Concerns of patients seeking treatment for TMJ dysfunction

CRANIOMANDIBULAR

Concerns of patients dysfunction

FUNCTION

seeking

Hana K. Al-Hasson, B.D.S., M.S.,* Amid Major M. Ash, Jr., D.D.S., M.S.*** University

of Michigan,

Schools of Dentistry

I. Ismail,

D

REVIEW

OF THE LITERATURE

Epidemiologic studies revealed that patients with masticatory disorders suffer from pain on opening of the mouth, limitation of mandibular movements, and clicking or crepitation, or both.’ It was also reported that patients with these signs and symptoms may also have a *Student, McGill University, Montreal, Quebec; formerly, Clinical Instructor, Department of Occlusion, School of Dentistry, University of Michigan. **Assistam Professor, McGill University Faculty of Dentistry, Montreal, Quebec; formerly Assistant Professor, Program in Dental Public Health, School of Public Health, University of Michigan. ***Professor and Chairman. Department of Occlusion, School of Dent1strv. THE

JOURNAL

OF PROSTHETIC

DENTISTRY

treatment B.D.S., M.P.H.,

and Public Health, Ann Arbor.

uring the past decade, the disorders referred to as “TM J dysfunction” have been the subject of increasing interest. Clinics specializing in treatment of facial pain and temporomandibular joint (TM J) dysfunction have been established in dental schools worldwide. There is also a purported increase in the number of patients seeking treatment for these conditions, although the reasons for this increase have not yet been adequately investigated. This trend may be due to an actual increased prevalence of masticatory disorders in the population, or to an increased awareness on the part of patients and their dentists. Epidemiologic and clinical studies of masticatory dysfunction have provided inconclusive findings concerning the distribution of masticatory dysfunctions and have mostly described the demographic characteristics of the individuals examined and their most commonly reported symptoms.1-8 No specific evaluation has been carried out of the social impact of these conditions on the life of individuals with signs and symptoms of masticatory disorders, their reasons for seeking treatment, and how these people viewed their masticatory problems. The purpose of this study was to investigate the reasons why patients sought treatment at a Universitybased TM J clinic, their concerns, treatments previously received, and most commonly reported signs and symptoms of TMJ dysfunction. Patients in this study were referred for treatment to the TMJ/Oral Facial Pain Clinic, University of Michigan School of Dentistry.

AND DYSFUN

for TMJ Dr.P.H.,**

and

Mich.

Table I. Distribution and age -___

of patients

----_ .--._---- -Age

Gender Men Women

10-20 __ N (%) 5 (20.8) 18 (14.3)

by gender

21-30 __ N (%)

(2Z.2) ,::.7,

groups

(years) __-._._-31-40 41-50 ---.--. N (%I N (%)

51-m __. N (o/o)

i (29.2) 24 (19 0)

(4:) 25 (19.8)

4 (16.7) 19 (:5.1) .-_-._ - ------

history of other physical complaints, and frequent episodes of hospitalization and psychiatric counselling or therapy.” The patients reportedly suffered from these symptoms for a period ranging from a few months to years,“, I2 and most of them sought medical and dental advice on more than one occasion.” The most frequent treatments provided to their patients have been an occlusal splint and occlusal adjustment.” Aside from the finding that apparently most patients seeking treatment because of masticatory disorders are women between 20 and 50 years of age,l-Klittle is known about social and behavioral factors that prompted the patients to seek treatment, or are associated with an increased incidence of recurrence and exacerbation of the symptoms. The few studies that have investigated these factors reported that the patients came mostly from middle to upper income classes,5.“’whereas other studies have reported that the patients were mostly of “poor social situation.“‘5 These findings are affected by the type of the practice providing the treatment and its location. DATA

SOURCES

During a period of 2 months every patient who was referred to the TMJ/Oral Facial Pain Clinic of the School of Dentistry, University of Michigan, was given a self-administered questionnaire that enabled assessment of the following: (1) chief complaint, (2) treatment received before coming to the clinic, (3) the patient’s view of his/her problems, (4) impact of the problem on daily living, (5) what the patient thought would relieve the problem, (6) effectiveness of prior treatment, and (7) 217

