KLASYFIKACJE ZABURZEŃ SKRONIOWO-ŻUCHWOWYCH I PROTOKOŁÓW BADAŃ PACJENTÓW – ANALIZA PORÓWNAWCZA POD KĄTEM MOŻLIWOŚCI ICH CODZIENNEGO STOSOWANIA W PRAKTYCE KLINICZNEJ
Ulyana D. Telishevska, Oksana D. Telishevska
Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
Introduction: The problem of temporomandibular disorders (TMD) is relevant in today’s world and is considered one of the most common pathologies causing nonodontogenic pain syndromes of maxillofacial region. The morbidity of temporomandibular disorders is 27 to 76% among patients who seek dental care. There is now a significant number of classifications of TMD, however, clinically convenient, morphologically and pathogenetically substantiated classification of temporomandibular joint’s (TMJ) conditions has not yet been developed. Therefore, the patient’s examination protocols differ substantially.
The aim: To analyze and assess the quality of classifications and examination protocols for the patients with suspected TMD.
Materials and methods: A comparative analysis of 5 TMD classifications and 3 protocols for the examination of patients with suspected TMDs were performed.
Review: A comparative analysis of following TMD classifications was conducted: American Academy of Orofacial Pain, Research Diagnostic Criteria for TMD, by B.W.Neville, D.D.Damm, C.M.Allen, J.E.Bouquot, by Christian Köneke, international classification of diseases ICD-10. The analysis of the following protocols for the examination of patients with suspected TMDs was conducted: M. Helkimo index, Hamburg protocol, M. Kleinrok protocol.
Conclusions: Difficulties in interpreting diagnoses by dentists are caused by ambiguities in classifications, a considerable number of clinical entities and their construction principles. Organ principle of structure has proved to be the most convenient for clinical application. The evaluation protocols are cumbersome and duplicate each other. Owing to the lack of a common opinion about the origin and development of TMD, use of the evaluation protocols is based on the experience of dental practitioners.
Wiad Lek 2018, 71, 3 cz. II, -745
The term “temporomandibular disorder” (TMD) is a group of conditions characterized by lesions of temporomandibular joint’s (TMJ) structures and (or) masticatory muscles . It was proposed by an American scientist Bell in 1982. In 1983 it was approved by American Association of Dentists as a subtype of musculoskeletal disorders that simultaneously emphasized relevance and importance of the given issue. The term “TMJ dysfunction” has up to 18 synonyms: dysfunction; muscular imbalance; myofascial pain syndrome; musculoskeletal dysfunction; functional distensional diseases; extra-articular diseases of soft tissues; occlusion- articulation syndrome; Costen’s syndrome; myofascial pain-dysfunction syndrome, etc. [2, 3].
The issue of temporomandibular disorder does not lose its relevance in the modern world, along with caries and periodontal diseases, and is considered one of the most common nonodontogenic pain syndromes of the maxillofacial area . In connection with active research of issues, researchers were divided into adherents of occlusal and psychosomatic theories. Neither of them, to date, has been confirmed as the main one, and therefore each of them has the right of existence. The unconditional acceptance of one of the theories was not confirmed due to the compensatory mechanisms and a number of somatic pathologies that influence the development of such disorders. Therefore, approaches to the diagnosis and treatment of patients with TMD in different countries somewhat vary.
According to the data from different researchers, the prevalence of TMD is from 27 to 76% of patients seeking dental care [1, 5, 6, 7, 8, 9]. TMD affects from 14 to 29% among children and adolescents, especially with malocclusion .
There is a significant number of classifications of TMJ disorders. Until now, however, clinically convenient, morphologically and pathogenetically substantiated classification of TMJ conditions has not been developed [2, 11, 12, 13]. Some classifications have outlived in use due to etiological groundlessness. Arising from the lack of unanimity concerning the TMD etiology, most classifications cannot be unified, and they are discussed at international conferences for many years.
To perform a comparative analysis of TMD classifications and evaluate the quality of the examination protocols for the TMD suspected patients, proposed by independent dental schools, for convenience of their daily use in clinical practice.
