Temporomandibular disorders in adolescents. Epidemiological and methodological studies and a randomized controlled trial

The aim of the present thesis was to investigate different aspects of temporomandibular disorders (TMD) and pain such as prevalence, diagnostics, and treatment among adolescents. The reliability of a questionnaire and the clinical examination and diagnoses according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) were assessed. Overall, we found it possible to assess and diagnose TMD in adolescents in a reliable way. The prevalence of TMD pain, gender differences, and the need for treatment were investigated among 864 adolescents from a Public Dental Service clinic. Seven percent of the subjects received a pain diagnosis according to the RDCITMD, and the prevalence was higher among girls than boys. More subjects with TMD pain reported school absence and analgesic consumption compared to controls. Approximately every second subject who reported TMD pain also perceived a need for treatment. In an evaluation of psychosocial and dental factors, the following were found to play an important role in adolescents with TMD: stress, somatic complaints, and emotional problems. Three treatment methods were compared in a randomized controlled trial: brief information only, brief information and occlusal appliance, and brief information and relaxation therapy. In the brief information and occlusal appliance group, 60% — significantly more than in the other two groups — experienced a reduction of at least 50% in TMD pain. The influence of somatic and emotional stimuli was evaluated, and we found that adolescents with TMD pain were significantly more sensitive to not only aversive somatic but also pleasant somatic stimuli compared with healthy controls. The results suggest that not only nociceptive but also cognitive processes are implicated in chronic pain states in young TMD subjects. In conclusion, TMD pain is more common in girls than in boys and affects daily life. TMD pain in adolescents can best be improved by traditional treatment with occlusal appliance combined with brief information

Long-term treatment outcome for adolescents with temporomandibular pain

Objectives: This study aims to evaluate long-term, self-perceived outcome in adulthood for individuals treated as adolescents for temporomandibular disorder (TMD) pain in two previous randomized controlled trials (RCTs). Materials and methods: The study included 116 subjects (81% females) treated for frequent TMD pain in two separate RCTs 5–21 (M = 14.8, SD =4.9) years previously. Treatment consisted of occlusal appliance (OA) (n = 41, 35.3%) or relaxation training (RT) combined with information for the control (Co) group (n = 50, 43.1%), both compared to non-responders receiving additional, sequential treatment (ST) in a crossover study (n = 25, 21.6%). Participants answered a questionnaire on their experience of frequency and intensity of TMD pain impaired chewing capacity and daily social activities, help-seeking behaviour and treatment, general health, other pain, and depressive symptoms. Results: Older participants reported lower levels of frequency and intensity of TMD pain, impairment, and depressive symptoms, as well as better general health. Females reported more frequent and more intense TMD pain, greater impairment and more often reported ‘other pain’ compared to males. Non-responders receiving ST experienced significantly more TMD, and other pain and higher impairment levels compared to other groups. Those treated with an OA had sought additional treatment significantly less often since the RCTs than ST and RT/Co-treated individuals. Conclusions: Adolescents treated with OA showed somewhat better sustained improvement over the extended follow-up period than those treated with RT/Co. Non-responders to treatment and females exhibited a poorer outcome. These groups need particular attention and extended or different treatments to achieve a better long-term outcome

Treatment of temporomandibular disorders among adolescents : a comparison between occlusal appliance, relaxation training, and brief information

In a randomized trial the effects of occlusal appliance and relaxation therapy, each combined with brief information, were compared with brief information only, in adolescents with temporomandibular disor-der (TMD) pain. One-hundred-and-twenty-two adolescents (93 F and 29 M aged 12-18 years) were randomly assigned to one of the follow-ing 3 groups: brief information + occlusal appliance (BI + OA), brief information + relaxation therapy (BI + RT), or brief information (BI). Included were subjects reporting pain once a week or more often, in addition to receiving a diagnosis of TMD according to the Research Diagnostic Criteria (RDC/TMD). They were evaluated before and af-ter treatment and at a 6-month follow-up by means of self-reports and clinical assessment. The result revealed a significantly higher reduction in frequency of pain, in pain intensity (visual analog scale [VAS]), and in a composite pain index (intensity x frequency) for patients treated with BI + OA compared with those treated with BI alone. In the BI + OA group, 60% of the patients attained a clinically significant im-provement (at least 50% or more) on the pain index, a significantly higher proportion compared to that obtained in the other 2 treatment groups. Analgesic consumption was also significantly more reduced in the BI + OA group compared to the BI group. However, no significant differences were found between the treatment groups in jaw opening or in muscle and TMJ tenderness scores. Occlusal appliance was found to be superior to both relaxation therapy and brief information regarding pain reduction and can therefore be recommended when treating adolescents with TMD pain

The relationship between somatic and emotional stimuli : a com-parison between adolescents with temporomandibular disorders (TMD) and a control group

