Aims: We assessed and compared the diagnostic accuracy of two sets of diagnostic criteria for headache secondary to temporomandibular disorders (TMD).
Methods: In 373 headache subjects with TMD, a ...TMD headache reference standard was defined as: self-reported temple headache, consensus diagnosis of painful TMD and replication of the temple headache using TMD-based provocation tests. Revised diagnostic criteria for Headache attributed to TMD were selected using the RPART (recursive partitioning and regression trees) procedure, and refined in half of the data set. Using the remaining half of the data, the diagnostic accuracy of the revised criteria was compared to that of the International Headache Society’s International Classification of Headache Diseases (ICHD)-II criteria A to C for Headache or facial pain attributed to temporomandibular joint (TMJ) disorder.
Results: Relative to the TMD headache reference standard, ICHD-II criteria showed sensitivity of 84% and specificity of 33%. The revised criteria for Headache attributed to TMD had sensitivity of 89% with improved specificity of 87% (p < 0.001). These criteria are (1) temple area headache that is changed with jaw movement, function or parafunction and (2) provocation of that headache by temporalis muscle palpation or jaw movement.
Conclusion: Having significantly better specificity than the ICHD-II criteria A to C, the revised criteria are recommended to diagnose headache secondary to TMD.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
In contrast to sleep‐related oral parafunctional behaviors, little is known about waking oral parafunctional behaviors. The Oral Behaviors Checklist contains terms referring to a variety of ...non‐observable behaviors that are reliable when prompted (e.g. ‘clench’) but validity data are absent. Our goal was to assess whether (i) each behavioral term is distinct electromyographically, and (ii) temporomandibular disorder (TMD) subjects differ from non‐TMD subjects in their performance. Surface electromyographic (EMG) activity was used to measure bilateral masseter, temporalis, and suprahyoid muscles while subjects (27 patients with TMD; 27 healthy controls) performed ten oral behaviors without explanation. Electromyographic data were averaged between bilateral muscles and two trials. A multivariate construct (jaw muscle activity) was analyzed using Wilks lambda within multivariate analysis of variance (manova). Obvious behaviors (e.g. clench, read, tongue press) exhibited expected EMG patterns, and patients and controls produced identical profile plots of the EMG data. Of 10 tested behaviors, nine were found to be associated with significantly differing proportions of amplitudes across muscles and were thus unique. Behaviors with similar terms were associated with different EMG patterns. The present data support the specificity of behavioral terms and performances. Implications include causation related to TMD based on subtle behaviors that occur at a high frequency.
Chronic facial pain often overlaps with pain experienced elsewhere in the body, although previous studies have focused on a few, selected pain conditions when assessing the degree of overlap.
To ...quantify the degree of overlap between facial pain and pain reported at multiple locations throughout the body.
Data were from a case-control study of US adults participating in the Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) project. They were interviewed to determine the presence of chronic facial pain (n = 424 cases) or its absence (n = 912 controls). A mailed questionnaire with a body drawing asked about pain at other locations. Odds ratios (ORs) and 95% confidence limits (95% CLs) quantified the degree of overlap between facial pain and pain at other locations. For replication, cross-sectional data were analyzed from the UK Biobank study (n = 459,604 participants) and the US National Health Interview Survey (n = 27,731 participants).
In univariate analysis, facial pain had greatest overlap with headache (OR = 14.2, 95% CL = 9.7-20.8) followed by neck pain (OR = 8.5, 95% CL = 6.5-11.0), whereas overlap decreased substantially (ORs of 4.4 or less) for pain at successively remote locations below the neck. The same anatomically based ranking of ORs persisted in multivariable analysis that adjusted for demographics and risk factors for facial pain. Findings were replicated in the UK Biobank study and the US National Health Interview Survey. The observed anatomical selectivity in the degree of overlap could be a consequence of neurosensory and/or affective processes that differentially amplify pain according to its location.
In January 2019, the United States National Academy of Medicine initiated a comprehensive study of the status of current knowledge and clinical practices associated with temporomandibular disorders ...(TMDs). The National Academy of Sciences, which includes the National Academy of Medicine, was chartered by the US Government in the late 1800s as a non-profit institution working outside of government in order to provide unbiased, objective opinions on matters including healthcare. In this brief paper, we will discuss the open access 2020 report Temporomandibular disorders: priorities for research and care, available online. While the main focus of this report was the situation of TMDs in the US, the evidence base, authorship, expertise and literature scope was international and the findings therefore are at least in part generalisable to and important for the UK.The authors of this commentary were directly involved in the National Academy process, with RO a panel member, JD a consultant and CG one of 15 reviewers of the draft report. There was a wide variety of clinical and research fields involved in gathering the evidence and constructing the report. In addition, there was extensive involvement from affected patients with TMDs and their families, which is critical because their perspective is typically omitted in textbooks and professional consensus meetings.Key points The report on TMDs from the US National Academy of Medicine is a seminal book describing the problems that individuals with TMDs confront for diagnosis and treatment.The situation in the UK, according to UK colleagues, is similar with regards to challenges.The UK has implemented a number of initiatives to provide better diagnosis and treatment; identifying these excellent efforts in relation to the disease challenges is valuable.