AL-HASSON,

ISMAIL,

AND

ASH

60

60

0

Weeks

Months Duration

Weeks

Years

Fig. 1. Duration of reported symptoms of TMJ dysfunc-

Number

Months of symptoms

Years

Fig. 2. Number of symptoms of TMJ dysfunction.

tion.

professional care that had been sought before coming to the clinic. The questionnaire included multiple-choice questions and was tested on clinic patients for accuracy and simplicity. The distribution by gender and age of patients who answered the questionnaire is presented in Table I. One hundred fifty-seven patients, 10 to 75 years of age, answered the self-administered questionnaire, during the 2 months of the study, with a response rate of 90%. Women constituted 84% of the sample, half of them were 20 to 40 years of age.

RESULTS Symptoms

of TMJ disorder

Pain in muscles and the TM J was the chief complaint of 86 patients (54%), whereas 82 (52.2%) had discomfort and 73 (46.5%) had headache. Joint noises were reported as the chief complaint by 66 patients (42%), and locking was the problem of 38 patients (24.2%). The symptoms were constant and lasted for years in 95 patients (60.5%); 61 patients (38.8%) had symptoms for months or weeks (Fig. 1). Most patients (88) reported that the source or origin of the problem was the “bite,” whereas the TMJ and muscles of mastication were reported to be the source of the problem by 80 and 40 patients, respectively. Most of the patients had two or more symptoms of TM J dysfunction (Fig. 2). A positive correlation was found between the number of symptoms and their duration; as the number of symptoms increased the duration was longer. There was a significant correlation between wide opening of the mouth and (1) discomfort, (2) “tightness” in the muscles, and (3) locking of the joint (Table II). There was a significant correlation between inability to 218

chew and (1) pain, (2) discomfort, (3) tightness in the muscles, (4) locking and clicking of the joint; and (5) problems with the teeth (Table II).

Prior treatment

and methods

of diagnosis

Sixty-four of the 157 patients had been treated by two methods and 84 patients had three or more types of treatments. There was a significant correlation between an increased number of reported symptoms and an increased number of treatments. Of the 157 patients, only 3.2% had been treated by a single method (Fig. 3). The most frequently used treatment methods were pain medication (tranquilizers and/or aspirin), mouth guards (various types), and occlusal adjustment. Thirtythree patients (21%) thought the previous treatment(s) did not help at all, whereas 34 patients (21.7%) thought it helped some at first. Four previously used diagnostic procedures were reported by the subjects: radiographs were used in 41 patients (26.1%), arthrograms in seven (4.5%), and electromyography and kinesiography in eight (5.1%). Forty-three patients (27.4%) did not know which procedure(s) were used to diagnose the joint dysfunction, and 33 patients (21%) answered that none of the mentioned procedures were used to diagnose their problem. No patients reported the need for psychiatric treatment. Few patients thought surgery of the joint, orthodontics, or muscle exercises “may help the problem.”

Source of referrals Most patients (84.1%) were referred to the TM J Clinic by dentists (24.2% by a “TMJ specialist”, 19.1% by a periodontist, and the rest by a general practitioner). Thirty-eight percent were referred by either a physician AUGUST

1986

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TREATMENT

Table II. Percentages of patients with different

symptoms

during

performing

different

functions -___

------_ Wide opening Symptoms

Pain Discomfort Tightness Locking Clicking Problems

in muscles

with

N = 157. *P < .05 (Fisher tP < .Ol

teeth

exact test’s p-value;

Chewing food

N

%

N

%

N

%

63 60 44 35 42 11

68.5 65.2” 47.8t 3t3.0t 45.7 12.0

68 60 38 33 42 18

70.1t 61.9 39.2 34.0’ 43.3 18.6”

48 46 35 28 35 5

70.6” 67.6* 51.5t 41.2.f 51.5’ 7.4*

testing

for independence

between

(neurologist, otolaryngologist, osteopath, or psychiatrist) or by both a physician and a dentist. The presence of TMJ disorders was regarded as “depressing” by 26 patients (16.6%); 56 patients (35.7%) reported that they were “really concerned about it”; and 51 patients (32.5%) considered their problems as a “nuisance.” In 95 of the patients (60.5%), the presence of signs and symptoms of disorders did not cause them to miss work.

