

RESULTS

Out of 40 papers, three studies were included. The included subjects in this review were 1914 (1093 female and 821 male). Seven hundred and thirty-six on 1914 patients (38.4%) presented TMD. Among 1093 female, 489 (44.7%) presented TMD, while 247/821 male (30%) experienced TMD. Meta-analysis revealed that the female had a higher TMD prevalence than male (RR 2.10; 95% CI: 1.21-3.65).

CONCLUSION

TMD prevalence in children and adolescence varies between 20% and 60%. Female had a higher prevalence of TMDs compared to male.

Diagnostic criteria for temporomandibular disorders-INfORM recommendations: Comprehensive and short-form adaptations for children

BACKGROUND

The Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) are used worldwide in adults. Until now, no adaptation for use in children has been proposed.

OBJECTIVE

The aim of this study was to present comprehensive and short-form adaptations of Axis I and Axis II of the DC/TMD for adults that are appropriate for use with children in clinical and research settings.

METHODS

Global Delphi studies with experts in TMDs and in pain psychology identified ways of adapting the DC/TMD for children.

RESULTS

The proposed adaptation is suitable for children aged 6-9 years. Proposed changes in Axis I include (i) adapting the language of the Demographics and the Symptom Questionnaires to be developmentally appropriate for children, (ii) adding a general health questionnaire for children and one for their parents, (iii) replacing the TMD Pain Screener with the 3Q/TMD questionnaire and (iv) modifying the clinical examination protocol. Proposed changes in Axis II include (i) for the Graded Chronic Pain Scale, to be developmentally appropriate for children, (ii) adding anxiety and depression assessments that have been validated in children and (iii) adding three constructs (stress, catastrophising and sleep disorders) to assess psychosocial functioning in children.

CONCLUSION

The recommended DC/TMD, including Axis I and Axis II, for children aged 6-9 years, is appropriate for use in clinical and research settings. This adapted the first version for children includes changes in Axis I and Axis II changes requiring reliability and validity testing in international settings. Official translations to different languages according to INfORM requirements will enable a worldwide dissemination and implementation.