Background
Temporomandibular disorders (TMDs) are a group of musculoskeletal disorders affecting the jaw. They are frequently associated with pain that can be difficult to manage and may become ...persistent (chronic). Psychological therapies aim to support people with TMDs to manage their pain, leading to reduced pain, disability and distress.
Objectives
To assess the effects of psychological therapies in people (aged 12 years and over) with painful TMD lasting 3 months or longer.
Search methods
Cochrane Oral Health's Information Specialist searched six bibliographic databases up to 21 October 2021 and used additional search methods to identify published, unpublished and ongoing studies.
Selection criteria
We included randomised controlled trials (RCTs) of any psychological therapy (e.g. cognitive behaviour therapy (CBT), behaviour therapy (BT), acceptance and commitment therapy (ACT), mindfulness) for the management of painful TMD. We compared these against control or alternative treatment (e.g. oral appliance, medication, physiotherapy).
Data collection and analysis
We used standard methodological procedures expected by Cochrane. We reported outcome data immediately after treatment and at the longest available follow‐up.
We used the Cochrane RoB 1 tool to assess the risk of bias in included studies. Two review authors independently assessed each included study for any risk of bias in sequence generation, allocation concealment, blinding of outcome assessors, incomplete outcome data, selective reporting of outcomes, and other issues. We judged the certainty of the evidence for each key comparison and outcome as high, moderate, low or very low according to GRADE criteria.
Main results
We identified 22 RCTs (2001 participants), carried out between 1967 and 2021. We were able to include 12 of these studies in meta‐analyses. The risk of bias was high across studies, and we judged the certainty of the evidence to be low to very low overall; further research may change the findings. Our key outcomes of interest were: pain intensity, disability caused by pain, adverse events and psychological distress. Treatments varied in length, with the shortest being 4 weeks. The follow‐up time ranged from 3 months to 12 months. Most studies evaluated CBT.
At treatment completion, there was no evidence of a benefit of CBT on pain intensity when measured against alternative treatment (standardised mean difference (SMD) 0.03, confidence interval (CI) ‐0.21 to 0.28; P = 0.79; 5 studies, 509 participants) or control (SMD ‐0.09, CI ‐0.30 to 0.12; P = 0.41; 6 studies, 577 participants). At follow‐up, there was evidence of a small benefit of CBT for reducing pain intensity compared to alternative treatment (SMD ‐0.29, 95% CI ‐0.50 to ‐0.08; 5 studies, 475 participants) and control (SMD ‐0.30, CI ‐0.51 to ‐0.09; 6 studies, 639 participants).
At treatment completion, there was no evidence of a difference in disability outcomes (interference in activities caused by pain) between CBT and alternative treatment (SMD 0.15, CI ‐0.40 to 0.10; P = 0.25; 3 studies, 245 participants), or between CBT and control/usual care (SMD 0.02, CI ‐0.21 to 0.24; P = 0.88; 3 studies, 315 participants). Nor was there evidence of a difference at follow‐up (CBT versus alternative treatment: SMD ‐0.15, CI ‐0.42 to 0.12; 3 studies, 245 participants; CBT versus control: SMD 0.01 CI ‐ 0.61 to 0.64; 2 studies, 240 participants).
There were very few data on adverse events. From the data available, adverse effects associated with psychological treatment tended to be minor and to occur less often than in alternative treatment groups. There were, however, insufficient data available to draw firm conclusions.
CBT showed a small benefit in terms of reducing psychological distress at treatment completion compared to alternative treatment (SMD ‐0.32, 95% CI ‐0.50 to ‐0.15; 6 studies, 553 participants), which was maintained at follow‐up (SMD ‐0.32, 95% CI ‐0.51 to ‐0.13; 6 studies, 516 participants). For CBT versus control, only one study reported results for distress and did not find evidence of a difference between groups at treatment completion (mean difference (MD) 2.36, 95% CI ‐1.17 to 5.89; 101 participants) or follow‐up (MD ‐1.02, 95% CI ‐4.02 to 1.98; 101 participants).
We assessed the certainty of the evidence to be low or very low for all comparisons and outcomes.
The data were insufficient to draw any reliable conclusions about psychological therapies other than CBT.
Authors' conclusions
We found mixed evidence for the effects of psychological therapies on painful temporomandibular disorders (TMDs). There is low‐certainty evidence that CBT may reduce pain intensity more than alternative treatments or control when measured at longest follow‐up, but not at treatment completion. There is low‐certainty evidence that CBT may be better than alternative treatments, but not control, for reducing psychological distress at treatment completion and follow‐up. There is low‐certainty evidence that CBT may not be better than other treatments or control for pain disability outcomes.
There is insufficient evidence to draw conclusions about alternative psychological therapeutic approaches, and there are insufficient data to be clear about adverse effects that may be associated with psychological therapies for painful TMD.
Overall, we found insufficient evidence on which to base a reliable judgement about the efficacy of psychological therapies for painful TMD. Further research is needed to determine whether or not psychological therapies are effective, the most effective type of therapy and delivery method, and how it can best be targeted. In particular, high‐quality RCTs conducted in primary care and community settings are required, which evaluate a range of psychological approaches against alternative treatments or usual care, involve both adults and adolescents, and collect measures of pain intensity, pain disability and psychological distress until at least 12 months post‐treatment.
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