Patients’

concerns about their problem

The patients were also asked about what they thought would relieve their chief complaint. Most patients (58.6%) “did not know what would help them,” whereas “alignment of the jaw,” and “a new restoration would help” were each suggested by approximately 10% of the patients. The most frequently reported primary concern (119 patients) was related to worsening of the problem, irrespective of the dysfunctional symptoms (that is, clicking, pain, locking). Eleven patients were concerned about loss of teeth and eventual need for surgery to treat the disorders. It was most often the dentist who first informed the patient about the possible diagnosis for their problem (80 patients), with physicians as a second source (24 patients). The rest of the patients became concerned about their problem when they heard about the “TMJ problem” from friends and relatives, television, newspapers, and magazines. Twenty-seven patients had someone in the family who had suffered from the same TM J problem, and 13 patients had a friend similarly afllicted.

DISCUSSION The findings of this survey may indicate that one of the reasons for the increase in the number of patients seeking treatment for facial pain and TMJ dysfunction may be the increased recent attention given by dentists THE

JOURNAL

OF PROSTHETIC

Yawning

DENTISTRY

a symptom

and a mandibular

mandibular -_.__--__ Singing -_- -_.--N % 13 1 .F 7 a 10 2

72.2 83.3” 38.9 50.0” 55.6 11.1

function)

and the media to these problems. Most patients seeking treatment for TMJ dysfunction in this study were informed about their problems by their dentists. The chief concern of those patients was that their problems might worsen. The pattern depicted by the results of this analysis is in agreement with the widely known Health Belief Model (HBM).‘” Specifically, the HBM explains that the reason individuals seek treatment and preventive care is that (1) they feel susceptibfe to the particular illness and the probable severity of the condition; (2) the individual’s evaluation of the feasibility and benefits of the advocated treatment and preventive action weigh against the perception of physical, psychologic, financial, and other barri+zrs involved in the proposed action, and (3) there is a cue to action triggering the appropriate health behavior. The results of this analysis suggest that although most patients had the signs and symptoms of TM J dysfunction for years, they only sought treatment when they were told of their dentists’ perceived diagnosis of their conditions. This cue to action, coupled with the increased availability of treatment for TM J dysfunctions will lead, or has already led, to an increase in the number of individuals seeking treatment. This is not a new phenomenon in the medical and dental literature; Lous” suggested that patients’ demand for treatment services increases geometrically with the provision of services. Another finding of this analysis is the positive correlation between the number of treatment modalities received before visiting the University of Michigan TM J Clinic and the duration of signs and symptoms of TM J dysfunction. Current diagnostic methods that can clearly classify patients with TM J dysfunction according to the severity and prognosis of their conditions are not available. Scientific evaluation of the efficacy of different treatment modalities is also unavailable. Therefore, it is to be expected that dentists treating patients with complicated TMJ dysfunctions (as are most of the patients involved in this study) will attempt different 219

AL-HASSON,

ISMAIL,

AND

ASH

SUMMARY

Number

of treatments

Fig. 3. Percentage of reported received by TMJ patients.

previous

treatments

methods to solve the patients’ problem. The most commonly used methods reported by patients included pain medications, mouth guards, and occlusal adjustment. In Europe, by contrast, the most commonly reported treatments were bite planes, occlusal adjustment, and jaw exercises.” Women constituted most of the patients seeking treatment at the TMJ clinic, and a number of social, psychologic, and behavioral factors may explain this trend.18 Women tend to seek treatment for health problems more often than men.19 They also appear to have a higher prevalence of conditions that are associated with TM J dysfunction, such as headache, arthritis, and musculoskeletal disorders.20 Moreover, differences in pain tolerance and in the perception of, and susceptibility to, the disease have also been reported.2’s22