Materials and methods
An analysis of the following TMD classifications was performed: American Academy of Orofacial Pain (2008), Research Diagnostic Criteria for TMD (1992), by B.W.Neville, D.D.Damm, C.M.Allen, J.E.Bouquot (1995), by Christian Köneke (2010), International classification of diseases ICD-10. The analysis of the following examination protocols for the TMDs suspected patients was conducted: M. Helkimo index, Hamburg protocol, Polish M. Kleinrock protocol.
Review and discussion
To date, the classification of the American Academy of Orofacial Pain (Fig. 1) and Research Diagnostic Criteria for TMD have been most widely used (Fig. 2).
According to the classification of the American Academy of Orofacial Pain the disorders are divided into two groups: TMD associated with damage to the articular disc and TMD associated with damage to the masticatory muscles. Classification is formed by the organ principle, that is, it includes clinical entities according to the target organ. It also includes congenital and acquired disorders, primary and secondary lesions, traumatic disorders, disorders of inflammatory and noninflammatory origin. From our experience, all of these clinical entities are common in patients with TMD. The principle of division of these clinical entities into two groups depending on the damaged area is understandable when making a diagnosis and defining a treatment plan. However, the first group of disorders associated with the disk damage takes into account the clinical entities, in which the damage to the disk is secondary, that is not correct due to the different etiology of disorders. This, in turn, affects the treatment plan. Therefore, its application in clinical practice is somewhat complicated in terms of therapy monitoring.
In 1992, the Research Diagnostic Criteria for temporomandibular disorders (RDC/TMD)  were proposed for reliability, comparison of the results of studies and decrease of number of the research methods. As of today RDC/TMD have been translated into several languages [15, 16, 17]. Despite the fact that the RDC/TMD were developed to conduct clinical and epidemiological studies, they can be used in the dental practice, and they have become the most popular in examination of patients with suspected TMD. As well, RDC/TMD allows to make the diagnosis taking into account the physical and psychosocial condition of a patient. After a series of reviews, it continues to be actively used in different countries of the world despite the age of the classification.
There is a distribution by two axes: the first contains clinical entities of TMD, which are divided into three groups by organ principle, while the other one assesses the psychosocial condition that preceded or developed in the settings of the disease.
Clinical signs of TMD, axis I of RDC/TMD. Group I – muscular disorders. This diagnostic group includes myofascial pain disorders with and without limitation of the mouth opening. A mouth opening of less than 40 mm is considered to be limited. The patient should feel pain and hypersensitivity when palpating at least three of 20 points of palpation.
Group II – the disk displacement. The disk displacement with reduction – the diagnosis based on the noise in the TMJ, for example, a reciprocal popping that disappears in protruding opening of mouth. The disk displacement without limited mouth opening – the diagnosis is based on the limitation of mandibular movements. A mouth opening of less than 35 mm is considered to be limited. The disk displacement without reduction and limitation of mouth opening – the diagnosis of such condition is extremely complicated.
Group III – arthralgia, osteoarthritis, osteoporosis. Arthralgia is characterized by pain and discomfort in the area of the TMJ without crepitation. In the strict sense, arthralgia is a symptom, not a clinical entity. Osteoarthritis is accompanied by pain or discomfort in the area of the TMJ, as well as crepitation. TMJ osteoporosis is possibly one of the variants of articular pathology and is characterized by crepitation, the absence of pain and discomfort in the joint.
Diagnostic Axis II of RDC/TMD. The degree of impairment of mandibular activity and psychosomatic response of the body to pain are determined to assess the psychosocial status.
On the one hand, this classification takes into account both the sufficient volume of clinical entities and clinical manifestations and the psychosocial response to them. On the other hand, it is worth remembering that when diagnosing, an experienced physician always takes into account individual characteristics of the patient and correlates them with the classification.
During the course of study of TMD at the Prosthetic Dentistry Department of Danylo Halytsky Lviv National Medical University we applied the classification of temporomandibular disorders by B.W.Neville, D.D.Damm, C.M.Allen, J.E.Bouquot (1995) (Fig. 3), which is formed by the organ principle and, in our opinion, is clinically convenient, not too cumbersome and easy to understand. It contains congenital/acquired, primary/secondary, inflammatory/degenerative, metabolic/traumatic disorders associated with the TMJ structures and masticatory muscles. However, it does not take into account the possibility of combining clinical entities from different groups. Therefore, we supplemented it with the term “combined disorders”.