The overall purpose of this study was to determine whether adoles-cents with chronic temporomandibular disorder (TMD) pain are more sensitive to all types of somatic and emotional stimuli compared with a matched healthy control group. Sixty adolescents, 8 boys and 52 girls ranging from 12 to 18 years, participated in the study. Thirty of the subjects exhibited TMD, re-porting pain of at least 3 months duration. The age- and gender-matched control group consisted of 30 dental recall patients who re-ported TMD pain less than once a week. All participants completed a 40-item questionnaire comprising ten items each of pleasant and aver-sive qualities crossed with somatic and emotional forms of stimuli. The items, a selection of a broad range of familiar stimuli by a panel of experts, were rated based on intensity of experience (0–10, numeri-cal rating scale). Well-fitting items that formed a valid construct within each of the four domains were selected using Rasch analysis. The results showed that adolescents with TMD pain reported signifi-cantly greater sensitivity (p<0.05) to aversive somatic and pleasant somatic stimuli than the controls. The differences between groups for the aversive emotional and pleasant emotional stimuli were not sig-nificant. These findings suggest that chronic pain states in adolescents are accompanied by amplification of bodily, but not emotional, stim-uli and that cognitive systems are implicated, not only an alteration of the nociceptive systems

Treating temporomandibular disorders in adolescents : a randomized, controlled, sequential comparison of relaxation training and occlusal appliance therapy

AIMS: To compare the effects of occlusal appliance therapy (OA) and therapist-guided relaxation training (RT) on temporomandibular disorder (TMD) pain in adolescents, thereby replicating a previous randomized controlled trial, and to explore whether additional therapy administered in a crossover sequential design improves treatment outcomes. METHODS: The study involved 64 adolescents, aged 12 to 19 years, experiencing TMD pain at least once a week and diagnosed with myofascial pain in accordance with the Research Diagnostic Criteria for TMD. For phase 1 of the study, subjects were randomly assigned to OA or RT; nonresponders were offered the other treatment in phase 2. Self-reports of TMD pain and clinical assessments were performed before and after treatment in each phase and 6 months after the last treatment phase. Differences in outcomes between treatment groups across the different phases were analyzed by analysis of covariance (ANCOVA), and for differences in proportions, the chi-square test was used. RESULTS: After phase 1, a significantly higher proportion of adolescents treated with OA (62.1%) than those treated with RT (17.9%) responded to treatment, defined as a subjective report of "Completely well/Very much improved" or "Much improved." Similar differences in self- report of treatment effect occurred after phase 2. About two-thirds of all adolescents in both phases reported such an improvement level at the 6-month follow-up, including a somewhat higher proportion of phase 1 responders (79.2%) than phase 1 nonresponders (60%). CONCLUSION: The findings suggest that, for adolescents with TMD pain, use of standardized clinical treatment with OA is more effective than RT on self-evaluation of treatment improvement. For nonresponders, subsequent crossover treatment might be useful to improve subjective TMD pain

On-line capillary based quantitative analysis of a heterocyclic amine in human urine

A high through-put miniaturised separation-quantification method for the heterocyclic aromatic amine 2-amino-1-methyl-6-phenylimidazo[4,5-b]pyridine (PhIP) in urine was developed. The limit of detection was of 0.65 fmol (0.14 pg) injected or 65 pM. Heterocyclic aromatic amines are mutagenic and carcinogenic compounds formed at low levels in protein-rich food during cooking. Due to the low concentrations and the high complexity of the matrix in which they exist (food, blood, and urine), and the often small sample volumes (capillary blood; urine, blood and milk from small animals), very sensitive and selective analytical methods are required for their detection. Miniaturisation was accomplished by micro solid-phase extraction in capillaries with blue chitin as solid-phase, coupled on-line (in-capillary) to capillary electrophoresis with nanospray tandem mass spectrometric detection. This new technique provided a total analysis time of only 15 min, including extraction and separation, together with low sample and solvent consumption. Blue chitin showed high tolerance towards the urine matrix. Urine collected 12 h after consumption of fried chicken contained 1.8 nmol L-1 (0.40 pg mu L-1) of PhIP. (c) 2006 Elsevier B.V. All rights reserved

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

BackgroundStress 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.MethodsThis 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.ResultsChange in stress was associated with change in catastrophizing, psychological distress as well as limitation in general function and jaw function.ConclusionsThis 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

Orofacial pain in juvenile idiopathic arthritis is associated with stress as well as psychosocial and functional limitations

Background The aim of this study was to investigate relations between psychosocial factors, signs and symptoms of orofacial pain and jaw dysfunction in patients with juvenile idiopathic arthritis (JIA). Methods Forty-five patients with JIA (median age 12 years) and 16 healthy matched controls (median age 13 years) were examined according to the diagnostic criteria for temporomandibular disorders (DC/TMD). The subjects answered the DC/TMD questionnaires regarding psychosocial factors (pain intensity, pain–related disability, depression, stress, catastrophizing, pain locations and jaw function). Results JIA patients with orofacial pain had higher degree of stress, depression, catastrophizing and jaw dysfunction compared to subjects without. In turn, these factors were associated with orofacial pain intensity. Also, patients with orofacial pain had higher systemic inflammatory activity. Conclusions Orofacial pain in patients with JIA is associated with stress, psychological distress, jaw dysfunction and loss of daily living activities. Pain intensity seems to be the major pain aspect related to these factors. In addition, systemic inflammatory activity appears to be an important factor contributing to orofacial pain in JIA.Funding Agencies|Research Council in Southeast Sweden; Public dental health Scientific Funds in Ostergotland; County (Ostergotland County Council) Sweden; Swedish Dental-Societys Scientific Funds; American Dental Society of Sweden; Malmo University</p

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