One hundred fifty-seven patients, 126 women and 24 men, 10 to 75 years of age, completed a self-administered questionnaire. The questionnaire contained questions asking about the patients’ chief complaint, treatment received before coming to the clinic, the patients’ view of their problem, and who informed them of the possible end result of an untreated “TMJ problem.” The results revealed that pain was the most commonly reported complaint (54%), discomfort and headache came second and third (52.2% and 46.5%, respectively). A significant correlation was found between inability to chew and pain, discomfort, tightness in the masticatory muscles, and locking and clicking of the joint. Most patients had received three or more types of treatment before coming to the University of Michigan, TM J and Oral Facial Pain Clinic. A significant correlation was found between an increased number of reported symptoms and an increase in the number of treatments. The most frequently used treatment methods were pain medication, mouth guard (appliances), and occlusal adjustment. Most patients (84.1%) were referred to the TM J and Oral Facial Pain Clinic by dentists because of clicking, locking, and limitation of movement, with or without pain. REFERENCES 1.

2. 3. 4. 5. 6.

CONCLUSIONS 1. The most frequently reported concern was that “the problem is getting worse.” 2. Most patients were referred to the TMJ/Oral Facial Pain Clinic by dentists. 3. Women constituted 84% of the sample. Half of the women were between 20 and 40 years of age. 4. The treatment methods most frequently used before visiting our Clinic were pain medications, mouthguard, and occlusal adjustment. 5. The symptoms of TMJ muscle pain dysfunction syndrome had been present “for years” in 60.5% of the patients. 6. Pain was the most common reported complaint. 7. Most patients viewed the presence of TMJ dysfunction as something they were “really concerned about.”

8. Eighty-eight patients contended that the source of the problem was tt~ “bite.” 220

7. 8.

9.

10. 11.

12. 13.

Schwartz LL, Cobin HP: Symptoms associated with the temporomandibular joint. A study of 491 cases. Oral Surg 10~339, 1957. Thomson H: Mandibular dysfunction syndrome. Brit Dent J 130:187, 1971. Thomson H: Mandibular joint pain: A survey of 100 treated cases. Brit Dent J 107~243, 1959. Carraro JJ, Caffesse RG, Albino EA: Temporomandibular joint syndrome. Oral Surg 28~54, 1969. Franks AS: The social character of temporomandibular joint dysfunction. Dent Pratt 15:94, 1964. Butler JH, Folke LA, Bandt CL: A descriptive survey of signs and symptoms associated with the myofascial pain-dysfunction syndrome. J Am Dent Assoc g&635, 1975. Perry HT: The symptomatology cf temporomandibular joint disturbance. J PROSTHET DENT 19:288, 1968. Gelb H, Calderone JP, Gross SM, Kantor ME: The role of the dentist and the otolaryngologist in evaluating temporomandibular joint syndromes. J PROSTHET DENT 18:497, 1967. Solberg WK: Epidemiology, incidence and prevalence of temporomandibular disorders. In Laskin DM, Greenfield W, Gale E, et al: President’s Conference on the Examination, Diagnosis, and Management of Temporomandibular Disorders. Chicago, 1982, American Dental Association, p 30-39. Greene CS, Laskin DM: Chronic illness and illness behavior in MPD patients. J Dent Res 60A:349, 1981. Wedel A, Carlsson GE: Retrospective review of 350 patients referred to a TMJ clinic. Community Dent Oral Epidemiol 11:69, 1983. Heloe B: Comparison of two groups of patients with TMJdisorder. Community Dent Oral Epidemiol 7~117, 1979. Agerberg G, Carlsson GE: Symptoms of functional disturbances of the masticatory system. A comparison of frequencies in a population sample and in a group of patients. Acta Odont Stand 33~183, 1975. AUGUST

1986

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14

15.

OF PATIENTS

17. 18.

19.