There is a number of diseases, symptoms of which mimic the symptoms of TMD. This fact requires knowledge and extensive experience of clinicians. A diverse clinical picture and different combination of symptoms determines the need for a thorough differential diagnosis between TMD and diseases that mimic them.
Symptoms that accompany TMD have many variations that cause difficulties in diagnostic approaches (clinical examination or questionnaires). The main TMD symptoms are: pain in the TMJ area or masticatory muscles, the TMJ noises, limitation and deviation of the opening trajectory. Different scientists believe that the objective symptoms of TMD are observed in 1-75% of the population, and subjective in 5-33% . The subjective and objective results of the patient examination should be clear, correctly structured and easy to work with.
Classification of the diseases of TMJ by Christian Köneke (Fig. 4) is constructed according to the etiological principle and takes into account clinical entities of disorders depending on their origin without morphological or organ details. Clinical entities presented in the classification rarely occur in everyday practice. However, it is convenient when studying the etiology of TMD and determining the source of their occurrence.
Classification of the TMD published in the International Classification of Diseases ICD-10 (Table I) is not sufficiently adequate, does not cover the entire diversity of pathology and has no confirmation among scientists. Thus, its application in dental practice is limited and cannot be considered as a complete diagnosis.
Until now, scientists have not developed a unified examination protocol of the patients suspected with TMD. The issue of the convenience of using examination protocols is extremely relevant, due to the peculiarities of etiology, pathogenesis, clinical manifestations of TMD, and, in particular, differential diagnosis. The examination of such patients is long and cumbersome, counseling with other specialists complements the clinical picture and affects the diagnosis which should be described in the protocol.
There are pathologies and illnesses that can mimic TMD as well. In our opinion, the term “mimicked TMD” could be included in the classifications for the purpose of identifying a pathology that has no relation to TMJ and masticatory muscles, but has similar symptoms. They can be divided into two groups: of general-somatic and dental origin.
M. Helkimo Index (Fig. 5). Finnish scientist M. Helkimo proposed a protocol for a standardized patient examination with suspected TMD back in 1970 . The protocol includes the assessment of joint dysfunction with the subsequent calculation of the dysfunctional index (0 points – no dysfunction, 1-4 points – mild dysfunction, 5-9 points – dysfunction of moderate severity, 10-25 points – severe dysfunction), but a combination of heterogeneous information complicates the differential diagnosis of muscle and articular disorders. Moreover, the disadvantage of this system is the lack of calibration and the inability to avoid the impact of psychosocial aspects. Several modifications of the Helkimo Index did not spread significantly as well .
German researchers, M.O. Ahlers and H.A. Jakstat, consider that making the correct diagnosis requires multidisciplinary clinical functional analysis (cooperating with the patient) and assessment of his/her psycho-emotional status . They proposed well-known Hamburg Protocol for the TMJ’ examination and Short Hamburg Test (Fig. 6). The examination report includes a subjective and objective part. The subjective part is the questionnaire about stress and functional disorders, which are filled by the patient independently.
The “Stress Load” questionnaire (Fig. 7) is designed in such a way that the patient filles in the events that occurred in his/her life before the visit to a dentist and calculates them by scoring system. The physician assesses the total amount of points which determines the stress level experienced by the patient. Awareness of the patient’s stress level allows you to predetermine and outline the future treatment plan. The “Functional Disorders” questionnaire (Fig. 8), which is also filled in by the patient, focuses on patient’s responses to pain, feelings of distress and personal observations on dentition functions.
Next step “Clinical functional analysis” questionnaire (Fig. 9) concerns not only the analysis of the dentition function, but also other structures such as the spine condition. “Observation” Questionnaire (Fig. 10) allows to determine patient’s pain responses daily within two to three weeks during the treatment.
On the basis of previous observations, the amount of additional studies is determined, which appear in the form “Motivation of functional-analytical and therapeutic interventions”, (Fig. 11). It includes both the analysis of the patient’s occlusion in articulator, the use of x-ray and other additional diagnostic methods, followed by developing treatment plan.
Thus, when conducting regular clinical patient’s examination, it is important to point out: pain on palpation of the joints, pain on palpation of the masticatory muscles, joint noise, mouth opening disorders (deflection, deviation, or their combination), limited mouth opening, eccentric occlusion and premature tooth contacts and fill out the form “Express-detection” (fig. 6). When the two or more symptoms are positively identified, the patient is suspected of having TMD and requires further thorough and more detailed examination.