TREATMENT

Heloe B, Heloe LA: Characteristics of a group of patients with temporomandibular joint disorders. Community Dent Oral Epidemioi 3:73, 1975. Carlsson GE, Kopp S, Wedel A: Analysis of background variables in 350 patients with TMJ disorders as reported in a self-administered questionnaire. Community Dent Oral Epidem101 l&47.

16.

SEEKING

R&m+ E. B&&s, Jr., D.D.S.,* card N. Stewart, D.D.S.+** of Florida,

hyd -

College of Dentistry,

B. Welt+&, D.M.D., Gainesville,

T

ARTHROGRAPHY Recent articles have addressed the determination of temporomandibular joint (TM J) disk position, while a patient is in splint therapy, by the use of arthrography.‘s4 The reported advantage of this technique is that the exact position of the disk can be determined while the splint is being fabricated and then verified as necessary, to determine whether the disk is remaining in place. Clinical experience indicates that the deterniination of the exact splint position where the disk will remain in function is often difficult. i‘he advantages and disadvantages of arthrography

THE

Professor, Department of Basic Dental Sciences. Professor, Section of Fixed Prosthodontics. Department of Operative Dentistry.

JOURNAL

OF PROSTHETIC

DENTISTRY

22.

Vital and Health Statistics. Current clrt~m~~~~*s from the health IX. I9i2 li.S. interview survey USA 1972. Washingtorr Department of Health, Education and Welfare Ser\G(e. Srries No. 10 No. 85 DHEW Pub No. (HRH)Y&i5!2 Molin C, Schalling D, Edman G: t’sych~,logiral studies of patients with mandibular pain dysfuncuon 5: ndrome. II. ‘Tolerance for experimentally induced pain. S\%r~l L)cnt J 6&l 5, 1973. Lupton DE, Johnson DL: Myofarrial patn tiysfunctron syndrome, attitudes, and other personality charal terlstlcs related to tolerance for pain. J PROSTHET DEW 2Y:3?q~. i.j7i.

Reprint

requests

to.

DR. AMID ISMAIL MCGILL UNIVERSITV FACILITY OF DENTISTRY MONTREAL. QUEBEC, H3A

MS.,**

2B2

ind

Fla.

he determination of jaw position for the fabrication of an anterior repositioning splint may be critical to the outconie of splint therapy, particularly for patients with anteriorly displaced disks.’ The splint must be fabricated in a jaw position such that the reciprocal, or closing, click will not recur. 2 This position is often difficult to accomplish by manual manipulation of the mandible alone.

*Associate **Associate “**Instructor,

21.

1982.

Rosenstock I: Historical origins of the Health Belief Model. Health Educ Monograph 2:328, 1974. Lous I: The need-demand problem in patients with oromandibular functional disorders. J Oral Rehabil 4:51, 1977. Rugh JD, Solberg WK: Temporomandibular disorders: treatment and manpower needs with implications for dental education. J Dent Educ (in press). Richards ND: Utilization of dental services. In Richards ND, Cohen LK, editors: Social Sciences and Dentistry. A Critical Bibliography. The Hague, 1971, Fed Dent Int, p 209.

University

20.

have been described,‘x6 and include (1) limitation of splint fabrication to a facility where arthrography is done, (2) patient expense, (3) patient discomfort during and after the procedure, (4) the possibiiity of allergic or other advize reactions to the dye material used, (5) the consideration that a fluid filled joint is not a normally functioning joint, and (6) the problem that these joints make arthrography unattractive or inaccessible to most general dentists for use in splint fabrication.

CdNDYLE

PATH RECORDERS

The relationship between disk position and the condylar excursive path patterns is well known;Y and various methods have been used to record these condylar path patterns.8-‘5 A common characteristic of these methods is the ability to demonstrate the position of the opening and closing click in patients with internal derangement. This article describes a simple procedure that can be used chairside to determine click positions during the fabrication of a splint. This procedure can be used also during splint therapy to determine condylar movement patterns. The equipment is relatively inexpensive and the entire procedure can be accomplished in a matter of minutes. 221