The Polish school of TMD, located in Lublin, headed by M. Kleinrok , proposed the algorithm for diagnosing patients, which consists of three stages: I – Research diagnostic criteria, ІІ – Patient’s initial screening record (Fig. 12), ІІІ – Clinical examination form. During the first stage of examination the patient fills in seven pages of the questionnaire, which indicates his/her condition and data for anamnesis.
The second stage is the initial screening and interview with the patient, which includes: personal details, bad habits of masticatory system, symptoms and their description, defining painful areas on the face and neck (done independently by the patient), an assessment of pain sense by the VAS scale from 0 to 10 (0 – pain is absent, and 10 – unbearable pain), general illnesses, injuries, concurrent treatment, examination of the patient: examination of mandibular movements, assessment of the size and trajectory of mouth opening, tooth formula, assessment of central, anterior and lateral occlusion, central line, description of X-ray images.
The third stage is the interview concerning the presence of pain in the face and its location, assessment of lateral mandibular movement, jaw size, muscle/joint pain in vertical and sagittal movements, noises in the joints during lateral and vertical mandibular movements (popping or crepitation).
Based on the comparative analysis of the proposed TMD classifications, the following conclusions can be drawn: the standardized classification of TMD has not been developed, this causes difficulties in treating diagnoses by the dentists; number of clinical entities in various classifications differs; the organ principle of classification structure has proved to be the most convenient in the clinical practice; the issue of unified TMD classification with the possibility of therapy monitoring remains open and requires further research; a significant number of pathologies mimicking the TMD symptoms causes the need for inclusion of the term “mimicked TMD” in the classification. Findings of the patient’s evaluation protocols analysis: the data volume is very large to describe; all protocols are structured according to different principles, but all their points overlap; the sequence and volume of examinations in each protocol are different, due to the interdisciplinary approach to diagnosis; protocols are expanded every time, making them bulky and difficult to understand at follow-up visits; the use of questionnaires for patients is subjective and requires counseling a psychotherapist for their analysis; the issue of developing a unified protocol for examination of patients with suspected TMD remains open; each doctor should choose the most convenient in his/her opinion protocol according to the experience.
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This article is an abstract of a comprehensive research of the Prosthetic Dentistry Department of Danylo Halytsky Lviv National Medical University “Development and improvement of clinical methods and technological means of complex treatment of patients with anodontia, deformities and damage of dentofacial system” (state registration number 0114U000112)
ADDRESS FOR CORRESPONDENCE
Ulyana D. Telishevska
3a Glinky st., apt. 2, 79012, Lviv, Ukraine
Figure 1. Classification of temporomandibular disorders by American Academy of Orofacial Pain (De Leeuw, 2008)
Table I. Classification of diseases of the temporomandibular joint in accordance with the international classification of diseases ICD-10
K07.6. Temporomandibular joint disorders
Costen complex or syndrome
Derangement of temporomandibular joint
Temporomandibular joint-pain-dysfunction syndrome
Excl.: current temporomandibular joint:
• dislocation (S03.0)
• strain (S03.4)
Figure 2. Research diagnostic criteria of temporomandibular disorders (Dworkin S, LeResche L, 1992)
Figure 3. Classification of temporomandibular disorders by B.W.Neville, D.D.Damm, C.M.Allen, J.E.Bouquot (1995).
Figure 4. Classification of diseases of the temporomandibular joint by Christian Köneke (2010).
Figure 5. M. Helkimo Index (1970).
Figure 6. Short Hamburg Test (Express Detection).
Figure 7. Hamburg evaluation protocol. “Stress Load” Questionnaire.
Figure 8. Hamburg evaluation protocol. “Functional Disorders” Questionnaire.
Figure 9. Hamburg evaluation protocol.
“Clinical Functional Analysis” Questionnaire.
Figure 10. Hamburg evaluation protocol. “On Observation” Questionnaire.
Figure 11. Hamburg evaluation protocol. “Motivation of Functional-Analytical and Therapeutic Measures” form.
Figure 12. Patient’s initial screening record by M. Kleinrok